Senate committee substitute makes the following changes to the 2nd edition.
Amends proposed GS 58-50-56.1 by adding the following. Requires each insurer to include a clear statement in any application and any benefit booklets for exclusive provider benefit plans that out-of-network coverage for insureds in the exclusive provider benefit plan only applies for emergency services and medically necessary covered services when an in-network provider is not reasonably available. Specifies that any provisions of GS Chapter 58 that apply to preferred provider benefit plans or preferred provider benefit organizations as of July 1, 2021, also apply to exclusive provider benefit plans or exclusive provider benefit organizations (this was previously uncodified in Section 2 of the act, which has now been deleted).
Summary date: Apr 29 2021 - View summary
Summary date: Apr 28 2021 - View summary
Senate committee substitute makes the following changes to the 1st edition.
Changes the section number for previously proposed GS 58-50-56.1 to GS 58-50-56.2 and makes the following changes to the proposed statute. Removes the defined terms exclusive provider benefit plan and insurer. Adds to the required notice on the date of enrollment by an insurer offering an exclusive provider benefit plan required to provide transition coverage for a newly covered insured covered because of the individual's employer has changed benefit plans and who is undergoing treatment from a provider for an ongoing special condition, to include the method and time line by which the insured should contact the insurer regarding the right to elect continuation of coverage of treatment by a provider that is not contracted with the exclusive provider benefit plan. Regarding permitted conditions of coverage, allows the provider to agree to accept the preferred provider organization rate or other rate agreed to by the provider or insurer plus applicable copayments for reimbursement in full from the insurer and the insured for all covered services provided by a provider not contracted with the exclusive provider benefit plan but who the insured elects to continue coverage of ongoing treatment under subsection (c). Makes technical and clarifying changes.
Enacts new GS 58-50-56.1, authorizing insurers to contract for an exclusive provider organization, as defined, with licensed health care providers of all kinds, with contracts not disapproved by the Commissioner of Insurance within 90 days of filing deemed approved. Voids any contractual provision between an insurer offering an exclusive provider benefit plan, as defined, and a health care provider that restricts the provider's right to enter into provider contracts with other persons. Mandates applicable contracts to provide all participating providers information about the insurer and the insurer's exclusive provider benefit plans, as specified. Makes the Commissioner's rules applicable to preferred provider organizations related to provider accessibility for the insured group, adequacy of providers, availability of services at reasonable times, and financial solvency also applicable to exclusive provider organizations. Provides for summary data and annual disclosures to the Commissioner by insurers offering an exclusive provider benefit plan. Includes defined terms.
Deletes the proposed conforming changes to GS 58-50-56(i).
Changes the act's effective date, making the act now applicable to insurance contracts issued, renewed, or amended on or after July 1, 2021 (was October 1, 2021). Adds that any provisions of GS Chapter 58 that apply to preferred provider benefit plans or preferred provider benefit organizations as of July 1, 2021, also apply to exclusive provider benefit plans or exclusive provider benefit organizations.
Summary date: Mar 10 2021 - View summary
Enacts GS 58-50-56.1 as follows. Regarding continuity of care following a termination of a contract between an insurer and a health care provider offering an exclusive provider benefit plan due to a change in the terms of provider participation in the benefit plan when an insured is undergoing treatment from the provider for an ongoing special condition on the date of termination, requires the insurer to timely notify the insurer of the right to elect continuation of coverage of treatment by the provider during a transitional period, subject to the insured having a claim for services provided by the terminated provider or the insured otherwise being known as a patient of the terminated provider by the insurer. Defines ongoing special condition to include specified acute illnesses, chronic illnesses, and terminal illnesses, and pregnancy from the start of the second trimester. Defines exclusive provider benefit plan (benefit plan), insurer, and terminated or termination.
Requires each benefit plan offered by an insurer to provide transition coverage to individuals who are newly covered by a benefit plan because the individual's employer has changed benefit plans and are undergoing treatment from a provider for an ongoing special condition. Requires an insurer to notify the newly covered insured on the date of enrollment of the right to elect continuation of coverage of treatment by a provider that is not contracted with the benefit plan and permit the newly covered insured to elect to continue to be covered with respect to the treatment by the provider of an ongoing special condition during a transitional period.
Allows the treating hospital care provider to determine the length of the transitional period, not exceeding 90 days after the date of the notice to the individual regarding termination of the provider or the date of enrollment in a new benefit plan, as described.
Provides for specified extensions of the general transitional period for individuals who had scheduled or were on a waiting list to schedule surgery, organ transplantation, or inpatient care; individuals entering the second trimester of pregnancy; and individuals who were terminally ill.
Identifies six terms and conditions upon which an insurer can condition coverage of a continued treatment by a provider, including that the provider agrees to adhere to the insurer's established policies and procedures for participating providers.
Provides parameters for the statute's construction, including that the statute does not require an insurer to offer a transitional period when the insurer terminates a provider's contract for reasons relating to quality of care or fraud.
Requires insurers to include a clear description of an insured's rights under the statute in its evidence of coverage and summary plan description.
Authorizes the Department of Insurance to adopt temporary implementing rules.
Makes conforming changes to GS 58-50-56(i).
Applies to insurance contracts issued, renewed, or amended on or after October 1, 2021.