§ 26.1-53.1-01 — Definitions

North Dakota § 26.1-53.1-01

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-53.1: Discount Plans

Text

For purposes of this chapter, unless the context otherwise requires:
1. "Affiliate" means a person that directly, or indirectly through one or more
intermediaries, controls, or is controlled by, or is under common control with, the
person specified.
2. "Ancillary services" includes audiology, dental, vision, mental health, substance abuse,
chiropractic, and podiatry services.
3. "Control", "controlled by", or "under control with" means the possession, direct or
indirect, of the power to direct or cause the direction of the management and policies
of a person, whether through the ownership of voting securities, by contract other than
a commercial contract for goods or nonmanagement services, or otherwise, unless the
power is the result of an official position with or corporate office held by the person.
Control is presumed to exist if any person, directly or indirectly, owns, controls, holds
with the power to vote, or holds proxies representing ten percent or more of the voting
securities of any other person. This presumption may be rebutted by a showing made
in the manner provided by section 26.1-10-04, that control does not exist in fact. The
commissioner may determine, after furnishing all persons in interest notice and
opportunity to be heard and making specific findings of fact to support such
determination, that control exists in fact, notwithstanding the absence of a presumption
to that effect.
4. "Direct primary care" means any private contract between a provider and consumer for
services associated with that provider.
5. "Discount plan" means a business arrangement or contract in which a person, in
exchange for fees, dues, charges, or other consideration, offers members the access
to providers of medical or ancillary services and the right to receive discounts on
medical or ancillary services provided under the discount plan from those providers.
The term includes a discount prescription drug plan. The term does not include:
a. A plan that does not charge a membership, payment, dues, other consideration,
or other fee to use the discount plan;
b. Any product otherwise regulated under title 26.1;
c. Direct primary care;
d. A patient access program; or
e. A Medicare prescription drug plan.
6. "Discount plan organization" means an entity that, in exchange for fees, dues,
charges, or other consideration, provides access for discount plan members to
providers of medical or ancillary services and the right to receive medical or specialty
services from those providers at a discount. It is the organization that contracts with
providers, provider networks, or other discount plan organizations to offer access to
medical or specialty services at a discount and determines the charge to discount plan
members.
7. "Discount prescription drug plan" means a business arrangement or contract in which
a person, in exchange for fees, dues, charges, or other consideration, provides
members the access to providers of pharmacy services and the right to receive
discounts on pharmacy services provided under the discount prescription drug plan
from those providers.
8. "Facility" means an institution providing medical or ancillary services or a health care
setting. The term includes:
a. A hospital or other licensed inpatient center;
b. An ambulatory surgical or treatment center;
c. A skilled nursing center;
d. A residential treatment center;
e. A rehabilitation center; and
f. A diagnostic, laboratory, or imaging center.

9. "Health care professional" means a physician, pharmacist, or other health care
practitioner who is licensed, accredited, or certified to perform specified medical or
ancillary services within the scope of the professional's license, accreditation,
certification, or other appropriate authority consistent with state law.
10. "Health insurer" means an entity subject to the insurance laws and regulations of this
state, or subject to the jurisdiction of the commissioner, that contracts or offers to
contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health
care services, including a sickness and accident insurance company, a health
maintenance organization, a nonprofit hospital and health service corporation, or any
other entity providing a plan of health insurance, health benefits, or medical or ancillary
services.
11. "Marketer" means a person that markets, promotes, sells, or distributes a discount
plan, including a private label entity that places the entity's name on and markets or
distributes a discount plan pursuant to a marketing agreement with a discount plan
organization.
12. "Medical services" means any maintenance care of, or preventive care for, the human
body, or care, service, or treatment of an illness or dysfunction of, or injury to, the
human body. The term includes physician care, inpatient care, hospital surgical
services, emergency services, ambulance services, dental care services, vision care
services, mental health services, substance abuse services, chiropractic services,
podiatric services, laboratory services, medical equipment and supplies, pharmacy
services, and ancillary services.
13. "Medicare prescription drug plan" means a plan that provides Medicare part D
prescription drug benefits in accordance with the requirements of the federal Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 [Pub. L. 108-173].
14. "Member" means any individual who pays fees, dues, charges, or other consideration
for the right to receive the benefits of a discount plan or discount prescription drug
plan.
15. "Patient access program" means a voluntary program sponsored by a pharmaceutical
manufacturer, or a consortium of pharmaceutical manufacturers, which provide free or
discounted health care products directly to low-income or uninsured individuals either
through a discount card or direct shipment.
16. "Person" means an individual, a corporation, a partnership, an association, a joint
venture, a joint stock company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
17. "Pharmacy services" includes pharmaceutical supplies and prescription drugs.
18. "Provider" means any health care professional or facility that has contracted, directly
or indirectly, with a discount plan organization to provide medical or ancillary services
to members.
19. "Provider network" means an entity that negotiates, directly or indirectly, with a
discount plan organization on behalf of more than one provider to provide medical or
ancillary services to members.