North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1800 - PPO BENEFIT PLAN PRODUCT LIMITATIONS › Section 12 .1803 - GENERAL REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
No insurer shall provide any PPO benefit plan unless it
				  complies with the following:
(1) Where
				the covered benefits of a PPO benefit plan include coinsurance, the difference
				in coinsurance rates between in-network covered services and out-of-network
				covered services shall not exceed 30 percentage points.
(2) If the schedule of benefits for a PPO
				benefit plan imposes a deductible for in-network covered services, the amount
				of any separate annual deductible per enrollee or per family for out-of-network
				covered services may not exceed two times the amount of the annual per enrollee
				or per family deductible applied to in-network covered services.
(3) If the schedule of benefits for a PPO
				benefit plan does not include an annual deductible for in-network covered
				services, the annual deductibles for out-of-network covered services shall not
				exceed two hundred and fifty dollars ($250.00) per enrollee and the family
				deductible may not exceed seven hundred and fifty dollars ($750.00).
(4) The portion of any charge for
				out-of-network covered services to be applied to an annual deductible may be
				based on actual charges or the insurer's usual and customary charges.
(5) If there are benefit maximums for
				in-network covered services, the amount of any annual and lifetime maximum
				limits for out-of-network covered services shall not be less than one-half of
				the amount of any annual and lifetime maximum limits for in-network covered
				services.
(6) If a PPO benefit plan
				includes copayments for both in-network covered services and out-of-network
				covered services, the amount of the copayment for an out-of-network covered
				service shall not exceed the copayment for an in-network covered service by
				more than twenty dollars ($20.00) or 100%, whichever is greater.
(7) If the schedule of benefits for a PPO
				benefit plan limits the annual out-of-pocket expenses of enrollees to a maximum
				amount for in-network covered services, the amount of any separate annual
				out-of-pocket maximum for out-of-network covered services may not exceed two
				times the maximum amount for in-network covered services.
(8) If the schedule of benefits for a PPO
				benefit plan does not include an annual maximum limit on out-of-pocket expenses
				for in-network covered services, the maximum limit on out-of-pocket expenses
				for out-of-network covered services shall not exceed one thousand two hundred
				and fifty dollars ($1,250) per enrollee or three thousand seven hundred and
				fifty dollars ($3,750) per family.
(9) An insurer offering a PPO benefit plan
				may limit coverage for annual physicals and health screenings performed for
				preventative purposes to those services provided on an in-network basis, except
				that services provided in connection with mandated benefits must be available
				on both an in-network and out-of-network basis. An insurer shall provide
				coverage on both an in-network and out-of-network basis for all other covered
				services.
(10) PPO benefit plans
				shall give enrollees the option to choose in-network covered services or
				out-of-network covered services each time those covered services are
				authorized, obtained, or rendered; and shall not require enrollees to obtain
				insurer approval to exercise that option.
(11) An insurer offering a PPO benefit plan
				shall not impose different medical management requirements, including
				utilization review criteria or prior approval requirements, for out-of-network
				covered services than are imposed on in-network covered services. Those medical
				management requirements shall not restrict enrollees' abilities to seek covered
				services on out-of-network bases.
Authority
				  G.S.
				  58-2-40;
				  58-50-56;
Temporary
				  Adoption Eff. January 1, 1998;
Eff. August 1, 1998;
Readopted Eff. May 1, 2020.