North Carolina Health Insurance Guide
North Carolina Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
As a North Carolina resident you can choose from health insurance plans provided to individuals and groups by private insurance carriers. Eligible individuals and families may also take advantage of low-cost and no-cost health insurance offered by North Carolina State-funded programs, as well as government-sponsored programs such as Medicaid, COBRA and the Pre-Existing Conditions Insurance Plan (PCIP).
North Carolina Guaranteed Issue Policy
North Carolina is not a guaranteed issue state for individuals. That means private insurers are not required to sell health insurance to individuals who do not meet their underwriting criteria. You may be turned down, asked to pay a higher premium or offered limited coverage because of a pre-existing condition (see North Carolina and the Affordable Care Act below for exceptions regarding pre-existing conditions). When you renew your individual policy, the insurer has the right to increase your premiums based on age and other factors. All small group policies are guarantee issue.
North Carolina Guaranteed Renewal Policy
North Carolina is a guaranteed renewal state. While your insurance company has the right to increase the premiums on your individual health care policy based on age and other factors, they cannot cancel your policy as long as you pay your premiums, do not defraud the insurers, and in the case of some managed health programs, do not move out of the coverage area. If your North Carolina health insurance is provided through an employer’s group plan, your coverage cannot be canceled or subject to higher premiums because of your health.
North Carolina and the Affordable Care Act of 2010
The Affordable Care Act (ACA) has no direct impact on individual state mandates, however it may have significant impact on some aspects of your health care. As of September 23, 2010:
- Insurers can no longer impose pre-existing condition exclusions on children under age 19. The ban includes both benefit limitations and outright denial of coverage. These protections apply to all types of insurance except individual policies that are grandfathered. Beginning in 2014, these protections will be extended to all ages.
- ACA eliminates the use of lifetime benefit caps on such essential services as ambulatory patient care, hospitalization, emergency services, chronic disease management, lab services, maternity and newborn care, preventive and wellness care, and prescription drugs.
- Health insurance providers must provide full coverage for preventive health care recommended by the Centers for Disease control including immunizations.
- New ACA rules make emergency services more accessible by prohibiting health plans and insurers from charging higher copayments or coinsurance for emergency services obtained out of a plan network.
- ACA allows children under age 26 to stay on their parents’ family policy or be added to it. Grandfathered group plans can limit this benefit to adult children who do not have any other offer of employment-based coverage.
A number of additional ACA mandates are scheduled to go into effect in 2014.
North Carolina State Mandated Health Benefits
North Carolina currently has a number of state-mandated benefits that exceed ACA requirements and that private providers must provide or offer in health insurance policies, depending on plan. They currently include:
- Adopted children coverage under parent’s policy
- Alcoholism and drug abuse
- Birthing centers/midwives
- Bone mass measurement
- Breast reconstruction
- Cervical cancer and HPV screening
- Cleft palate
- Clinical trials
- Continuation/dependents coverage under parent’s policy
- Continuation/employees coverage
- Conversion to non-group coverage
- Diabetes supplies and self management
- Emergency services
- Handicapped dependent coverage under parent’s policy
- Home health care
- Mastectomy and mastectomy stays
- Maternity and maternity stays
- Newborn coverage under parent’s policy
- Newborn hearing screening
- Off-label drug use
- TMJ disorders
- Well-child care
- Second surgical opinion
Private Health Care Options in North Carolina
Individuals and small businesses in North Carolina may chose from a variety of Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans.
- For Individuals and Families –There is a 12-month look-back and a 12-month exclusionary period for pre-existing conditions for applicants without proof of prior creditable coverage. Eligibility is subject to medical underwriting. If you are denied coverage because of a medical condition, you may be eligible for coverage through Inclusive Health. Plan costs including premiums, copayments and coinsurance will vary. There are no rate caps in the North Carolina individual insurance market.
- For Small Businesses (1 – 50 employees) – There is a maximum 6-month look-back period and a maximum 12-month exclusionary period for pre-existing conditions for enrollees without prior creditable coverage. Pre-existing conditions are covered. Employees must work 30 or more hours a week to be eligible. Owner can count as an employee. Costs to employer depend on level of contribution and are +/- 20% of the insurance company’s index rate.
Public Health Care Programs in North Carolina
Regulating Agencies and Insurance Information Resources
North Carolina Department of Insurance
430 N Salisbury St.
Raleigh, NC 27603-5926
(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.
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.
110 William Street
New York, NY 10038