AN ACT TO CLARIFY CERTAIN PROVIDER AND PATIENT RIGHTS REGARDING HEALTH BENEFIT PLAN CONTRACTS FOR THE PROVISION OF DENTAL SERVICES.
Senate committee substitute makes the following changes to the 1st edition.
Deletes proposed GS 58-50-291, prohibiting an insurer who provides a health benefit plan for dental services from using more than 25% of its prepaid charges or premiums for marketing and administrative expenses.
Makes the following changes to proposed GS 58-50-292 regarding dental provider networks. Changes the statute's terminology, now defining provider network contract rather than dental provider network contract. Excludes from the definition of third party an employer group or other group for which the insurer provides administrative services, including payment of claims. Deletes the statute's substantive provisions. Instead sets forth three conditions that must be met for an insurer to grant a third-party access to its provider network contract, including giving providers in the carrier's network the opportunity to opt out of third party access to the contract at the time the provider network contract is entered or renewed, listing all third parties who have been granted access to the contract on the insurer's website, and the third party complying with the provider network contract's terms. Exempts from the statute's provisions any assignments of, or access to, a provider network contract to an entity operating under the same brand license program as the contracting entity or any affiliates of the contracting entity.
Deletes the proposed changes to GS 58-3-200(a) and GS 58-3-190(g), which removed dental plans from the kinds of insurance not included in the definition of health benefit plan under those statutes.
Instead amends GS 58-3-200(c) to prohibit an insurer from subsequently retracting its determination that services, supplies, or other items are covered under its dental plan after the services, supplies, or other items have been provided, or reduce payments for the same in reliance upon the determination, unless the determination was based on a material misrepresentation about the insured's health condition was knowingly made, as specified. Defines pretreatment estimate.
Changes the act's effective date to now apply to health benefit contracts issued, renewed, or amended on or after January 1, 2020, rather than October 1, 2019.
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