§ 58-3-200. Miscellaneous insurance and managed care coverage and network provisions. - North Carolina Statutes

§ 58‑3‑200. Miscellaneous insurance and managed care coverage and network provisions.

(a)        Definitions. – Asused in this section:

(1)        "Health benefitplan" means any of the following if written by an insurer: an accident andhealth insurance policy or certificate; a nonprofit hospital or medical servicecorporation contract; a health maintenance organization subscriber contract; ora plan provided by a multiple employer welfare arrangement. "Healthbenefit plan" does not mean any plan implemented or administered throughthe Department of Health and Human Services or its representatives."Health benefit plan" also does not mean any of the following kindsof insurance:

a.         Accident.

b.         Credit.

c.         Disability income.

d.         Long‑term ornursing home care.

e.         Medicare supplement.

f.          Specified disease.

g.         Dental or vision.

h.         Coverage issued as asupplement to liability insurance.

i.          Workers'compensation.

j.          Medical paymentsunder automobile or homeowners insurance.

k.         Hospital income orindemnity.

l.          Insurance under whichbenefits are payable with or without regard to fault and that is statutorilyrequired to be contained in any liability policy or equivalent self‑insurance.

(2)        "Insurer"means an entity that writes a health benefit plan and that is an insurancecompany subject to this Chapter, a service corporation under Article 65 of thisChapter, a health maintenance organization under Article 67 of this Chapter, ora multiple employer welfare arrangement under Article 49 of this Chapter.

(b)        Medical Necessity.– An insurer that limits its health benefit plan coverage to medicallynecessary services and supplies shall define "medically necessary servicesor supplies" in its health benefit plan as those covered services orsupplies that are:

(1)        Provided for thediagnosis, treatment, cure, or relief of a health condition, illness, injury,or disease; and, except as allowed under G.S. 58‑3‑255, not forexperimental, investigational, or cosmetic purposes.

(2)        Necessary for andappropriate to the diagnosis, treatment, cure, or relief of a health condition,illness, injury, disease, or its symptoms.

(3)        Within generallyaccepted standards of medical care in the community.

(4)        Not solely for theconvenience of the insured, the insured's family, or the provider.

For medically necessaryservices, nothing in this subsection precludes an insurer from comparing thecost‑effectiveness of alternative services or supplies when determiningwhich of the services or supplies will be covered.

(c)        CoverageDeterminations. – If an insurer or its authorized representative determinesthat services, supplies, or other items are covered under its health benefitplan, including any determination under G.S. 58‑50‑61, the insurershall not subsequently retract its determination after the services, supplies,or other items have been provided, or reduce payments for a service, supply, orother item furnished in reliance on such a determination, unless thedetermination was based on a material misrepresentation about the insured'shealth condition that was knowingly made by the insured or the provider of theservice, supply, or other item.

(d)        Services OutsideProvider Networks. – No insurer shall penalize an insured or subject an insuredto the out‑of‑network benefit levels offered under the insured'sapproved health benefit plan, including an insured receiving an extended orstanding referral under G.S. 58‑3‑223, unless contracting healthcare providers able to meet health needs of the insured are reasonablyavailable to the insured without unreasonable delay.

(e)        NondiscriminationAgainst High‑Risk Populations. – No insurer shall establish providerselection or contract renewal standards or procedures that are designed toavoid or otherwise have the effect of avoiding enrolling high‑riskpopulations by excluding providers because they are located in geographic areasthat contain high‑risk populations or because they treat or specialize intreating populations that present a risk of higher‑than‑averageclaims or health care services utilization. This subsection does not prohibitan insurer from declining to select a provider or from not renewing a contractwith a provider who fails to meet the insurer's selection criteria.

(f)         Continuing CareRetirement Community Residents. – As used in this subsection, "Medicarebenefits" means medical and health products, benefits, and services usedin accordance with Title XVIII of the Social Security Act. If an insured withcoverage for Medicare benefits or similar benefits under a plan for retiredfederal government employees is a resident of a continuing care retirementcommunity regulated under Article 64 of this Chapter, and the insured's primarycare physician determines that it is medically necessary for the insured to bereferred to a skilled nursing facility upon discharge from an acute carefacility, the insurer shall not require that the insured relocate to a skillednursing facility outside the continuing care retirement community if thecontinuing care retirement community:

(1)        Is a Medicare‑certifiedskilled nursing facility.

(2)        Agrees to bereimbursed at the insurer's contract rate negotiated with similar providers forthe same services and supplies.

(3)        Agrees not to billthe insured for fees over and above the insurer's contract rate.

(4)        Meets all guidelinesestablished by the insurer related to quality of care, including:

a.         Quality assuranceprograms that promote continuous quality improvement.

b.         Standards forperformance measurement for measuring and reporting the quality of health careservices provided to insureds.

c.         Utilization review,including compliance with utilization management procedures.

d.         Confidentiality ofmedical information.

e.         Insured grievancesand appeals from adverse treatment decisions.

f.          Nondiscrimination.

(5)        Agrees to comply withthe insurer's procedures for referral authorization, risk assumption, use ofinsurer services, and other criteria applicable to providers under contract forthe same services and supplies.

A continuing care retirementcommunity that satisfies subdivisions (1) through (5) of this subsection shallnot be obligated to accept, as a skilled nursing facility, any patient otherthan a resident of the continuing care retirement community, and neither theinsurer nor the retirement community shall be allowed to list or otherwiseadvertise the skilled nursing facility as a participating network provider forMedicare benefits for anyone other than residents of the continuing careretirement community. (1997‑443, s. 11A.122; 1997‑519, s. 2.1; 2001‑446,ss. 5(b), 1.2A.)