North Carolina § 135-48 - 32. Contracts to provide benefits.

§ 135-48. 32. Contracts to provide benefits.

The Plan benefits shall be provided under contracts between the Plan and the claims processors selected by the Plan. The contracts necessarily will conform to applicable State law. Unless otherwise directed by the Plan, each Claims Processor shall provide the Plan with a Claims Data Feed, which includes all Claim Payment Data, at a frequency agreed to by the Plan and the Claims Processor. The frequency shall be no less than monthly. The Claims Processor is not required to disclose Claim Payment Data that reflects rates negotiated with or agreed to by a noncontracted third party but, upon request, shall provide to the Plan sufficient documentation to support the payment of claims for which Claim Payment Data is withheld on such basis. Any provision of any contract between a Claims Processor and a health care provider, subcontractor, or third party that would prevent or prohibit the Claims Processor from disclosing Claim Payment Data to the Plan, in accordance with this section, shall be void and unenforceable, but only to the extent the provision prevents and prohibits disclosure to the Plan. The Plan may use and disclose Claim Payment Data solely for the purpose of administering and operating the State Health Plan for Teachers and State Employees in accordance with G.S. 135-48.2 and the provisions of this Article. The Plan shall not make any use or disclosure of Claim Payment Data that would compromise the proprietary nature of the data or, as applicable, its status as a trade secret, or otherwise misappropriate the data. The Plan may not use a provider's Claim Payment Data to negotiate rates, fee schedules, or other master charges with that provider or any other provider. The Plan may disclose Claim Payment Data to a third party to use on the Plan's behalf as agreed upon between the Plan and the Claims Processor. The Plan must obtain the agreement of the Claims Processor for each third party to whom the Plan seeks to disclose Claim Payment Data and for each use the third party will make of the data. The Plan may not disclose Claim Payment Data to any third party without first entering into a contract with the third party that contains restrictions on the use and disclosure of the Claim Payment Data by the third party that are at least as restrictive as the provisions of this section. A Claims Processor who discloses Claim Payment Data in accordance with this section shall not incur any civil liability and shall not be subject to equitable relief in connection for the disclosure. History (2008-168, s. 3(c); 2009-16, ss. 2(f), 5(h); 2009-281, s. 1; 2009-313, s. 2; 2010-194, s. 18(b); 2011-85, ss. 2.6(a), 2.10; 2016-104, s. 3.) 2009 Health Benefit Changes. - Session Laws 2009-16, s. 2(a), provides: "Eliminate PPO Plus Option. - Effective July 1, 2009, the PPO Plus option (90/10 in-network coverage) under the State Health Plan for Teachers and State Employees ('Plan') is eliminated. The Executive Administrator shall provide notice to all members of the Plan that this option will no longer be available as of July 1, 2009. Employees enrolled in the Plan's Plus option shall have the choice of enrolling in the Basic or Standard Plan options for the 2009-2010 benefit year." Session Laws 2009-16, s. 2(h), provides: "Pharmacy Benefit Savings. - The Plan shall direct its pharmacy benefit manager (PBM), within the terms of the Plan's PBM contract, to achieve the sum of eighteen million dollars ($18,000,000) in savings in pharmacy benefit costs in the 2009-2010 fiscal year, and the sum of twenty million dollars ($20,000,000) in savings in pharmacy benefit costs in the 2010-2011 fiscal year through reduced reimbursements paid to pharmacies for prescription drugs. If the savings achieved in each six-month period of the fiscal year do not exceed one hundred five percent (105%) of the savings amount specified in this section for that fiscal year, there shall be no further adjustment to reimbursements paid to pharmacies for that six-month period. If the total savings achieved, by fiscal year, exceeds one hundred five percent (105%) of the specified savings amount in each six-month period of the fiscal year, the Plan shall adjust pharmacy reimbursement reductions accordingly. The Plan shall review savings achieved twice annually to ensure compliance with this section. The Plan shall calculate the savings to be achieved based on Plan enrollment and estimated cost and utilization trends incorporated in the Plan's Financial Projections as of March 20, 2009. The total savings by fiscal year achieved in this section may be increased or decreased without adjustment based on a change in total enrollment provided that the rate of savings achieved on a per-member per-month basis remains constant. Not later than 60 days immediately following each six-month period, the Plan shall report the amount of savings achieved and any adjustments made for that period to the Committee on Employee Hospital and Medical Benefits." Session Laws 2009-16, s. 7(a)-(f), as amended by Session Laws 2009-571, s. 1, as amended by Session Laws 2011-266, s. 