Plan design (indemnity, HMO, PPO, POS), cost sharing, HSAs and the ACA framework are covered in the national Medical Plans guide. This guide covers the North Dakota statutes and rules on medical expense coverage that the Accident and Health exam tests. They come mainly from N.D.C.C. chapters 26.1-36, 26.1-36.4, 26.1-36.5 and 26.1-36.8, and N.D. Admin. Code Title 45.

Delivery and the free look

• Free look. Every individual accident and health policy must carry a notice, on or attached to the first page, that the applicant may return it within 10 days of delivery for a refund of premium (26.1-36-02.1). Life policies and annuities have a 20-day free look.
• Misrepresentation. A misstatement in the application avoids the policy only if it was made with intent to deceive or increased the risk of loss (26.1-29-25).
• Prompt payment. A health insurer must act on a claim within 15 business days of receiving it, and within 15 business days after receiving any information it requested (26.1-36-37.1).
• Loss ratios. Minimum loss ratios are 70% for group policies and 55% for individual policies (26.1-36-37.2).

Coverage North Dakota requires

• Intoxication and narcotics. Hospital, medical, surgical and major medical policies must cover losses from intoxication or narcotics like any other illness, subject only to the illegal-act limits (26.1-36-09.13).
• Suicide and self-injury. The same policies must cover injury or illness from suicide, attempted suicide or self-inflicted injury (26.1-36-09.12).
• Newborns and adopted children (26.1-36-07):
  • Coverage begins at the moment of birth, or at physical placement for adoption.
  • It includes diagnosed congenital defects and birth abnormalities.
  • The policy may require notice and any added premium within 31 days.
• Disabled dependents stay covered past the limiting age if proof is given within 31 days of reaching it (26.1-36-22).
• Children's coverage (26.1-36.5):
  • An insurer may not deny a child's enrollment because the child was born out of wedlock, isn't claimed as a tax dependent, or doesn't live with the parent.
  • A court-ordered child must be enrolled without regard to open enrollment limits.
  • The custodial parent may file claims without the other parent's approval.

Renewability and portability (26.1-36.4)

• Prior coverage. Prior coverage counts toward any waiting period if the gap is less than 63 days.
• Allowed reasons for nonrenewal: nonpayment, fraud or intentional material misrepresentation, and other listed reasons unrelated to health.
• Dropping a product. The insurer gives at least 90 days' notice and offers its other plans.
• Leaving the whole market. The insurer gives 180 days' notice and can't write new business in that market for five years.

Short-term health plans (26.1-36.8)

• Only licensed and appointed producers may sell them. The producer's signature and ID go on the application.
• An individual plan may last 12 months, including renewals. Association plans may run up to 36 months in total.
• The insured gets notice at least 15 days before renewal or the end of the term. There's no re-underwriting at renewal.

Advertising and underwriting rules (N.D. Admin. Code Title 45)

Advertising (45-06-04)

• Phrases like "extra cash" can't describe hospital-confinement benefits.
• "No medical examination required" can't be used.
• An invitation to inquire is a brief ad that doesn't mention cost.
• Ads are kept four years, or until the next exam report if that's longer.

HIV testing (45-03-11)

• Testing requires the applicant's informed written consent on the prescribed form.
• Abnormal results are reported to the state department of health.
• Only a generic code goes to MIB.

Sex discrimination (45-03-10). Insurers may not:

• treat pregnancy complications differently from other illnesses
• offer women lower maximum monthly disability benefits than men in the same class

Common exam traps

• The individual A&H free look is 10 days, and the notice goes on the first page.
• Major medical must cover intoxication losses. North Dakota doesn't allow the usual intoxicants exclusion in these policies.
• Newborns are covered from birth, with notice and premium due within 31 days.
• Individual short-term plans max out at 12 months.
• The individual loss ratio is 55%, and the group loss ratio is 70%.