§ 58-50-56. Insurers, preferred provider organizations, and preferred provider benefit plans.
§ 58‑50‑56. Insurers, preferred provider organizations, and preferred provider benefitplans.
(a) Definitions. Asused in this section:
(1) "Insurer"means an insurer or service corporation subject to this Chapter.
(2) "Preferredprovider" means a health care provider who has agreed to accept specialreimbursement or other terms for health care services from an insurer forhealth care services on a fee‑for‑service basis. A "preferredprovider" is not a health care provider participating in any prepaid healthservice or capitation arrangement implemented or administered by the Departmentof Health and Human Services or its representatives.
(3) "Preferredprovider benefit plan" means a health benefit plan offered by an insurerin which covered services are available from health care providers who areunder a contract with the insurer in accordance with this section and in whichenrollees are given incentives through differentials in deductibles,coinsurance, or copayments to obtain covered health care services fromcontracted health care providers.
(4) "Preferredprovider organization" or "PPO" means an insurer holdingcontracts with preferred providers to be used by or offered to insurersoffering preferred provider benefit plans.
(b) Insurers may enterinto preferred provider contracts or enter into other cost containmentarrangements approved by the Commissioner to reduce the costs of providinghealth care services. These contracts or arrangements may be entered into withlicensed health care providers of all kinds without regard to specialty ofservices or limitation to a specific type of practice. A preferred providercontract or other cost containment arrangement that is not disapproved by theCommissioner within 90 days of its filing by the insurer shall be deemed to beapproved.
(c) At the initialoffering of a preferred provider plan to the public, health care providers maysubmit proposals for participation in accordance with the terms of thepreferred provider plan within 30 days after that offering. After that timeperiod, any health care provider may submit a proposal, and the insureroffering the preferred provider benefit plan shall consider all pendingapplications for participation and give reasons for any rejections or failureto act on an application on at least an annual basis. Any health care providerseeking to participate in the preferred provider benefit plan, whether upon theinitial offering or subsequently, may be permitted to do so in the discretionof the insurer offering the preferred provider benefit plan. G.S. 58‑50‑30applies to preferred provider benefit plans.
(d) Any provision of acontract between an insurer offering a preferred provider benefit plan and ahealth care provider that restricts the provider's right to enter into preferredprovider contracts with other persons is prohibited, is void ab initio, and isnot enforceable. The existence of that restriction does not invalidate anyother provision of the contract.
(e) Except wherespecifically prohibited either by this section or by rules adopted by theCommissioner, the contractual terms and conditions for special reimbursementsshall be those that the parties find mutually agreeable.
(f) Every insureroffering a preferred provider benefit plan and contracting with a PPO shallrequire by contract that the PPO shall provide all of the preferred providerswith whom it holds contracts information about the insurer and the insurer'spreferred provider benefit plans. This information shall include for eachinsurer and preferred provider benefit plan the benefit designs and incentivesthat are used to encourage insureds to use preferred providers.
(g) The Commissionermay adopt rules applicable to insurers offering preferred provider benefitplans under this section. These rules shall provide for:
(1) Accessibility ofpreferred provider services to individuals within the insured group.
(2) The adequacy of thenumber and locations of health care providers.
(3) The availability ofservices at reasonable times.
(4) Financial solvency.
(h) Each insureroffering a preferred provider benefit plan shall provide the Commissioner withsummary data about the financial reimbursements offered to health careproviders. All such insurers shall disclose annually the following information:
(1) The name by whichthe preferred provider benefit plan is known and its business address.
(2) The name, address,and nature of any PPO or other separate organization that administers thepreferred provider benefit plan for the insurer.
(3) The terms of theagreements entered into by the insurer with preferred providers.
(4) Any otherinformation necessary to determine compliance with this section, rules adoptedunder this section, or other requirements applicable to preferred providerbenefit plans.
(i) A person enrolledin a preferred provider benefit plan may obtain covered health care servicesfrom a provider who does not participate in the plan. In accordance with rulesadopted by the Commissioner and subject to G.S. 58‑3‑200(d), thepreferred provider benefit plan may limit coverage for health care servicesobtained from a nonparticipating provider. The Commissioner shall adopt ruleson product limitations, including payment differentials for services renderedby nonparticipating providers. These rules shall be similar in substance torules governing HMO point‑of‑service products.
(j) A list of thecurrent participating providers in the geographic area in which a substantialportion of health care services will be available shall be provided to insuredsand contracting parties. The list shall include participating physicianassistants and their supervising physician.
(k) Publications oradvertisements of preferred provider benefit plans or organizations shall notrefer to the quality or efficiency of the services of nonparticipatingproviders. (1997‑443,s. 11A.122; 1997‑519, s. 3.1; 1998‑211, s. 2; 1999‑210, s. 3;2001‑297, s. 3; 2001‑334, s. 2.1.)