North Carolina Administrative Code
Title 11 - INSURANCE
Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS
Section .0100 - MANAGED CARE DEFINITIONS
Section 20 .0101 - SCOPE AND DEFINITIONS
Universal Citation: 11 NC Admin Code 20 .0101
Current through Register Vol. 39, No. 6, September 16, 2024
(a) Scope.
(1) Sections .0200, .0300, and .0400 of this
Chapter shall apply to HMOs, licensed insurers offering PPO benefit plans, and
any other entity that is a network plan carrier as defined in this
Rule.
(2) Sections .0500 and .0600
of this Chapter shall apply only to HMOs.
(3) Nothing in this Chapter shall apply to
service corporations offering benefit plans pursuant to
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 pursuant to Chapter
90 of the General Statutes; 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
insured 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, pursuant to
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;
or
(ii) enrollees are given
incentives via benefit differentials to limit the receipt of covered services
to those furnished by participating providers; and
(B) health care services are provided by
participating providers who are paid on negotiated or discounted
fee-for-service bases or have agreed to accept special reimbursement or other
terms for health care services under a contract with the hospital or medical
service corporation or network plan carrier.
(9) "Provider" means a health care
provider.
(10) "Quality management"
means a program of reviews, studies, evaluations, and other activities used to
monitor and enhance the quality of health care and services provided to
members.
(11) "Service area" means
the geographic area in North Carolina as described by the HMO pursuant to
G.S.
58-67-10(c)(11) where an HMO
enrolls persons who either work in the service area, reside in the service
area, or work and reside in the service area, as approved by the Commissioner
pursuant to
G.S.
58-67-20.
(12) "Service corporation" means a medical or
hospital service corporation operating pursuant to Article 65 of Chapter 58 of
the General Statutes.
(13) "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.
(14) "Utilization
review" has the same meaning as in
G.S.
58-50-61(17).
Authority
G.S.
58-2-40(1);
58-50-61;
58-65-1;
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;
Temporary
Amendment Eff. September 24, 2018;
Amended Eff. February 1,
2019.
Disclaimer: These regulations may not be the most recent version. North Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
