North Carolina § 58-50-30 - Right to choose services of certain providers.

§ 58-50-30. Right to choose services of certain providers.

Repealed by Session Laws 2001-297, s. 1, effective January 1, 2001. Whenever any health benefit plan, subscriber contract, or policy of insurance issued by a health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter provides for coverage for, payment of, or reimbursement for any service rendered in connection with a condition or complaint that is within the scope of practice of a provider listed in subsection (b) of this section, the insured or other persons entitled to benefits under the policy shall be entitled to coverage of, payment of, or reimbursement for the services, whether the services be performed by a duly licensed physician, or a provider listed in subsection (b) of this section, notwithstanding any provision contained in the plan or policy limiting access to the providers. The policyholder, insured, or beneficiary shall have the right to choose the provider of services notwithstanding any provision to the contrary in any other statute, subject to the utilization review, referral, and prior approval requirements of the plan that apply to all providers for that service; provided that: In the case of plans that require the use of network providers as a condition of obtaining benefits under the plan or policy, the policyholder, insured, or beneficiary must choose a provider of the services within the network; and In the case of plans that require the use of network providers as a condition of obtaining a higher level of benefits under the plan or policy, the policyholder, insured, or beneficiary must choose a provider of the services within the network in order to obtain the higher level of benefits. Whenever any policy of insurance governed by Articles 1 through 64 of this Chapter provides for certification of disability that is within the scope of practice of a provider listed in subsection (b) of this section, the insured or other persons entitled to benefits under the policy shall be entitled to payment of or reimbursement for the disability whether the disability be certified by a duly licensed physician, or a provider listed in subsection (b) of this section, notwithstanding any provisions contained in the policy. The policyholder, insured, or beneficiary shall have the right to choose the provider of the services notwithstanding any provision to the contrary in any other statute; provided that for plans that require the use of network providers either as a condition of obtaining benefits under the plan or policy or to access a higher level of benefits under the plan or policy, the policyholder, insured, or beneficiary must choose a provider of the services within the network, subject to the requirements of the plan or policy. Whenever any health benefit plan, subscriber contract, or policy of insurance issued by a health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter provides coverage for medically necessary treatment, the insurer shall not impose any limitation on treatment or levels of coverage if performed by a duly licensed chiropractor acting within the scope of the chiropractor's practice as defined in G.S. 90-151 unless a comparable limitation is imposed on the medically necessary treatment if performed or authorized by any other duly licensed physician. This section applies to the following provider types: A duly licensed optometrist. A duly licensed dentist. A duly licensed podiatrist. A duly licensed chiropractor. An advanced practice registered nurse, subject to subsection (d) of this section. For purposes of this section, an "advanced practice registered nurse" means only a registered nurse who is duly licensed or certified as a nurse practitioner, clinical specialist in psychiatric and mental health nursing, or nurse midwife. A psychologist who is one of the following: A licensed psychologist who holds permanent licensure and certification as a health services provider psychologist issued by the North Carolina Psychology Board. A licensed psychological associate who holds permanent licensure. A licensed clinical social worker, as defined in G.S. 90B-3(2) who is licensed by the North Carolina Social Work Certification and Licensure Board pursuant to Chapter 90B of the General Statutes. A duly licensed pharmacist, subject to the provisions of subsection (e) of this section. A fee-based practicing pastoral counselor certified by the North Carolina State Board of Examiners of Fee-Based Practicing Pastoral Counselors pursuant to Article 26 of Chapter 90 of the General Statutes. A substance abuse professional certified