Section 45-06-07-07 - Other requirements1.Description of providers.a. A health maintenance organization shall provide its subscribers with a list of the names and locations of all of its providers no later than the time of enrollment or the time the group or individual contract and evidence of coverage are issued and upon reenrollment. If a provider is no longer affiliated with a health maintenance organization, the health maintenance organization shall provide notice of such change to its affected subscribers within thirty days. Subject to the approval of the commissioner, a health maintenance organization may provide its subscribers with a list of providers or provider groups for a segment of the service area. However, a list of all providers must be made available to subscribers upon request. b. Any list of providers must contain a notice regarding the availability of the listed primary care physicians. Such notice must be in not less than twelve-point type and be placed in a prominent place on the list of providers. The notice must contain the following or similar language: Enrolling in [name of health maintenance organization] does not guarantee services by a particular provider on this list. If you wish to receive care from specific providers listed, you should contact those providers to be sure that they are accepting additional patients for [name of health maintenance organization].
2.Description of the services area. A health maintenance organization shall provide its subscribers with a description of its service area no later than the time of enrollment or the time the group or individual contract and evidence of coverage is issued and upon request thereafter. If the description of the service area is changed, the health maintenance organization shall provide at such time a new description of the service area to its subscribers. 3.Copayments and deductibles. A health maintenance organization may require copayments or deductibles of enrollees as a condition for the receipt of specific health care services. Copayments for basic health care services must be shown in the group or individual contract and evidence of coverage as a specified dollar amount. Copayments and deductibles must be the only allowable charge, other than premiums, assessed to subscribers for basic, supplemental, and nonbasic health care services. 4.Grievance procedure.a. A grievance procedure must be established and maintained by a health maintenance organization to provide reasonable procedures for the prompt and effective resolution of written grievances. b. A health maintenance organization shall provide grievance forms to be given to enrollees who wish to register written grievances. Such forms must include the address and telephone number to which grievances must be directed and must also specify any required time limits imposed by the health maintenance organization. c. The grievance procedure must provide for written acknowledgment of grievances and grievances to be resolved or to have a final determination of the grievance by the health maintenance organization within a reasonable period of time, but not more than ninety days from the date the grievance is received. This period may be extended in the event of a delay in obtaining the documents or records necessary for the resolution of the grievance, or by the mutual written agreement of the health maintenance organization and the enrollee. d. Prior to the resolution of a grievance filed by a subscriber or enrollee, coverage may not be terminated for any reason which is the subject of the written grievance, except if the health maintenance organization has, in good faith, made a reasonable effort to resolve the written grievance through its grievance procedure and coverage is being terminated as provided for in subsection 8 of section 45-06-07-04. e. If enrollee's grievances may be resolved through a specified arbitration agreement, the enrollee must be advised in writing of the enrollee's rights and duties under the agreement at the time the grievance is registered. Any such agreement must be accompanied by a statement setting forth in writing the terms and conditions of binding arbitration. Any health maintenance organization that makes such binding arbitration a condition of enrollment must fully disclose this requirement to its enrollees in the group or individual contract and evidence of coverage. N.D. Admin Code 45-06-07-07
General Authority: NDCC 26.1-18.1
Law Implemented: NDCC 26.1-18.1