§ 58‑67‑35. Powers of health maintenance organizations.
(a) The powers of ahealth maintenance organization include, but are not limited to the following:
(1) The purchase, lease,construction, renovation, operation, or maintenance of hospitals, medical facilities,or both, and their ancillary equipment, and such property as may reasonably berequired for its principal office or for such other purposes as may benecessary in the transaction of the business of the organization;
(2) The making of loansto a medical group under contract with it in furtherance of its program or themaking of loans to a corporation or corporations under its control for thepurpose of acquiring or constructing medical facilities and hospitals or infurtherance of a program providing health care services to enrollees;
(3) The furnishing ofhealth care services through providers which are under contract with oremployed by the health maintenance organization;
(4) The contracting withany person for the performance on its behalf of certain functions such asmarketing, enrollment and administration;
(5) The contracting withan insurance company licensed in this State, or with a hospital or medicalservice corporation authorized to do business in this State, for the provisionof insurance, indemnity, or reimbursement against the cost of health careservices provided by the health maintenance organization;
(6) The offering andcontracting for the provision or arranging of, in addition to health careservices, of:
a. Additional healthcare services;
b. Indemnity benefits,covering out‑of‑area or emergency services;
c. Indemnity benefits,in addition to those relating to out‑of‑area and emergencyservices, provided through insurers or hospital or medical servicecorporations; and
d. Point‑of‑serviceproducts, for which an HMO may precertify out‑of‑plan coveredservices on the same basis as it precertifies in‑plan covered services,and for which the Commissioner shall adopt rules governing:
1. The percentage of anHMO's total health care expenditures for out‑of‑plan coveredservices for all of its members that may be spent on those services, which maynot exceed twenty percent (20%);
2. Product limitations,which may provide for payment differentials for services rendered by providerswho are not in an HMO network, subject to G.S. 58‑3‑200(d).
3. Deposit and otherfinancial requirements; and
4. Other requirementsfor marketing and administering those products.
(b) (1) Ahealth maintenance organization shall file notice, with adequate supporting information,with the Commissioner prior to the exercise of any power granted in subsections(a)(1) or (2). The Commissioner shall disapprove such exercise of power if inhis opinion it would substantially and adversely affect the financial soundnessof the health maintenance organization and endanger its ability to meet itsobligations. If the Commissioner does not disapprove within 30 days of thefiling, it shall be deemed approved.
(2) The Commissioner maypromulgate rules and regulations exempting from the filing requirement ofsubdivision (1) those activities having a de minimis effect. (1977, c. 580, s. 1; 1979, c.876, s. 1; 1991 (Reg. Sess., 1992), c. 837, s. 8; 1997‑519, s. 3.18; 2001‑334,s. 8.2.)
§ 58‑67‑35. Powers of health maintenance organizations.
(a) The powers of ahealth maintenance organization include, but are not limited to the following:
(1) The purchase, lease,construction, renovation, operation, or maintenance of hospitals, medical facilities,or both, and their ancillary equipment, and such property as may reasonably berequired for its principal office or for such other purposes as may benecessary in the transaction of the business of the organization;
(2) The making of loansto a medical group under contract with it in furtherance of its program or themaking of loans to a corporation or corporations under its control for thepurpose of acquiring or constructing medical facilities and hospitals or infurtherance of a program providing health care services to enrollees;
(3) The furnishing ofhealth care services through providers which are under contract with oremployed by the health maintenance organization;
(4) The contracting withany person for the performance on its behalf of certain functions such asmarketing, enrollment and administration;
(5) The contracting withan insurance company licensed in this State, or with a hospital or medicalservice corporation authorized to do business in this State, for the provisionof insurance, indemnity, or reimbursement against the cost of health careservices provided by the health maintenance organization;
(6) The offering andcontracting for the provision or arranging of, in addition to health careservices, of:
a. Additional healthcare services;
b. Indemnity benefits,covering out‑of‑area or emergency services;
c. Indemnity benefits,in addition to those relating to out‑of‑area and emergencyservices, provided through insurers or hospital or medical servicecorporations; and
d. Point‑of‑serviceproducts, for which an HMO may precertify out‑of‑plan coveredservices on the same basis as it precertifies in‑plan covered services,and for which the Commissioner shall adopt rules governing:
1. The percentage of anHMO's total health care expenditures for out‑of‑plan coveredservices for all of its members that may be spent on those services, which maynot exceed twenty percent (20%);
2. Product limitations,which may provide for payment differentials for services rendered by providerswho are not in an HMO network, subject to G.S. 58‑3‑200(d).