by the North Carolina Substance Abuse Professional Certification Board pursuant to Article 5C of Chapter 90 of the General Statutes. A physician assistant, as defined by G.S. 90-18.1 and subject to subsection (f) of this section. A clinical mental health counselor licensed by the North Carolina Board of Licensed Clinical Mental Health Counselors pursuant to Article 24 of Chapter 90 of the General Statutes. A marriage and family therapist licensed by the North Carolina Marriage and Family Therapy Licensure Board pursuant to Article 18C of Chapter 90 of the General Statutes. A physical therapist licensed by the North Carolina Board of Physical Therapy Examiners pursuant to Article 18E of Chapter 90 of the General Statutes. A hearing aid specialist licensed by the North Carolina State Hearing Aid Dealers and Fitters Board under Chapter 93D of the General Statutes to engage in fitting or selling hearing aids. For purposes of this subdivision, the term "fitting and selling hearing aids" has the same meaning as defined in G.S. 93D-1. An occupational therapist licensed by the North Carolina Board of Occupational Therapy pursuant to Article 18D of Chapter 90 of the General Statutes. Recodified as G.S. 58-50-30(b)(7). Recodified as G.S. 58-50-30(b)(9). Recodified as G.S. 58-50-30(b)(10). Recodified as G.S. 58-50-30(b)(12). Recodified as G.S. 58-50-30(b)(13). Recodified as G.S. 58-50-30(b)(14). Payment or reimbursement is required by this section for a service performed by an advanced practice registered nurse only when: The service performed is within the nurse's lawful scope of practice; The policy currently provides benefits for identical services performed by other licensed health care providers; The service is not performed while the nurse is a regular employee in an office of a licensed physician; The service is not performed while the registered nurse is employed by a nursing facility (including a hospital, skilled nursing facility, intermediate care facility, or home care agency); and Nothing in this section is intended to authorize payment to more than one provider for the same service. Payment or reimbursement is required by this section for a service performed by a duly licensed pharmacist only when: The service performed is within the lawful scope of practice of the pharmacist; The service performed is not initial counseling services required under State or federal law or regulation of the North Carolina Board of Pharmacy; The policy currently provides reimbursement for identical services performed by other licensed health care providers; and The service is identified as a separate service that is performed by other licensed health care providers and is reimbursed by identical payment methods. Payment or reimbursement is required by this section for a service performed by a duly licensed physician assistant only when: The service performed is within the lawful scope of practice of the physician assistant in accordance with rules adopted by the North Carolina Medical Board pursuant to G.S. 90-18.1; The policy currently provides reimbursement for identical services performed by other licensed health care providers; and The reimbursement is made to the physician, clinic, agency, or institution employing the physician assistant. A health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter shall not exclude from participation in its provider network or from eligibility to provide particular covered services under the plan or policy any duly licensed physician or provider listed in subsection (b) of this section, acting within the scope of the provider's license or certification under North Carolina law, solely on the basis of the provider's license or certification. Any health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter that offers coverage through a network plan may condition participation in the network on satisfying written participation criteria, including credentialing, quality, and accessibility criteria. The participation criteria shall be developed and applied in a like manner consistent with the licensure and scope of practice for each type of provider. Any health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter that excludes a provider listed in subsection (b) of this section from participation in its network or from eligibility to provide particular covered services under the plan or policy shall provide the affected listed provider with a written explanation of the basis for its decision. A health maintenance organization, hospital or medical service corporation, or insurer governed by Articles 1 through 67 of this Chapter shall not exclude from