Key Takeaways
- North Dakota uses the federal HealthCare.gov marketplace for ACA coverage
- The North Dakota Insurance Department regulates health insurance in the state
- Pre-existing condition exclusions are prohibited under ACA-compliant plans
- North Dakota has mental health parity requirements for group health plans
- Small group is defined as 1-50 employees in North Dakota
North Dakota Health Insurance Policy Requirements
North Dakota has health insurance regulations that work alongside federal requirements under Title 26.1 of the North Dakota Century Code.
Regulatory Structure
North Dakota health coverage is regulated by the North Dakota Insurance Department:
| Agency | Role |
|---|---|
| North Dakota Insurance Department | Regulates all health insurance, reviews rates and forms |
| Federal CMS | Operates the HealthCare.gov marketplace for North Dakota |
Health Insurance Marketplace
North Dakota uses the federal HealthCare.gov marketplace:
- Federally facilitated marketplace
- Provides access to qualified health plans (QHPs)
- Premium tax credits available for eligible residents
- Open enrollment and special enrollment periods apply
Metal Tier Plans
| Tier | Actuarial Value | Cost Sharing |
|---|---|---|
| Bronze | 60% | Higher out-of-pocket costs |
| Silver | 70% | Moderate cost sharing |
| Gold | 80% | Lower out-of-pocket costs |
| Platinum | 90% | Lowest out-of-pocket costs |
Small Group Definition
North Dakota defines small employer groups as:
- 1 to 50 employees (can include sole proprietors)
- Must include at least one eligible employee
- Self-employed individuals may qualify
Pre-Existing Condition Protections
North Dakota prohibits pre-existing condition exclusions in ACA-compliant plans:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited by federal law |
Guaranteed Issue and Renewal
North Dakota requires:
Guaranteed Issue
- Insurers must accept all applicants for ACA-compliant plans
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with proper notice)
Mental Health Parity
North Dakota has mental health parity requirements:
State Parity Law Requirements
North Dakota law requires group health plans to provide:
- Mental health coverage comparable to medical/surgical coverage
- Substance use disorder treatment coverage
- No financial requirements more restrictive than medical
Federal MHPAEA Compliance
North Dakota requires insurers to comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA):
- Financial requirements must be comparable
- Treatment limitations must be comparable
- Prior authorization requirements must be comparable
- Out-of-pocket costs must be comparable
Exam Tip: North Dakota requires mental health benefits to be provided at parity with medical/surgical benefits for group health plans.
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Claims Handling Requirements
North Dakota has specific claims handling timeframes for health insurance:
| Requirement | Timeframe |
|---|---|
| Acknowledgment | Reasonable promptness |
| Clean Claims | 30 days typical |
| Denial Notice | Must provide written explanation |
External Review
North Dakota provides external review rights:
- Consumers can appeal denied claims
- Independent external review available
- Binding decision on insurer
Which marketplace does North Dakota use for individual health insurance under the ACA?
How does North Dakota define a small employer for health insurance purposes?
What does North Dakota law require for mental health coverage in group health plans?
Can North Dakota health insurers deny coverage based on pre-existing conditions?
What rights do North Dakota consumers have when a health insurance claim is denied?