CHAPTER 20 ‑ MANAGED CARE HEALTH BENEFIT PLANS
SECTION .0100 ‑ MANAGED CARE DEFINITIONS
11 NCAC 20 .0101 SCOPE AND DEFINITIONS
(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
(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
(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
(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
(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
(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
(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
(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.