MANDATED BENEFITS

Emergency Services
Health plans must provide coverage for emergency medical services needed to screen and to stabilize a person. Prior authorization cannot be required if an ordinary person (prudent layperson) acting reasonably would have believed that an emergency medical condition existed. The member may obtain emergency-related services from a non-network provider if the person reasonably believes that the delay in seeking care from a network provider would worsen the emergency. The health plan may charge its regular coinsurance, copayments or deductibles but may not charge additional cost sharing amounts for using a non-network provider (NCGS 58-3-190).

Mammograms & Pap Smears
Health plans must provide coverage for periodic pap smears and mammograms. Coverage of pap smears will be provided once a year or more often if recommended by a physician. Mammograms must be covered according to the following schedule:

• One or more mammograms a year, as recommended by a physician, for any woman who is at risk of breast cancer;
  
• One baseline mammogram for any woman 35-39 years of age;
  
• A mammogram every other year for any woman 40-49 years of age or more frequently upon a physician’s recommendation; or
  
• A mammogram every year for any woman 50 years of age or older.
  

Health plans may not impose higher copayments on pap smears or mammograms than it does on other similar screening tests (NCGS 58-67-76; 58-51-57, 58-65-92).

Prostate-Specific Antigen Test
Health plans must cover prostate-specific antigen (PSA) tests or other tests for the presence of prostate cancer. A physician must order a PSA test in order for it to be covered. PSAs must be covered at the same level as other similar services (NCGS 58-67-77; 58-51-58; 58-65-93). In other words, plans may not impose higher copayments on PSA tests than it does on other similar screening tests.

Diabetes Self-Care
Health plans must also provide coverage for diabetes outpatient self-management training, equipment, supplies, medications and laboratory procedures used to treat diabetes. The insurer may decide who shall provide and be reimbursed for the outpatient self-management training and educational services (NCGS 58-67-74, 58-51-61, 58-65-91).

Cancer Treatment
Health plans that cover the medication cost for the treatment of one type of cancer must, under certain circumstances, also cover the costs of that medication for the treatment of another type of cancer. For this protection to apply, the following standards must be met:

• The drug must be approved by the US Food and Drug Administration (FDA);
  
• It must have been proven effective; and
  
• It must be accepted for the additional use by the American Medical Association Drug Evaluations, the American Hospital formulary Service Drug Information, or the United States Pharmacopoeia Drug Information.
  

Coverage may be denied if the medication is experimental or investigational or if the FDA finds that the drug should not be used to treat the other type of cancer (NCGS 58-67-78, 58-51-59, 58-65-94).

Maternity Care
Health plans are not required to provide maternity coverage. When the company does provide coverage, benefits must be the same as for other services (NCGS 58-3-170). In other words, plans may not impose higher copayments on maternity care than it does on other similar care. Regardless of whether the policy provides maternity coverage, a complication of pregnancy must be treated similarly to other illnesses or sicknesses covered under the health plan’s contract. A non-elective cesarean section is considered a complication of pregnancy (11 NCAC 12.0323). Health plans may not deny maternity coverage to an unmarried woman if the coverage is available to married women.

Also, any health benefit plan that provides maternity coverage must pay for inpatient care for a mother and her newly born child for at least 48 hours after vaginal delivery or 96 hours after a cesarean section (NCGS 58-3-169, 58-3-170).

Reconstructive Breast Surgery
Health plans that cover mastectomies must also cover reconstructive breast surgery following a mastectomy (NCGS 58-67-79, 58-51-62). The decision to discharge a patient following a mastectomy must be made in consultation by the attending physician and the patient (NCGS 58-3-168).

Chemical Dependency Treatment
Health plans must offer groups coverage for the treatment of chemical dependency. If the health plan provides the group total annual benefits for all services in excess of $8,000, then that plan must provide a minimum of $8,000 for the necessary care and treatment of chemical dependency. The plan must provide a lifetime maximum of no less than $16,000. While health plans are required to offer this coverage, groups may reject it (NCGS 58-67-70; 58-51-50; 58-65-75).

Temporamandibular Joint Treatment
Health plans must provide coverage for diagnostic, therapeutic or surgical procedures involving bones or joints of the jaw, face or head, including the temporomandibular joint (TMJ), if the procedure is medically necessary. These insurers must provide coverage if the condition is caused by congenital deformity, disease, or traumatic injury (NCGS 58-3-121).

Tax-Supported Institutions
Insurance companies must provide the same coverage for services provided in a tax-supported institution, such as a state psychiatric institution, as the company provides for services in other public or private health care facilities. This provision only applies to group coverage, and does not apply to HMOs (NCGS 58-51-40, 58-65-65).

Public Health Measures
HMOs and local health departments are required to collaborate and cooperate to protect the public health. For example, HMOs and local health departments could jointly sponsor a local health promotion or disease prevention activity (NCGS 58-67-66).

Prescription Contraceptive Drugs or Devices
Beginning January 1, 2000, health plans that provide coverage for prescription drugs or devices must also cover contraceptive drugs and devices. Coverage must include the insertion and removal of contraceptive devices as well as contraceptive examinations. The health plan must apply the same cost sharing or copayment on the contraceptive drugs and devices as it imposes for prescription drugs. Religious employers may exclude coverage for prescription contraceptive drugs or devices that are contrary to the employer’s religious tenets (NCGS 58-3-176).

Non-Formulary Medications
Beginning January 1, 2000, health plans that use a closed formulary must have a process to allow exceptions to the formulary. To obtain coverage of a non-formulary drug, a participating provider must notify the health plan that:

• the drugs on the formulary have been ineffective in treating the patient’s condition or
  
• the drugs on the formulary are reasonably expected to cause a harmful reaction in the patient.
  

In addition, the drug must be prescribed in accordance with the health plan’s clinical protocol. Health plans may not charge patients any additional cost sharing or a higher copayment for using non-formulary medications when they meet the requirements for an exception to the formulary (NCGS 58-3-221).


Bone Mass Measurements
Beginning January 1, 2000, health plans must provide coverage of bone mass measurements for individuals who are at risk of developing osteoporosis or low bone mass. Coverage must include bone mass measurements at least every 23 months and more frequently if follow-up measurements are medically necessary. Coverage for the bone mass measurements shall be the same as for other similar services. Individuals who qualify for coverage of bone mass measurements include those with:

• estrogen-deficiency and risk of osteoporosis or low bone mass;
  
• radiographic osteopenia anywhere in the skeleton;
• long-term steroid therapy;
  
• primary hyperparathyroidism;
  
• monitoring to assess their response to osteoporosis drug therapies;
  
• histories of low-trauma fractures; or
  
• other known conditions or on medical therapies known to cause osteoporosis or low-bone mass. (NCGS 58-3-174, 58-50-155).

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