Enacts new Part 8 in Article 50 of GS Chapter 58, titled the North Carolina Health Benefit Exchange Act, to establish the nonprofit entity of the North Carolina Health Benefit Exchange (Exchange) and provide for its membership, authority, and operation.
Definitions. Provides definitions applicable to new Part 8. Defines qualified health plan as a health benefit plan that meets certification criteria described in section 1311(c) of the federal Patient Protection and Affordable Care Act, as amended, meets criteria in GS 58-50-324 (health benefit plan certification requirements in proposed Part 8), and meets any additional requirements. A qualified employer (1) elects to make full-time employees eligible for one or more qualified health plans offered through the SHOP Exchange and, at the employer's option, some or all of its part-time employees; (2) has its principal place of business in North Carolina; (3) elects to provide coverage through the SHOP Exchange to all eligible employees, wherever employed; and (4) employs no more than the maximum number of employees allowable. The SHOP Exchange is the Small Business Health Options Program established in Part 8. Defines qualified individual as an individual, including a minor, who (1) is seeking to enroll in a qualified health plan offered to individuals through the Exchange; (2) is legally domiciled in North Carolina on the date of enrollment; (3) is not incarcerated at the time of enrollment, other than incarceration pending disposition of charges; and (4) is a citizen or national of the United States or an alien lawfully present in the U.S., and is also reasonably expected to be in the U.S. for the entire period for which enrollment is sought.
Exchange. Provides that the Exchange, established under Part 8, is not an instrumentality of North Carolina, and will operate under the Exchange Board of Directors. Requires the Exchange to make qualified health plans available to qualified individuals and qualified employers beginning on or after January 1, 2014. Authorizes the Exchange to offer only qualified health plans, unless it is a limited scope dental benefit, as specified. Allows a qualified health plan to voluntarily offer benefits in addition to essential health benefits, unless the Exchange Board of Directors determines it is not in the public interest. Requires the state to defray the costs of the additional benefits to the extent that state law or regulation requires that qualified health plans provide additional benefits. Prohibits the Exchange and any health carrier from charging a fee or penalty for termination of coverage in specified circumstances. Creates a Board of Directors (Board) of the Exchange, consisting of the Commissioner of Insurance (Commissioner), the Director of the Division of Medical Assistance, and eight appointed members, as listed. Details appointment, term, and meeting guidelines. Includes an indemnification provision for the Board and employees of the Exchange and classifies members of the Board as public servants under GS Chapter 138A. Lists additional ethics provisions and subjects the Board to Article 33C of GS Chapter 143 (governing meetings of public bodies). Enumerates the general duties and powers of the Exchange, including the duty to facilitate the purchase and sale of qualified health plans and to assist qualified individuals and qualified employers with enrollment. Also directs the Exchange to establish a SHOP Exchange (1) through which qualified employers may access coverage for their employees and (2) which will enable any qualified employer to specify a level of coverage so any employee may enroll in any qualified health plan offered through the SHOP Exchange at the specified level of coverage.
Sets forth duties, including reporting requirements, for the Board. Requires the Board to develop and submit a Plan of Operation for the Exchange to the Commissioner containing specified information. Provides for public inspection and public comment and specifies components for inclusion in the Plan of Operation.
Health Benefit Plan Certification. Directs the Exchange to certify a health benefit plan as a qualified health plan if the plan meets all of the detailed requirements. Prohibits the Exchange from excluding a health benefit plan by imposing premium price controls. Further prohibits the Exchange from excluding a plan solely because the plan is a fee-for-service plan or because the plan provides treatments necessary to prevent patients' deaths in circumstances the Exchange deems inappropriate or too costly. Provides additional requirements applicable to the certification of qualified health plans and includes criteria related to qualified dental plans. Allows a qualified individual enrolled in a qualified health plan to pay any applicable premium owed by the individual to the insurer issuing the plan.
Consumer Choice. Provides that nothing in Part 8 or in the federal Patient Protection and Affordable Care Act (Affordable Care Act) will be construed to: (1) prohibit a properly authorized insurer from offering a health benefit plan to a qualified individual or employer outside the Exchange; (2) prohibit a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health benefit plan outside the Exchange; (3) terminate, abridge, or limit the operation of any requirement under state law with respect to any health benefit plan outside the Exchange; (4) restrict the choice of a qualified individual to enroll or not enroll in a qualified health benefit plan or to participate in the Exchange; or (5) compel an individual to enroll in a qualified health plan or participate in the Exchange. Allows a qualified individual to enroll in any qualified health plan, except that in the case of a catastrophic plan, as described, the individual may enroll in the plan only if the individual is eligible under the Affordable Care Act.
Risk Pooling. Requires an insurer who delivers or issues for delivery any health benefit plan in North Carolina to consider all enrollees in all health benefit plans, other than grandfathered health plans offered by the insurer in the individual market or in the small group market, including enrollees who do not enroll in individual plans or small group plans, to be members of a single risk pool. Authorizes the Commissioner to merge or separate the individual and small group insurance markets, if appropriate.
Funding. Shares the funding stream, beginning in 2014, currently supporting the North Carolina Health Insurance Risk Pool to support the Exchange in 2015 and subsequent years. Provides criteria for charging assessments or user fees. Requires the Exchange to publish the average costs of taxes, assessments, licensing, regulatory fees, administrative costs, monies lost to fraud and waste, and any other payments, on the Internet. Provides for an annual audit and exempts the Exchange from all state taxes.
Additional Provisions. Authorizes the Board and the Commissioner to adopt rules, as required, to implement Part 8. Deems all documents, made or received in connection with the Exchange, public records and subject to GS Chapter 132 (governing public records), except as protected under state or federal law. States that nothing in Part 8 will be construed to conflict with, preempt, or supersede the Commissioner's authority to regulate the business of insurance. Requires all health carriers offering qualified health plans to comply fully with all applicable laws, unless specifically excepted. Reserves GS 58-50-344 through GS 58-50-349 for future codification purposes.
Directs the Exchange to study and make recommendations to the 2013 Regular Session of the General Assembly regarding a Board fund for administrative expenses. Directs the Exchange to study and make recommendations to the Department of Insurance (DOI) regarding whether large employers, as defined, should be offered coverage through the Exchange in or after 2017. Also requires collaboration with DOI to study costs associated with mandated coverage and to report the results and any recommendations before the 2012 session convenes.
Enacts new GS 58-3-300 to direct the Commissioner to establish, no later than January 1, 2014, a reinsurance program, as specified in the Affordable Care Act, for the individual market. Directs the Commissioner to either assess a charge on or make a payment to health plans and health insurers, depending upon whether the actuarial risk of the enrollees of the plans or coverage for a year is more or less than the average actuarial risk of all enrollees in all plans or covered in the state for that year that are not self-insured group health plans and which are subject to the federal Employee Retirement Income Security Act of 1974, as amended. Defines applicable terms.
Enacts new GS 58-3-305 to require insurers providing coverage under a health benefit plan in the individual or group markets to comply with section 1311(e)(3) of the Affordable Care Act (transparency in coverage), except that a plan or coverage that is not offered through the Exchange will only be required to (1) submit the information required to the U.S. Department of Health and Human Services and to the Commissioner and (2) make that information public. Defines applicable terms.
Bill H 126 (2011-2012)Summary date: Feb 17 2011 - View summary