BISMARCK, N.D. – Insurance Commissioner Jon Godfread announced today a market examination of Sanford Health Plan.
“One of our primary roles at the North Dakota Insurance Department is to ensure that those in the state with health insurance are receiving the benefits promised to them by their insurance company,” Godfread said. “One of the main focuses of this exam will be on mental health and addiction services. Other focus areas include claims processing and fraud reporting. The purpose of the exam is to make sure one of our larger health insurance companies is following our laws and upholding their promises to North Dakotans.”
Sanford Health Plan is domiciled in South Dakota, and this will be the first market conduct exam of Sanford Health Plan performed by the North Dakota Insurance Department. This exam is in accordance with a 2021 law passed by the North Dakota Legislature requiring market conduct exams every five years for health insurance companies that have more than 25 percent of the North Dakota market share. During the 2020 plan year, Sanford Health Plan covered 36.62 percent of lives in the North Dakota market.
The examination is scheduled to begin between April 1 and May 31. The examination will cover the company’s operations from Jan. 1, 2016 through Dec. 31, 2020. Areas of the examination will include, but are not limited to:
- Claims processing
- Mental and behavioral health and substance abuse claims, including Mental Health Parity and Addiction Equity Act compliance
- Comparative analyses for Non-Quantitative Treatment Limitations (NQTLs) and Quantitative Treatment Limitations (QTLs) associated with the Mental Health Parity and Addiction Equity Act (MHPAEA)
- Telehealth services coverage and claims
- Independent external review assignments and procedures
- Coordination of benefits with auto insurance
- Advertising and issuance of Medicare Supplement products
- Insurance fraud reporting
- Policy form filing
- Agent licensing, in conjunction with Underwriting
- Corporate governance, and governance of subsidiaries
- Pharmacy Benefit Management contracts
- Complaints
The examination is expected to take six to eight months to complete. The examination report becomes a public record fifteen days following adoption of the final report by the Insurance Commissioner.