CurrentNorth Dakota Insurance DepartmentPolicy 86-3

Nursing Home Coverage

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Clarifies North Dakota requirements for nursing home benefits, skilled-care claims, and Medicare-approval payment conditions across applicable policies and contracts issued in North Dakota.

Policy Summary

PayerNorth Dakota Insurance Department

PolicyNursing Home Coverage

Policy CodePolicy 86-3

Change TypeClarification and new claims-handling requirement

Effective DateNot specified

Next Review DateNot specified

Key ActionDo not condition payment for nursing home services on Medicare approval of the service or facility.

SourceLink

POLICY UPDATE CHANGES

The Department interprets the applicable nursing home coverage provision to include standalone nursing home policies, specific nursing home coverage riders, Medicare supplement policies, major medical policies, and hospital indemnity policies that provide nursing home benefits.

For nursing home coverage claims, skilled care is treated as care other than custodial care when the confinement was physician-ordered.

Policy provisions that condition payment on Medicare approval of the service or facility are ineffective under North Dakota requirements.

2Code sections addressed

5Coverage types included

NDState of application

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CurrentNorth Dakota Insurance DepartmentPolicy 86-3

Nursing Home Coverage

Customize your policy alerts

Sign up for North Dakota Insurance Department Policy 86-3 alerts

Get alerted when Policy 86-3 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clarifies North Dakota requirements for nursing home benefits, skilled-care claims, and Medicare-approval payment conditions across applicable policies and contracts issued in North Dakota.

Policy Summary

PayerNorth Dakota Insurance Department

PolicyNursing Home Coverage

Policy CodePolicy 86-3

Change TypeClarification and new claims-handling requirement

Effective DateNot specified

Next Review DateNot specified

Key ActionDo not condition payment for nursing home services on Medicare approval of the service or facility.

SourceLink

POLICY UPDATE CHANGES

For nursing home coverage claims, skilled care is treated as care other than custodial care when the confinement was physician-ordered.

Policy provisions that condition payment on Medicare approval of the service or facility are ineffective under North Dakota requirements.

2Code sections addressed

5Coverage types included

NDState of application

Nursing Home Coverage and Claims Processing

Nursing home coverage and claims processing

For contracts issued in North Dakota, apply the following nursing home coverage and claims-handling requirements:

ALL of the following

ONE of
- Nursing home policy.
- Specific nursing home coverage rider.
- Medicare supplement policy providing nursing home coverage.
- Major medical policy providing nursing home benefits.
- Hospital indemnity policy providing nursing home benefits.
The covered person was confined to a nursing home under a physician's order for care other than custodial care.
Care other than custodial care is treated as skilled care; the claim must not be refused solely because the care is not custodial.
Payment is not conditioned on Medicare approval of the service or facility.
Any policy provision conditioning payment on Medicare approval is ineffective and must be construed accordingly.
Claims are processed in conformance with the current provisions of the North Dakota Century Code.
Claim handling that refuses payment in these circumstances may be scrutinized as a possible unfair claims settlement practice.

Claims Processing Requirements

Billing Rule

Recognize Skilled Care Coverage

Process coverage claims for nursing home confinement when the confinement is physician ordered for care other than custodial care. Skilled care is defined as care other than custodial care and must not be treated as excluded solely because it is skilled care.

Denial Risk

Do Not Require Medicare Approval

Do not condition payment for nursing home services on Medicare approval of the service or the facility. Any policy provision imposing that condition is ineffective under North Dakota requirements.

Billing Rule

Care Classification

Skilled care

DefinitionCare ordered by a physician that is other than custodial care.

Statutory distinctionSkilled care is defined as care "other than custodial."

Claims relevanceRefusing to pay a claim for physician-ordered confinement for care other than custodial care may constitute an unfair claims settlement practice.

Custodial care

DefinitionCare that is not care other than custodial care.

Coverage distinctionThe bulletin uses the phrase "other than custodial care" to distinguish care that may qualify as skilled care.

Relationship to skilled care