State Codes and Statutes
Statutes > North-carolina > Chapter_58 > GS_58-3-250§ 58‑3‑250. Payment obligations for covered services.
(a) If an insurercalculates a benefit amount for a covered service under a health benefit planthrough a method other than a fixed dollar co‑payment, the insurer shallclearly explain in its evidence of coverage and plan summaries how itdetermines its payment obligations and the payment obligations of the insured.The explanation shall include:
(1) An example of thesteps the insurer would take in calculating the benefit amount and the paymentobligations of each party.
(2) Whether the insurerhas obtained the agreement of health care providers not to bill an insured forany amounts by which a provider's charge exceeds the insurer's recognizedcharge for a covered service and whether the insured may be liable for payingany excess amount.
(3) Which party isresponsible for filing a claim or bill with the insurer.
(b) If an insured isliable for an amount that differs from a stated fixed dollar co‑paymentor may differ from a stated coinsurance percentage because the coinsuranceamount is based on a plan allowance or other such amount rather than the actualcharges and providers are permitted to balance bill the insured, the evidenceof coverage, plan summaries, and marketing and advertising materials thatinclude information on benefit levels shall contain the following statement:"NOTICE: Your actual expenses for covered services may exceed the stated[coinsurance percentage or co‑payment amount] because actual providercharges may not be used to determine [plan/insurer or similar term] and[insured/member/enrollee or similar term] payment obligations." (2001‑446, s. 2.3.)
