11 NCAC 12 .1403             GENERAL REQUIREMENTS

No HMO shall provide any point‑of‑service product unless it complies with the following requirements and with G.S. 58‑67‑10(d)(1):

(1)           Where the covered benefits of a point‑of‑service product include coinsurance, the difference in coinsurance rates between in‑plan covered services and out‑of‑plan covered services shall not exceed 30 percentage points.

(2)           If the schedule of benefits for a point‑of‑service product imposes a deductible for in‑plan covered services, the amount of any annual deductible per enrollee or per family for out‑of‑plan covered services may not exceed five times the amount of the corresponding annual deductible applied to in‑plan covered services.

(3)           If the schedule of benefits for a point‑of‑service product does not include an annual deductible for in‑plan covered services, the annual deductibles for out‑of‑plan covered services shall not exceed two thousand dollars ($2000) per enrollee and the family deductible may not exceed three times the amount of the corresponding annual deductible for the enrollee.

(4)           The portion of any charge for out‑of‑plan covered services to be applied to an annual deductible may be based on the amount the HMO would have recognized as an allowable charge had the service been rendered as an in‑plan covered service.

(5)           If there is a lifetime maximum benefit for in‑plan covered services, the amount of any annual and lifetime maximum limits for out‑of‑plan covered services shall not be less than one‑half of the amount of any annual and lifetime maximum limits for in‑plan covered services.

(6)           If a point‑of‑service product includes copayments for both in‑plan covered services and out‑of‑plan covered services, the amount of the copayment for an out‑of‑plan covered service shall not exceed the copayment for an in‑plan covered service by more than fifty dollars ($50.00) or 100%, whichever is greater.

(7)           A point‑of‑service product shall make all mandated benefits available in the form of in‑plan covered services.

(8)           Point‑of‑service products shall provide incentives, including financial incentives, for enrollees to use in‑plan covered services.

(9)           Any offered out‑of‑plan covered service must be available on an in‑plan covered service basis.

(10)         A HMO offering a point‑of‑service product may exclude coverage for preventive health care services provided on an out‑of‑plan basis.

(11)         Point‑of‑service products shall give enrollees the option to choose in‑plan covered services or out‑of‑plan covered services each time such covered services are authorized, obtained, or rendered.

History Note:        Authority G.S. 58‑2‑40; 58‑67‑35; 58‑67‑150;

Eff. January 1, 1994;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.