11 NCAC 12 .1802             DEFINITIONS

The definitions contained in G.S. 58-50-56(a) are incorporated into this Section by reference and as used in this Section, the following terms have the meanings ascribed to them:

(1)           "Coinsurance" means the percentage of an allowed charge or expense, or usual and customary charge for a covered health care service that an enrollee must pay.

(2)           "Copayment" means a fixed dollar amount that an enrollee must pay each time a covered health care service is provided.

(3)           "Deductible" means a specified amount of covered health care services, expressed in dollars, that must be incurred by an enrollee before the insurer will assume any financial liability for all or part of covered health care services.

(4)           "Emergency health care services" means those services as defined and delivered in accordance with G.S. 58-3-190.

(5)           "Enrollee" means an individual who is covered by a PPO benefit plan.

(6)           "In-network covered services" means covered health care services that are received according to the rules of the health benefit plan from providers employed by, under contract with, or approved in advance by the insurer; and means emergency health care services regardless of the status or affiliation of the provider of such services.

(7)           "Out-of-network covered services" means non-emergency, medically necessary covered health care services that are not received according to the rules of the health benefit plan, including services from affiliated providers that are received without the approval of the insurer.

(8)           "Out-of-pocket expense" means a specified dollar amount of coinsurance incurred and payable by an enrollee for covered health care services in a specified period.  Out-of-pocket expense may or may not include deductible amounts, copayment amounts, charges in excess of the amount allowed by the insurer, amounts exceeding the maximum benefits, or any other disallowed or noncovered expenses under the rules of the health benefit plan.

(9)           "PPO benefit plan" has the same meaning as "preferred provider benefit plan" in G.S. 58-50-56(a)(3).


History Note:        Authority G.S. 58-2-40; 58-50-56;

Temporary Adoption Eff. January 1, 1998;

Eff. August 1, 1998.