Section .0100 ‑ Managed Care Definitions

Link to law: 11 - insurance/chapter 20 - managed care health benefit plans/11 ncac 20 .0101.html
Published: 2015

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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


(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

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


(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

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


(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.