26.1-18.1-07. Requirements for group contract, individual contract, and evidence of coverage

26.1-18.1-07. Requirements for group contract, individual contract, and evidence of

coverage.

1. a. Every group and individual contractholder is entitled to a group or individual

contract.

b. The contract may not contain provisions or statements which are unjust, unfair,

inequitable, misleading, deceptive, or which encourage misrepresentation as

defined by chapter 26.1-04.

c. The contract must contain a clear statement of the following:

(1) Name and address of the health maintenance organization.

(2) Eligibility requirements.

(3) Benefits and services within the service area.

(4) Emergency care benefits and services.

(5) Out-of-area benefits and services, if any.

(6) Copayments, deductibles, or other out-of-pocket expenses.

(7) Limitations and exclusions.

(8) Enrollee termination.

(9) Enrollee reinstatement, if any.

(10) Claims procedures.

(11) Enrollee grievance procedures.

(12) Continuation of coverage.

(13) Conversion.

(14) Extension of benefits, if any.

(15) Coordination of benefits, if applicable.

(16) Subrogation, if any.

(17) Description of the service area.

(18) Entire contract provision.

(19) Term of coverage.

(20) Cancellation of group or individual contractholder.

(21) Renewal.

(22) Reinstatement of group or individual contractholder, if any.

(23) Grace period.

(24) Conformity with state law.

An evidence of coverage may be filed as part of the group contract to describe

the provisions required in this subdivision.

2. In addition to those provisions required in subdivision c of subsection 1, an individual

contract must provide for a ten-day period to examine and return the contract and

have the premium refunded. If services were received during the ten-day period, and

the person returns the contract to receive a refund of the premium paid, the person

must pay for the services.

3. a. Every subscriber shall receive an evidence of coverage from the group

contractholder or the health maintenance organization.

b. The evidence of coverage may not contain provisions or statements which are

unfair, unjust, inequitable, misleading, deceptive, or which encourage

misrepresentation as defined by chapter 26.1-04.

c. The evidence of coverage must contain a clear statement of the provisions

required in subdivision c of subsection 1.

4. The commissioner may adopt rules establishing readability standards for individual

contract, group contract, and evidence of coverage forms.

5. No group or individual contract, evidence of coverage, or amendment thereto may be

delivered or issued for delivery in this state, unless its form has been filed with and

approved by the commissioner, as provided by sections 26.1-30-19 and 26.1-30-20.

6. The provisions set forth in sections 26.1-30-20 and 26.1-30-21 govern the approval

and disapproval of forms required to be filed under this section.

7. The commissioner may require the submission of whatever relevant information the

commissioner deems necessary in determining whether to approve or disapprove a

filing made pursuant to this section.