North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-06 - Accident and Health Insurance
Chapter 45-06-05 - Long-Term Care Insurance Model Regulation
Section 45-06-05-04 - Policy practices and provisions
Universal Citation: ND Admin Code ยง 45-06-05-04
Current through Supplement No. 394, October, 2024
1. Renewability. The terms "guaranteed renewable" and "noncancelable" may not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of section 45-06-04-05.
a. No such policy issued to an individual may
contain renewal provisions less favorable to the insured than "guaranteed
renewable" or "noncancelable".
b.
The term "guaranteed renewable" may be used only when the insured has the right
to continue the long-term care insurance in force by the timely payment of
premiums and when the insurer has no unilateral right to make any change in any
provision of the policy or rider while the insurance is in force, and cannot
decline to renew, except that rates may be revised by the insurer on a class
basis.
c. The term "noncancelable"
may be used only when the insured has the right to continue the long-term care
insurance in force by the timely payment of premiums during which period the
insurer has no right to unilaterally make any change in any provision of the
insurance or in the premium rate.
2. Limitations and exclusions. No policy may be delivered or issued for delivery in this state as long-term care insurance if such policy limits or excludes coverage by type of illness, treatment, medical condition, or accident, except as follows:
a. Preexisting conditions or diseases;
b. Mental or nervous disorders;
however, this does not permit exclusion or limitation of benefits on the basis
of alzheimer's disease;
c.
Alcoholism and drug addiction;
d.
Illness, treatment, or medical condition arising out of:
(1) War or act of war (whether declared or
undeclared);
(2) Participation in
a felony, riot, or insurrection;
(3) Service in the armed forces or units
auxiliary thereto;
(4) Suicide
(sane or insane), attempted suicide, or intentionally self-inflicted injury; or
(5) Aviation (this exclusion
applies only to nonfare paying passenger).
e. Treatment provided in a government
facility (unless otherwise required by law), services for which benefits are
available under medicare or other governmental program (except medicaid), any
state or federal workers' compensation, employer's liability or occupational
disease law, or any motor vehicle no-fault law, services provided by a member
of the covered person's immediate family and services for which no charge is
normally made in the absence of insurance.
f. This subsection is not intended to
prohibit exclusions and limitations by type of provider or territorial
limitations.
3. Extension of benefits. Termination of long-term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the long-term care insurance was in force and continues without interruption after termination. Such extension of benefits beyond the period the long-term care insurance was in force may be limited to the duration of the benefit period, if any, or to payment of the maximum benefits and may be subject to any policy waiting period, and all other applicable provisions of the policy.
4. Continuation or conversion.
a. Group long-term care insurance issued in
this state on or after October 1, 1989, shall provide covered individuals with
a basis for continuation or conversion of coverage.
b. For the purposes of this section, "a basis
for continuation of coverage" means a policy provision which maintains coverage
under the existing group policy when such coverage would otherwise terminate
and which is subject only to the continued timely payment of premium when due.
Group policies that restrict provision of benefits and services to, or contain
incentives to use, certain providers or facilities may provide continuation
benefits that are substantially equivalent to the benefits of the existing
group policy. The commissioner shall make a determination as to the substantial
equivalency of benefits, and in doing so, shall take into consideration the
differences between managed and nonmanaged plans, including provider system
arrangements, service availability, benefit levels, and administrative
complexity.
c. For the purposes of
this section, "a basis for conversion of coverage" means a policy provision
that an individual whose coverage under the group policy would otherwise
terminate or has been terminated for any reason, including discontinuance of
the group policy in its entirety or with respect to an insurance class, and who
has been continuously insured under the group policy (and any group policy
which it replaced), for at least six months immediately prior to termination,
shall be entitled to the issuance of a converted policy by the insurer under
whose group policy he or she is covered, without evidence of
insurability.
d. For the purposes
of this section, "converted policy" means an individual policy of long-term
care insurance providing benefits identical to or benefits determined by the
commissioner to be substantially equivalent to or in excess of those provided
under the group policy from which conversion is made. Where the group policy
from which conversion is made restricts the provision of benefits and services
to, or contains incentives to use, certain providers or facilities the
commissioner, in making a determination as to the substantial equivalency of
benefits, shall take into consideration the differences between managed and
nonmanaged plans, including, but not limited to, provider system arrangements,
service availability, benefit levels, and administrative complexity.
e. Written application for the converted
policy must be made and the first premium due, if any, must be paid as directed
by the insurer not later than thirty-one days after termination of coverage
under the group policy. The converted policy must be issued effective on the
day following the termination of coverage under the group policy, and must be
renewable annually.
f. Unless the
group policy from which conversion is made replaced previous group coverage,
the premium for the converted policy must be calculated on the basis of the
insured's age at inception of coverage under the group policy from which the
conversion is made. Where the group policy from which conversion is made
replaced previous group coverage, the premium for the converted policy must be
calculated on the basis of the insured's age at inception of coverage under the
group policy replaced.
g.
Continuation of coverage or issuance of a converted policy shall be mandatory,
except where:
(1) Termination of group
coverage resulted from an individual's failure to make any required payment of
premium or contribution when due; or
(2) The terminating coverage is replaced not
later than thirty-one days after termination by group coverage effective on the
day following the termination of coverage:
(a) Providing benefits identical to or
benefits determined by the commissioner to be substantially equivalent to or in
excess of those provided by the terminating coverage; and
(b) The premium for which is calculated in a
manner consistent with the requirements of subdivision f.
h. Notwithstanding any other
provision of this section, a converted policy issued to an individual who at
the time of conversion is covered by another long-term care insurance policy
which provides benefits on the basis of incurred expenses, may contain a
provision which results in a reduction of benefits payable if the benefits
provided under the additional coverage, together with the full benefits
provided by the converted policy, would result in payment of more than one
hundred percent of incurred expenses. Such provision shall only be included in
the converted policy if the converted policy also provides for a premium
decrease or refund which reflects the reduction in benefits payable.
i. The converted policy may provide that the
benefits payable under the converted policy, together with the benefits payable
under the group policy from which conversion is made, shall not exceed those
that would have been payable had the individual's coverage under the group
policy remained in force and effect.
j. Notwithstanding any other provision of
this section, any insured individual whose eligibility for group long-term care
coverage is based upon his or her relationship to another person shall be
entitled to continuation of coverage under the group policy upon termination of
the qualifying relationship by death or dissolution of marriage.
5. Discontinuance and replacement. If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to individuals by the insurer and premiums charged to persons under the new group policy:
a. May not result in any exclusion for
preexisting conditions that would have been covered under the group policy
being replaced; and
b. May not
vary or otherwise depend on the individual's health or disability status, claim
experience, or use of long-term care services.
6. The premiums charged to an insured for long-term care insurance may not increase due to either:
a. The increasing age of the insured at ages
beyond sixty-five; or
b. The
duration the insured has been covered under the policy.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-45
Disclaimer: These regulations may not be the most recent version. North Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
