POINT-OF-SERVICE PROTECTIONS

Covered Services
Point of Service (POS) plans must make all benefits available for in-plan covered services. But they need not cover preventive services on an out-of-plan basis. Any out-of-plan covered service must also be available on an in-plan covered service basis. POS products must give members the option to choose in-plan or out-of-plan covered services each time the member seeks services. POS products must provide incentives for members to use in-plan services (11 NCAC 12.1403).

Out of Pocket Payments
In POS plans members have the option of seeking care outside of the network. Usually members have to pay deductibles, higher copayments and/or more coinsurance than they would if they received care inside the network. North Carolina laws put limits on the amount that HMOs can charge for using out-of-network providers. For example, coinsurance for out-of-plan covered services may not be more than 30 percent more than coinsurance for in-plan coverage. The deductible may not be more than five times the amount of the annual deductible for in-plan coverage. The deductible may not be more than $2,000/$6,000 for individuals/family coverage if the in-plan does not have a deductible. The copayments may not exceed the copayments for in-plan covered services by more than $50 or 100%, whichever is greater. The annual and lifetime maximum, if any, may not be less than one-half of the amount of any annual or lifetime maximums for in-plan covered services (11 NCAC 12.1403).

Disclosure of Cost Sharing to Members
All marketing materials, Evidence of Coverage, member handbooks and other materials must explain the method of reimbursement, applicable cost sharing amounts and any uncovered costs or charges. Materials should also explain covered benefits that a member may receive on an out-of-plan basis and instructions to submit claims for out-of-plan covered services (11 NCAC 12.1404).

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