North Carolina Health Insurance Guide
North Carolina Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
When you live in North Carolina you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for North Carolina State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
North Carolina is not a guarantee issue state. By law, private insurance companies that sell individual policies must medically underwrite them and are required to sell you an individual health insurance policy if you do not meet their criteria. You can be turned down for any number of reasons including your past or current health and lifestyle habits. In North Carolina, insurers are permitted a 12-month exclusionary period and a 12-month look-back period for pre-existing conditions, if you file a claim during the first two years that your policy is in effect. After the two-year period, there is no look-back permitted. North Carolina does not require an insurer to give you credit for prior creditable coverage. North Carolina does permit health insurance providers to issue Elimination Riders that exclude coverage for specific health conditions. Premiums, which are not regulated by the state, can be based on your health, your age and lifestyle factors. There are no requirements for insurers to issue standardized policies to individuals.
North Carolina is a guarantee issue state for group health plans issued to small businesses. If your North Carolina health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. The insurer can impose a 12-month exclusionary period and a six-month look-back period for pre-existing medical conditions. Credit for prior creditable coverage is mandated if you have had no more than a 63-day break in your health insurance coverage. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance may be underwritten and the insurer can charge a premium not to exceed 20% of its index rate if your group has a history of unfavorable health. If you are self-employed you can qualify as a group of one but you can be denied coverage for all plans but the two standardized plans the state requires that small group insurance providers offer. You may also be required to show proof of business ownership.
North Carolina is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. However, your premiums can be increased to reflect your current health status. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
North Carolina Mandated Health Benefits
North Carolina laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism and Drug Abuse Treatment
- Birthing Centers and Midwives
- Bone Mass Measurements
- Breast Reconstruction
- Cervical Cancer and HPV Screening
- Cleft Palate
- Clinical Trials
- Contraceptives
- Dental Anesthesia
- Diabetes Supplies and Self Management
- Emergency Services
- Home Health Care
- Mammography
- Mastectomy and Mastectomy Stays
- Maternity and Maternity Stays
- Newborn Hearing Screening
- Off Label Drug Use
- Prostate Cancer Screening
- TMJ Disorders
- Well-Child Care
- Coverage for newborns under their parent’s policy
- Coverage for adopted children under their parent’s policy
- Coverage for handicapped dependents under their parent’s policy
- Coverage for continuation/dependents under their parent’s policy
- Coverage for continuation/employees
- Coverage for conversion to non-group
Types Health Insurance Plans Available in North Carolina
The following major medical health insurance plans are generally available in North Carolina. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in North Carolina
The North Carolina Health Insurance Risk Pool
NCHIRP, also known as Inclusive Health, is the state-sponsored high-risk pool that offers health insurance to state residents who have been unable to secure coverage from private insurers because of a pre-existing condition or certain other qualifiers. You can choose from three plans. Deductibles, co-pays, coinsurance and maximum out-of-pocket expenses will vary based on the plan you choose. Premiums are based on the plan you select, your sex, your age and whether or not you smoke, but are capped between 150% and 200% of the standard rate charged for similar coverage in North Carolina.
NCHIRP enrollment is open. There is a 12-month exclusionary period for pre-existing conditions, but it can be waived if you can show proof of continuous creditable coverage or if you are HIPAA-eligible.
North Carolina Health Choice
NCHC provides comprehensive free or low-cost health care for resident children up to age 21, whose families meet income requirements. Two plans are available with assignment based on family income. No premiums are charged but co-pays and coinsurance will vary depending on plan but cannot exceed 5% of family income. There are no waiting periods for most applicants. Enrollment is open but is subject to review and renewal.
Regulating Agency
The North Carolina Department of Insurance is responsible for regulating North Carolina’s health insurance industry.
Get access to North Carolina health insurance quotes from http://www.einsurance.com/health-insurance.
North Carolina Department of Insurance
Dobbs Building
430 N Salisbury St
Raleigh, NC 27603-5926
(919) 807-6750 or (800) 546-5664 (NC only)
http://www.ncdoi.com
North Carolina Health Insurance Risk Pool
(866) 665-2117
contactus@inclusivehealth.org
http://nchirp.org
North Carolina Health Choice (NCHC)
(800) 662-7030 (NC only)
http://www.dhhs.state.nc.us/dma/healthchoice
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/