11 NCAC 12 .1404             DISCLOSURE REQUIREMENTS

(a)  Every explanation of benefits shall contain an explanation of coverage for out‑of‑plan covered services that allows each enrollee to determine his or her obligations with respect to such services.

(b)  Marketing materials, evidences of coverage, enrollee handbooks, and other materials given to enrollees by an HMO that offers a point‑of‑service product shall contain an explanation of the point‑of‑service product. The explanation shall include:

(1)           the method of reimbursement;

(2)           applicable copayment and deductible amounts;

(3)           any other uncovered costs or charges;

(4)           the covered health care services that an enrollee may receive on an out‑of‑plan basis; and

(5)           instructions for submittal of claims for out‑of‑plan covered services.


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.