State Law

North Dakota Admin. Code-Title 45-Article 45-06-Chapter 45-06-07. Model Reg. to Implement Rules Regarding Contracts and Services of HMOs

08/13/2023 North Dakota Section 45-06-07-03


Medical Necessity-Definition

See bold text below:

Group or individual contract or evidence of coverage delivered or issued for delivery to any person in this state by a health maintenance organization required to obtain a certificate of authority in this state may not contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this section. Definitions other than those in this section may be used as appropriate, providing that they do not contradict these requirements. All definitions used in the group or individual contract and evidence of coverage must be in alphabetical order. As used in this chapter and as used in the group or individual contract and evidence of coverage:

1. “Basic health care services” means the following medically necessary services: preventive
care, emergency care, inpatient and outpatient hospital and physician care, diagnostic
laboratory, and diagnostic and therapeutic radiological services. It does not include mental
health services or services for alcohol or drug abuse, dental or vision services, or long-term
rehabilitation treatment.

2. “Copayment” means the amount an enrollee must pay in order to receive a specific service
that is not fully prepaid.

3. “Deductible” means the amount an enrollee is responsible to pay out of pocket before the
health maintenance organization begins to pay the costs or provide the services associated
with treatment.

4. “Eligible dependent” means any member of a subscriber’s family who meets the eligibility
requirements set forth in subsection 2 of section 45-06-07-04.

5. “Emergency care services” means:

a. Within the service area: covered health care services rendered by affiliated or
nonaffiliated providers under unforeseen conditions that require immediate medical
attention. Emergency care services within the service area include covered health care
services from nonaffiliated providers only when delay in receiving care from the health
maintenance organization could reasonably be expected to cause severe jeopardy to the
enrollee’s condition.

b. Outside the service area: medically necessary health care services that are immediately
required because of unforeseen illness or injury while the enrollee is outside the
geographical limits of the health maintenance organization’s service area.

6. “Enrollee” means an individual who is covered by a health maintenance organization.

7. “Evidence of coverage” means a statement of the essential features and services of the health maintenance organization coverage which is given to the subscriber by the health
maintenance organization or by the group contractholder.

8. “Extension of benefits” means the continuation of coverage of a particular benefit provided
under a group or individual contract following termination with respect to an enrollee who is
totally disabled on the date of termination.

9. “Grievance” means a written complaint submitted in accordance with the health maintenance organization’s formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization relative to the enrollee.

10. “Group contract” means a contract for health care services which by its terms limits eligibility to enrollees of a specified group. The group contract may include coverage for dependents.

11. “Group contractholder” means the person to whom a group contract has been issued.

12. “Health maintenance organization” means any person who undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for
enrollee responsibility for copayments or deductibles.

13. “Hospital” means a duly licensed institution that provides general and specialized inpatient medical care. The term “hospital” does not include a convalescent facility, nursing home, or any institution or part of an institution which is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged.

14. “Individual contract” means a contract for health care services issued to and covering an
individual. The individual contract may include coverage for dependents of the subscriber.

Medical Necessity-Definition

15. “Medical necessity” or “medically necessary” means appropriate and necessary services as determined by any provider affiliated with the health maintenance organization which are rendered to an enrollee for any condition requiring, according to generally accepted principles of good medical practice, the diagnosis or direct care and treatment of an illness or injury and are not provided only as a convenience. This does not preclude the health maintenance organization from establishing standards by which providers make their decisions as to what is medically necessary or from penalizing providers for failure to meet these standards. In the case of emergency medical services, the health maintenance organization has the right to make the final determination of whether services should be covered.

16. “Nonbasic health care services” means any health care services, other than basic health care services, that may be provided in the absence of basic health care services.

17. “Out-of-area services” means the health care services that a health maintenance organization covers when its enrollees are outside of the service area.

18. “Participating provider” means a provider as defined in this section who, under an express or implied contract with the health maintenance organization or with its contractor or
subcontractor, has agreed to provide health care services to enrollees with an expectation of
receiving payment, other than copayment or deductible, directly or indirectly from the health
maintenance organization.

19. “Physician” means a duly licensed doctor of medicine or osteopathy practicing within the
scope of such a license.

20. “Primary care physician” means a physician who supervises, coordinates, and provides initial and basic care to enrollees, and who initiates their referral for specialist care and maintains continuity of patient care.

21. “Provider” means any physician, hospital, or other person licensed or otherwise authorized to furnish health care services.

22. “Replacement coverage” means the benefits provided by a succeeding carrier.

23. “Service area” means the geographical area as approved by the commissioner within which the health maintenance organization provides or arranges for health care services that are available and accessible to enrollees.

24. “Skilled nursing facility” means a facility that is operated pursuant to law and is primarily
engaged in providing room and board accommodations and skilled nursing care under the
supervision of a duly licensed physician.

25. “Subscriber” means an individual whose employment or other status, except family
dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued.

26. “Supplemental health care services” means any health care services that are provided in
addition to basic health care services.