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Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Some of the state provisions are as follows:
From Chapter 26.1-04:
- Refusing coverage solely because of blindness or partial blindness is considered unfair discrimination. Persons who are blind or partially blind must be subject to the same standards as are sighted persons.
From Chapter 26.1-36:
- Optional prescription drugs and medicines.
- Optional services rendered and care administered by licensed chiropractors.
- If coverage for drugs is provided off-label uses of drugs must be covered.
- Newly born children are covered from the moment of birth or date of physical placement of adopted children, includes congenital defects and birth abnormalities.
- Alcoholism, drug addiction, or other related illnesses are to be treated as other illnesses. The plan must provide for inpatient or outpatient treatment. The plan must not establish a deductible or a copayment for the first five visits in any calendar year, and may not establish a copayment greater than twenty percent for the remaining visits. The deductible limitation of this subdivision does not apply to a high-deductible health plan used to establish a health savings account pursuant to and as defined in section 223 of the Internal Revenue Code [26 U.S.C. 223].
- Mental disorders and other related illnesses are to be treated as other illnesses. The plan must not establish a deductible or a copayment for the first five hours in any calendar year, and may not establish a copayment greater than twenty percent for the remaining hours. The deductible limitation of this subdivision does not apply to a high-deductible health plan used to establish a health savings account pursuant to and as defined in section 223 of the Internal Revenue Code [26 U.S.C. 223].
- Coverage for surgical and nonsurgical treatment of temporomandibular joint disorder and craniomandibular disorder.
- The standard health benefit plan must provide coverage for prenatal care visits for a covered person and recommended immunizations and well child visits for a covered person from birth to the age of five years.
- Direct reimbursement is required for services of advanced registered nurse practitioners.
- Coverage for annual prostate-specific antigen tests for asymptomatic males 50 years old and older, and black makes and those with family history of prostate cancer 40 years old and older.
- If the plan covers prescriptions, it must cover medical foods and low-protein modified food products medically necessary for the therapeutic treatment of an inherited metabolic disease.
- Coverage for anesthesia and hospitalization for dental care for children who are under age nine, severely disabled, or who have medical conditions and require hospitalization or general anesthesia for dental care.
- If the plan covers prehospital emergency medical services, it must cover services in the case of an emergency medical condition.
- In case of accident or sickness, plans cannot deny participants the right to consult or employ any doctor they choose, or to enter any hospital or sanitarium.
- Freedom of choice for pharmacy services.
- If an existing or prospective employer group desires a dual choice option between a nonprofit health service corporation or an insurance company and a health maintenance organization. There must be at least 15 employees in the group.
- The plan must cover health services for injury or illness resulting from any loss sustained or contracted in the consequence of the insured's being intoxicated or under the influence of any narcotic.
From Bulletin 2018-1:
Policies must cover Autism Spectrum Disorder, effective for grandfathered plans 10/1/18, and for non-grandfathered plans 1/1/19. Plans may not exclude applied behavior analysis therapy to treat children with autism spectrum disorder.
State
Contact
North Dakota Insurance Department
Regulations
North Dakota Century Code, Ch. 26.1-04 Prohibited Practices in Insurance Business (discrimination)
North Dakota Century Code, Ch. 26.1-36 Accident and Health Insurance
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)