1.33(a), provides: "(a) State Health Plan Blue Ribbon Task Force. - There is established the Blue Ribbon Task Force on the State Health Plan for Teachers and State Employees (Task Force). The purpose of the Task Force is to review the governance of the State Health Plan for Teachers and State Employees (Plan) and to make recommendations for changes that will ensure the ongoing financial stability of the Plan, increase and maintain high participation rates for dependent coverage under the Plan, study and compare coverage and costs of the Plan to coverage and costs of other State health plans in the region, and address issues of cost, quality, and access to health care coverage under the Plan. In conducting its review of the Plan the Task Force shall consider all of the following: "(1) The feasibility of transferring the ongoing day-to-day oversight of the Plan to an independent board or to a State agency. "(2) Tiered premium rates for member-only coverage for employees and future retirees based on income or ability to pay. "(3) Ways to increase participation in dependent coverage including supplements from the State or other methods for reducing dependent premiums. "(4) The benefits of implementing a closed prescription drug formulary. "(5) Whether it is advisable to move the Plan to a calendar year, the costs involved in the move, and the benefits that accrue to the Plan and the members as a result of moving to a calendar year. "(6) Any other matters the Task Force considers relevant to its purpose. "(b) The Task Force shall consist of 15 members, appointed as follows: "(1) Six members by the Speaker of the House of Representatives, three of whom shall be members of the House of Representatives, one shall be a public schoolteacher, one shall be a State or covered local government retiree other than a retired public schoolteacher, and one at-large. Of the three legislators appointed to the Task Force, one shall be a member of the minority party. "(2) Six members by the President Pro Tempore of the Senate, three of whom shall be members of the Senate, one shall be a State employee who is not a public schoolteacher, one shall be a retired State public school employee, and one at-large. Of the three legislators appointed to the Task Force, one shall be a member of the minority party. "(3) One member by the Governor with expertise in the business of health insurance or in administering health care services other than an insurance company or third-party administrator or contractor of the Plan. "(4) The chair of the Board of Trustees of the State Health Plan or the chair's designee. "(5) The Commissioner of Insurance or the Commissioner's designee. "(c) The cochairs of the Task Force shall convene the first meeting as soon as possible after appointments have been made. The Task Force may engage the services of a consultant to provide independent analysis of Plan costs and recommendations on how to strengthen the Plan's financial stability, benefit structure and coverage, and the most effective and efficient location for Plan administration. "(d) The Task force shall terminate on or before July 1, 2011. "(e) A majority of the Task Force members shall constitute a quorum for the transaction of business. The Speaker of the House of Representatives and the President Pro Tempore of the Senate shall each appoint one Task Force member as chair. Appointments shall be made as soon as possible after this act becomes law. Task Force members shall receive no compensation for their service but shall be paid per diem, subsistence, and travel expenses in accordance with G.S. 120-3.1 , G.S. 138-5 , and G.S. 138-6 , as applicable. "(f) Repealed by Session Laws 2011-266, 1.33(a), effective July 1, 2011." Editor's Note. - Session Laws 2011-85, s. 2.6(a), effective January 1, 2012, recodified former G.S. 135-45(d) as G.S. 135-48.32 . Former G.S. 135-45(a) and (e) are recodified as G.S. 135-48.2 . Former G.S. 135-45(c) is recodified as G.S. 135-48.8 . Former G.S. 135-45(d1) is recodified as G.S. 135-48.33 . The remainder of G.S. 135-45 is repealed by Session Laws 2011-85, s. 2.9, effective January 1, 2012. Former G.S. 135-45 itself was formerly codified as G.S. 135-39.12 under Part 3A of Article 3A of Chapter 135 by Session Laws 2008-168, s. 3(c), effective July 1, 2008, but was renumbered as G.S. 135-45 at the direction of the Revisor of Statutes. Session Laws 2010-3, s. 2, provides: "The Executive Administrator of the State Health Plan for Teachers and State Employees shall consult with the Committee on Employee and Hospital Medical Benefits prior to implementing any program to verify tobacco usage by members of the Plan." Session Laws 2016-104, s. 9, made the rewriting of this section by Session Laws 2016-104, s. 3, applicable to contracts entered into on or after July 22, 2016. Effect of Amendments. - Session Laws 2011-85, s. 2.10, effective January 1, 2012, in the introductory paragraph, twice substituted "State Treasurer" for "Executive Administrator" and "this Article" for "G.S. 135-45.1 through G.S. 135-45.15." Session Laws 2016-104, s. 3, effective July 22, 2016, rewrote the section. See editor's note for applicability.