11 NCAC 12 .1804             DISCLOSURE REQUIREMENTS

(a)  If an enrollee utilizes out-of-network covered services, the explanation of benefits shall contain an explanation of coverage for out-of-network covered services that allows each enrollee to determine his or her obligations with respect to those services.

(b)  Marketing materials, evidences of coverage, enrollee handbooks, and other materials given to enrollees by an insurer that offers a PPO benefit plan shall contain a clear and comprehensive explanation of the PPO benefit plan. The explanation shall include the following information:

(1)           the method of reimbursement, including whether actual charges or usual and customary charges are used in making all benefit calculations;

(2)           applicable coinsurance, 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-network basis, including whether or not annual physicals and health screenings are available out-of-network; and

(5)           instructions for submittal of claims for out-of-network covered services.


History Note:        Authority G.S. 58-2-40; 58-3-191(b); 58-50-56;

Temporary Adoption Eff. January 1, 1998;

Eff. August 1, 1998;

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