HB 373/SB 228 – Allow Employers to Offer EPO Benefit Plans

HB 373/SB 228 – Allow Employers to Offer EPO Benefit Plans

Primary Senate Sponsors: Sen. Chuck Edwards (R-Buncombe, Henderson, Transylvania); Sen. Joyce Krawiec (R-Davie, Forsyth); Sen. Jim Burgin (R-Harnett, Johnston, Lee)

Primary House Sponsors: Rep. Dana Bumgardner (R-Gaston); Rep. Kyle Hall (R-Rockingham, Stokes, Surry); Rep. Jason Saine (R-Lincoln)

Summary

This bill:

  • Revises GS 58-50-56(i) to permit any person enrolled in a preferred provider benefit plans, other than an exclusive provider benefit plan, to obtain covered health services from a provider who does not participate in the plan.
  • Defines an exclusive provider benefit plan as “a preferred provider benefit plan in which enrollees must receive covered services from health care providers who are under contract with the insurer and under which there is no requirement of coverage for care received from a health care provider who is not under contract with the insurer except for certain emergency services and certain medically covered services.
  • Requires certain actions to take place upon the termination of a contract offering an exclusive provider benefit plan by the provider or by the insurer or when the insurer or benefits/coverage provided by the insurer are terminated due to a change in the terms of provider participation if the insured is undergoing treatment from the provider for an ongoing special condition on the date of the termination including:
    1. The insurer must notify the insured on a timely basis of the provider’s termination of the contract and of the insured’s right to elect continuation of coverage of treatment by the provider if the insured has a claim with the insurer for services provided by the terminated provider or if the insurer knows the insured is a patient of the terminated provider.
    2. The insurer must permit an insured to elect to continue to be covered with respect to the treatment by the terminated provider for the ongoing special condition during a transitional period.
  • Defines “ongoing special condition” to include certain categories of acute and chronic illness, terminal illness for which an individual has a medical prognosis of a life expectancy of 6 months or less, and pregnancy from the start of the second trimester.
  • States that the length of a general transition period should be determined by the treating health care provider so long as it does not exceed 90 days after the date of the notice of termination or the date of enrollment in a new plan.
  • Provides for specific extensions of the general transition period for (1) individuals who had scheduled or who were on a waiting list to schedule surgery, organ transplant, or inpatient care, (2) individuals entering the second trimester of pregnancy, and (3) terminally ill individuals.
  • Requires exclusive provider benefit plans to provide transition coverage to individuals who are (1) newly covered because the individual’s employer has changed benefit plans and (2) are undergoing treatment from a provider for an ongoing special condition.
  • Identifies 6 terms and conditions upon which an insurer can condition coverage of continued treatment by a provider following termination of a provider or to a newly covered insured including:
  1. When care is provided following termination of a provider, the provider must agree to accept reimbursement form the insurer and, with respect to cost-sharing, from the insured at the rates applicable before the start of the transitional period as payment in full.
  2. When care is provided to a newly covered insured, the provider must agree to accept the prevailing rate based on contracts the insurer has with the same or similar providers in the same or similar geographic area, plus the applicable copayment.
  3. The provider must agree to comply with the quality assurance programs of the insurer responsible for payment and to provide the insurer with necessary medical information related to the care provided.
  4. The provider agrees to the insurer’s established policies and procedures for participating providers.
  5. The receipt of notification from the insured within 45 days of the date of the notice of termination of the contract by the insured or the new enrollment of a newly covered insured that insured elects to continue receiving treatment by the provider.
  6. The provider must agree to discontinue providing services at the end of the transition period and to assist the insured in an orderly transition to a network provider.
  • States that an insurer is not required to offer a transitional period when the insurer terminates a provider’s contract for reasons relating to quality of care or fraud.

Movement

SB 228

Filed – 3/10/2021

This bill was referred to Rules and Operations on 3/11/2021, but it was withdrawn from Committee on 3/18/2021.

This bill was referred to the following Senate Committees:

-Commerce and Insurance

-Health Care

-Rules and Operations

HB 373

Filed 3/23/2021

This bill was referred to the following House Committees:

-Insurance

-Rules, Calendar, and Operations

 
 

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