3. Deposit and otherfinancial requirements; and
4. Other requirementsfor marketing and administering those products.
(b) (1) Ahealth maintenance organization shall file notice, with adequate supporting information,with the Commissioner prior to the exercise of any power granted in subsections(a)(1) or (2). The Commissioner shall disapprove such exercise of power if inhis opinion it would substantially and adversely affect the financial soundnessof the health maintenance organization and endanger its ability to meet itsobligations. If the Commissioner does not disapprove within 30 days of thefiling, it shall be deemed approved.
(2) The Commissioner maypromulgate rules and regulations exempting from the filing requirement ofsubdivision (1) those activities having a de minimis effect. (1977, c. 580, s. 1; 1979, c.876, s. 1; 1991 (Reg. Sess., 1992), c. 837, s. 8; 1997‑519, s. 3.18; 2001‑334,s. 8.2.)
§ 58‑67‑35. Powers of health maintenance organizations.
(a) The powers of ahealth maintenance organization include, but are not limited to the following:
(1) The purchase, lease,construction, renovation, operation, or maintenance of hospitals, medical facilities,or both, and their ancillary equipment, and such property as may reasonably berequired for its principal office or for such other purposes as may benecessary in the transaction of the business of the organization;
(2) The making of loansto a medical group under contract with it in furtherance of its program or themaking of loans to a corporation or corporations under its control for thepurpose of acquiring or constructing medical facilities and hospitals or infurtherance of a program providing health care services to enrollees;
(3) The furnishing ofhealth care services through providers which are under contract with oremployed by the health maintenance organization;
(4) The contracting withany person for the performance on its behalf of certain functions such asmarketing, enrollment and administration;
(5) The contracting withan insurance company licensed in this State, or with a hospital or medicalservice corporation authorized to do business in this State, for the provisionof insurance, indemnity, or reimbursement against the cost of health careservices provided by the health maintenance organization;
(6) The offering andcontracting for the provision or arranging of, in addition to health careservices, of:
a. Additional healthcare services;
b. Indemnity benefits,covering out‑of‑area or emergency services;
c. Indemnity benefits,in addition to those relating to out‑of‑area and emergencyservices, provided through insurers or hospital or medical servicecorporations; and
d. Point‑of‑serviceproducts, for which an HMO may precertify out‑of‑plan coveredservices on the same basis as it precertifies in‑plan covered services,and for which the Commissioner shall adopt rules governing:
1. The percentage of anHMO's total health care expenditures for out‑of‑plan coveredservices for all of its members that may be spent on those services, which maynot exceed twenty percent (20%);
2. Product limitations,which may provide for payment differentials for services rendered by providerswho are not in an HMO network, subject to G.S. 58‑3‑200(d).
3. Deposit and otherfinancial requirements; and
4. Other requirementsfor marketing and administering those products.
(b) (1) Ahealth maintenance organization shall file notice, with adequate supporting information,with the Commissioner prior to the exercise of any power granted in subsections(a)(1) or (2). The Commissioner shall disapprove such exercise of power if inhis opinion it would substantially and adversely affect the financial soundnessof the health maintenance organization and endanger its ability to meet itsobligations. If the Commissioner does not disapprove within 30 days of thefiling, it shall be deemed approved.
(2) The Commissioner maypromulgate rules and regulations exempting from the filing requirement ofsubdivision (1) those activities having a de minimis effect. (1977, c. 580, s. 1; 1979, c.876, s. 1; 1991 (Reg. Sess., 1992), c. 837, s. 8; 1997‑519, s. 3.18; 2001‑334,s. 8.2.)