participation in its provider network a provider listed in subsection (b) of this section acting within the scope of the provider's license or certification under North Carolina law solely on the basis that the provider lacks hospital privileges, unless use of hospital services by the provider on behalf of a policy holder, insured, or beneficiary reasonably could be expected. Nothing in this section shall be construed as expanding the scope of practice of any duly licensed physician or provider listed in subsection (b) of this section. No lack of signature, referral, or employment by any other health care provider may be asserted to deny benefits under this provision, unless these plan requirements apply to all providers for that service. Nothing in this subsection authorizes payment to more than one provider for the same service. Nothing in this subsection is intended to authorize payment to more than one provider for the same service. History (1913, c. 91, s. 11; C.S., s. 6488; 1965, c. 396, s. 2; c. 1169, s. 2; 1967, c. 690, s. 2; 1969, c. 679; 1973, c. 610; 1977, c. 601, ss. 2, 31/2; 1991, c. 720, s. 29; 1993, c. 347, s. 2; c. 375, s. 3; c. 464, s. 2; c. 554, s. 1; 1995, c. 193, s. 41, c. 223, s. 1; c. 406, s. 3; 1997-197, ss. 1, 2; 1999-186, s. 1; 1999-199, s. 1; 1999-210, s. 2; 2001-297, s. 1; 2001-446, s. 1.7; 2001-487, s. 40(g); 2003-117, s. 1; 2003-368, s. 1; 2005-276, s. 6.29; 2005-345, ss. 3(a), 3(b); 2007-24, s. 1; 2012-129, s. 1; 2013-296, s. 1; 2017-24, s. 1; 2019-240, s. 3(f).) Cross References. - As to prohibition against discrimination between individuals of the same class in premiums or rates charged for policies covered by Articles 50 through 53 of Chapter 58 , or any other matter, see G.S. 58-3-120(b) . Editor's Note. - Session Laws 1965, c. 396, which amended this section, provided in s. 4 that the act should not be construed to equate optometrists with physicians except to the extent that each must be duly licensed. Session Laws 1967, c. 690, which amended this section, provided in s. 4: "Nothing in this act shall be construed to equate podiatrists with physicians except to the extent that each must be duly licensed." This section was amended by Session Laws 1993, c. 347, s. 2; c. 375, s. 3; c. 464, s. 2 and c. 554, s. 1. Present subsection (b) was so designated at the direction of the Revisor of Statutes. The subsection designated as subsection (b) by Session Laws 1993, c. 464, s. 2 was redesignated as subsection (d). Session Laws 2001-446, s. 8 provides: "Nothing in this act obligates the General Assembly to appropriate funds to implement this act." Session Laws 2017-24, s. 2, made subdivision (b)(16), as added by Session Laws 2017-24, s. 1, effective October 1, 2017, and applicable to health benefit contracts issued, renewed, or amended on or after that date. Session Laws 2019-240, s. 3(k), provides: "The Codifier of Rules shall make any conforming rule changes necessary to reflect the name changes made by this act.” Effect of Amendments. - Session Laws 2005-345, s. 3(b), effective March 1, 2006, added the last sentence in subsection (a3). Session Laws 2012-129, s. 1, effective October 1, 2012, inserted "physical therapist" in the section head, and inserted "a duly licensed physical therapist" in subsections (a1) and (a2), and added subsection (c5). Session Laws 2013-296, s. 1, effective October 1, 2013, rewrote the section heading and subsections (a1), (a2) and (b); deleted the former last paragraph of subsection (d), which read "For purposes of this section, an 'advanced practice registered nurse' means only a registered nurse who is duly licensed or certified as a nurse practitioner, clinical specialist in psychiatric and mental health nursing, or nurse midwife"; deleted the former last sentence of subsection (e), which formerly read "For the purposes of this section, a 'duly licensed physician assistant' is a physician assistant as defined by G.S. 90-18.1 "; and substituted "subsection (b)" for "subsection (a1)" throughout subsections (g) and (h). Session Laws 2017-24, s. 1, added subdivision (b)(16). For effective date and applicability, see editor's note. Session Laws 2019-240, s. 3(f), effective January 1, 2020, in subdivision (b)(12), substituted "clinical mental health counselor" for "professional counselor" near the beginning and substituted "Clinical Mental Health Counselors" for "Professional Counselors" near the middle. Legal Periodicals. - For note, "ERISA Preemption of State Mandated-Provider Laws," see 6 Duke L.J. Rev. 1194 (1985). For comment, "Patients' Bill of Rights; Legislative Cure-All or Prescription for Disaster?," see 81 N.C.L. Rev. 653 (2003).