Wednesday, March 6, 2024 - 08:30am Categories:

BISMARCK, N.D. – The North Dakota Insurance Department has completed and published a market conduct examination report of Sanford Health Plan (SHP), finding non-compliance with state and federal laws within the target areas of the examination. 

Announced in 2022, the examination, which took place from April 2022 to October 2023, reviewed the actions of Sanford Health Plan from 2016 to 2020 to ensure various SHP policies and procedures followed applicable laws. 

“The essential function of the North Dakota Insurance Department is to ensure that consumers are treated fairly and respectfully by their insurance company,” said Insurance Commissioner Jon Godfread. “A market conduct examination is a way of looking at specific cases to see how consumers have been treated and if the law was followed.”

The examination found non-compliance in the following areas of SHP:

  • 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 review  procedures
  • Coordination of benefits with auto insurance
  • Medicare Supplement products
  • Insurance fraud reporting
  • Pharmacy Benefit Management contracts

SHP agreed with most of the examination findings and will seek to correct the identified errors. While the violations do not comply with state and federal insurance laws, the findings did not adversely affect SHP policyholders.

The examination is required under the North Dakota Century Code, which requires regular market conduct examinations for health insurance companies with at least 25 percent of the market share. SHP is one of two health insurance companies that currently meet this criterion. A market conduct examination of Blue Cross Blue Shield of North Dakota was completed in 2019.

A copy of the full SHP examination report is available here.