GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1989

S	1 

SENATE BILL 827

Short Title:  State Employee Emerg. Hosp. Cert.	(Public)
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Sponsors: Senator Sands.
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Referred to:  Human Resources.
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April 10, 1989

A BILL TO BE ENTITLED
AN ACT TO EXCLUDE EMERGENCY INPATIENT HOSPITALIZATIONS FROM PREADMISSION CERTIFICATION REQUIREMENTS OF THE TEACHERS' AND STATE EMPLOYEES' COMPREHENSIVE MAJOR MEDICAL PLAN.
The General Assembly of North Carolina enacts:
Section 1.  G.S. 135-40.6(2) reads as rewritten:
"(2)	Limitations and Exclusions to In-Hospital Benefits.
a.	The services of physicians, surgeons and technicians not employed by or under contract to the hospital are not covered.
b.	Any admission for diagnostic tests or procedures which could be, and generally are, performed on an outpatient basis, if no hospitalization would have been required except for such diagnostic services is not covered. However, benefits are provided at ninety percent (90%) of Plan benefits for diagnostic tests and procedures consistent with the symptoms or diagnosis for which admitted.
c.	The Plan will not cover any admission to a hospital prior to the effective date of coverage or beginning prior to the expiration of any waiting period so long as the individual remains continuously in a hospital.
d.	Hospitalization for custodial, domiciliary or sanitarium care, or rest cures, is not covered.
e.	Hospitalization for dental care and treatment is not covered, except when a hospital setting is medically necessary.
f.	Prior to admission for scheduled inpatient hospitalization the admitting physician shall contact the Plan and secure approval certification for an inpatient admission, including a length of stay, based upon clinical criteria established by the medical community, before any in-hospital benefits are allowed under G.S. 135-40.8(a). Effective January 1, 1987, failure to secure certification, or denial of certification, shall result in in-hospital benefits being allowed at the rate maximum amount of out-of-pocket expenses established by G.S. 135-40.8(b). Denial of certification by the Plan shall be made only after contact with the admitting physician and shall be subject to appeal to the Executive Administrator and Board of Trustees."
Sec. 2.  This act shall become effective July 1, 1989.