State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_131E > GS_131E-275

Article 17.

Provider Sponsored Organization Licensing.

§ 131E‑275.  General provisions.

(a)        The General Assembly acknowledges that section 1855, etseq., of the federal Social Security Act permits provider sponsoredorganizations that are organized and licensed under State law as risk‑bearingentities, or that are otherwise certified as such by the federal government, tobe eligible to offer Medicare health insurance or health benefits coverage ineach state in which the provider sponsored organization offers aMedicare+Choice plan. The General Assembly declares that provider sponsoredorganizations are beneficial to North Carolina citizens who are Medicarebeneficiaries and should be encouraged, subject to appropriate regulation bythe Division of Medical Assistance of the Department of Health and HumanServices. The General Assembly further declares that, because providersponsored organizations provide health care directly and assume responsibilityfor the provision of health care services to Medicare beneficiaries under therequirements of the federal Medicare program, they require different regulatoryoversight to protect the public than health maintenance organizations andinsurance companies. The General Assembly further declares that the organizers andoperators of provider sponsored organizations which are licensed under theterms of this Article as risk‑bearing entities authorized to contractdirectly with the federal Medicare+Choice program shall not be subject toChapter 58 of the General Statutes or the insurance laws of this State, unlessotherwise specified in this Article.

It is the intent of the General Assembly to encourage innovativemethods by which sponsoring providers can directly or indirectly sharesubstantial financial risk in the PSO in any lawful manner.

(b)        As set forth in this Article, the Division of MedicalAssistance of the Department of Health and Human Services shall be the agencyof the State authorized to license provider sponsored organizations to contractwith Medicare to provide health care services to Medicare beneficiaries and toengage in the other related activities described in this Article.

(c)        Each provider sponsored organization shall obtain a licensefrom the Division or shall otherwise be certified by the federal governmentprior to establishing, maintaining, and operating a health care plan in thisState for Medicare+Choice beneficiaries. Nothing in this Article shall beconstrued to authorize a provider sponsored organization to establish,maintain, or operate a health care plan other than exclusively forMedicare+Choice beneficiaries. (1998‑227, s. 1.)