ACCESS TO PROVIDERS

Network Adequacy
Health plans that operate network-based plans (like HMOs or PPOs) must have systems to ensure the adequacy of the network. Health plans must set their own access standards and monitor how well they meet these internal standards. For example, the health plan’s access standards should include information about how long members must travel to access primary care, specialty care, hospital-based services and other facilities. Health plans must also monitor waiting times to find out how long it takes to get an appointment to network providers (NCGS 58-3-191(a)(4)(c)).

No Penalty for Going Outside a Network if Insufficient Providers
Health plans may not charge members more money or otherwise penalize members for using out-of-network providers, if the health plan lacks sufficient network providers to meet the health care needs of the patients without unreasonable delay (NCGS 58-3-191(a)(4)(b), 58-3-191(a)(4)(c)(2)(d), 58-3-200(d)).

Pharmacies
Health plans may not restrict members from selecting a pharmacy if the pharmacy has agreed to participate in the health benefit plan according to the terms offered by the insurer. Health plans may not charge higher cost sharing that would affect the members’ choice of a pharmacy (NCGS 58-51-37).

Obstetricians and Gynecologists
Health plans must allow female members 13 years or older to obtain the services of a contracting obstetrician-gynecologist (OB/GYN) without prior referral for obstetrical or gynecological related services (NCGS 58-51-38).

Continuing Care Retirement Communities
Health plans must allow residents of continuing care retirement communities who need nursing home care to obtain the care from a facility within the continuing care retirement community. However, the facility must be a Medicare-certified skilled nursing home and must agree to be reimbursed at the same rate negotiated with similar providers. The nursing home must meet the health plan’s billing, quality assurance, utilization review, confidentiality, nondiscrimination, grievance and appeal procedures (NCGS 58-3-200(f)).

Optometrists, Podiatrists, Dentists, Chiropractors, Psychologists, Clinical Social Workers, Nurse Practitioners & Physician Assistants
Insurance plans may not deny payment or reimbursement for any service which is within the scope of practice of a licensed optometrist, podiatrist, dentist, chiropractic, psychologist, clinical social worker, advanced practice nurse (such as a nurse practitioner or nurse midwife) or physician assistant. The goal is to give the member a choice of providers (NCGS 58-65-1; 58-65-36, 58-50-30, 58-50-26, 135-40). This provision does not apply to HMOs.

Provider Hold-Harmless Provisions
Providers are prohibited from charging HMO members for covered services other than the allowable coinsurance, copayments or deductibles. The providers may not charge patients for these services, even if the HMO fails to pay the provider (11 NCAC 20.0202). The patient can, however, agree to pay for non-covered services out-of-pocket. This protection only applies to members in HMOs.

Standing Referrals to Specialists
Beginning January 1, 2000, all health plans that require patients to obtain referrals before they can see a specialist must have new procedures to allow certain patients to obtain standing or extended referrals. Health plans must have a process to allow patients with chronic, degenerative, disabling or life-threatening diseases or conditions to obtain extended or standing referrals to in-network specialists. The standing referrals will not exceed 12 months, and shall be part of a treatment plan coordinated with the primary care physician, specialist and the health plan (NCGS 58-3-223).

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