10A NCAC 22L .0203       ACCESS TO CARE

(a)  In-plan and out-of-plan services shall be listed in the contract between the HMO and DMA.  The HMO shall pay for all in-plan services when provided in accordance with the HMO's policies and procedures.  DMA shall pay for all out-of-plan services provided in accordance with Medicaid policies and procedures.  The Division of Medical Assistance has the authority to deny payment for in-plan services not provided nor authorized by the HMO.

(b)  HMO members shall receive all in-plan services from their HMO or its subcontractors except:

(1)           emergency medical services as defined in 42 U.S.C. 1932(b)(2)(B) and (C), which could not be provided by the HMO because the time to reach the in-plan provider capable of providing such services would have meant risk of serious damage or injury to the member's health;

(2)           Medicaid-covered family planning services and supplies;

(3)           services provided by a public health department for the screening, diagnosis, counseling, or treatment of sexually transmitted diseases, tuberculosis or HIV; and

(4)           services for which the HMO has referred the member to an out-of-plan provider.

(c)  The HMO shall make payment for in-plan services in Paragraph (b), of this Rule, in an amount agreed upon by the provider and the HMO.  In the absence of such an agreement, payment shall be made in the amount of the Medicaid allowable fee.


History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999.