11 NCAC 20 .0101             SCOPE AND DEFINITIONS

(a)  Scope.

(1)           Sections .0200, .0300, and .0400 of this Chapter apply to HMOs, licensed insurers offering PPO benefit plans, and any other entity that falls under the definition of "network plan carrier".

(2)           Sections .0500 and .0600 of this Chapter apply only to HMOs.

(3)           Nothing in this Chapter applies to service corporations offering benefit plans under G.S. 58-65-25 or G.S. 58-65-30 that do not have any differences in copayments, coinsurance, or deductibles based on the use of network versus non-network providers.

(b)  Definitions.  As used in this Chapter:

(1)           "Carrier" means a network plan carrier.

(2)           "Health care provider" means any person who is licensed, registered, or certified under Chapter 90 of the General Statutes; or a health care facility as defined in G.S. 131E-176(9b); or a pharmacy.

(3)           "Health maintenance organization" or "HMO" has the same meaning as in G.S. 58-67-5(f).

(4)           "Intermediary" or "intermediary organization" means any entity that employs or contracts with health care providers for the provision of health care services, and that also contracts with a network plan carrier or its intermediary.

(5)           "Member" means an individual who is covered by a network plan carrier.

(6)           "Network plan carrier" means an insurer, health maintenance organization, or any other entity acting as an insurer, as defined in G.S. 58-1-5(3), that provides reimbursement or provides or arranges to provide health care services; and uses increased copayments, deductibles, or other benefit reductions for services rendered by non-network providers to encourage members to use network providers.

(7)           "Network provider" means any health care provider participating in a network utilized by a network plan carrier.

(8)           "PPO benefit plan" means a benefit plan that is offered by a hospital or medical service corporation or network plan carrier, under G.S. 58-50-56, in which plan:

(A)          either or both of the following features are present:

(i)            utilization review or quality management programs are used to manage the provision of covered services;

(ii)           enrollees are given incentives via benefit differentials to limit the receipt of covered services to those furnished by participating providers;

(B)          health care services are provided by participating providers who are paid on negotiated or discounted fee-for-service bases; and

(C)          there is no transfer of insurance risk to health care providers through capitated payment arrangements, fee withholds, bonuses, or other risk-sharing arrangements.

(9)           "Preferred provider" has the same meaning as in G.S 58-50-56 and 58-65-1.

(10)         "Provider" means a health care provider.

(11)         "Quality management" means a program of reviews, studies, evaluations, and other activities used to monitor and enhance quality of health care and services provided to members.

(12)         "Service area" means the geographic area in North Carolina as described by the HMO pursuant to G.S. 58-67-10(c)(11) in which an HMO enrolls persons who either work in the service area, reside in the service area, or work and reside in the service and as approved by the Commissioner pursuant to G.S. 58-67-20.

(13)         "Service corporation" means a medical or hospital service corporation operating under Article 65 of Chapter 58 of the General Statutes.

(14)         "Single service HMO" means an HMO that undertakes to provide or arrange for the delivery of a single type or single group of health care services to a defined population on a prepaid or capitated basis, except for a member's responsibility for non‑covered services, coinsurance, copayments, or deductibles.

(15)         "Utilization review" means those methodologies used to improve the quality and maximize the efficiency of the health care delivery system through review of particular instances of care, including, whenever performed, precertification, concurrent review, discharge planning, and retrospective review.


History Note:        Authority G.S. 58-2-40(1); 58-50-50; 58-50-55; 58-65-1; 58-65-140; 58-67-150;

Eff. October 1, 1996;

Amended Eff. July 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 16, 2014.