House committee substitute makes the following changes to 1st edition.
Adds a new section, stating that the purpose of the act is to establish the North Carolina Health Benefit Exchange Authority (Exchange Authority) to facilitate the purchase and role of qualified health plans in the individual and small employer market through education, outreach, and technical assistance.
Definitions. Clarifies that the SHOP Exchange is the Small Business Health Options Program established in proposed Part 8 to assist NC Qualified Employers who are small employers to facilitate the enrollment of their employees in Qualified Health Plans. Defines Individual Exchange as the Exchange through which Qualified Individuals purchase coverage. Clarifies the definition for Exchange Authority (was, Exchange in previous edition) and makes a conforming change to all references throughout Part 8. Adds new terms applicable to Part 8 and makes clarifying changes to definitions.
Exchange. Makes organizational and clarifying changes to the provisions establishing the Exchange Authority, the Exchange Authority Board of Directors (Board), and the powers and duties of each. Clarifies that the Exchange Authority is subject to the supervision of the Commissioner of Insurance (Commissioner). Also clarifies that the purpose of the Exchange Authority is to: (1) create and administer an Individual Exchange and a SHOP Exchange as two separate health benefit exchanges; (2) facilitate the purchase and sale of Qualified Health Plans to Qualified Individuals and Qualified Employers; and (3) assist Qualified Individuals and Qualified Employers in enrollment in Qualified Health Plans. Provides that the Board will consist of the Commissioner and the Director of the Division of Medical Assistance as ex officio nonvoting members, and 11 additional, appointed members. Details the appointing authority as follows: (1) four members appointed by the President Pro Tempore of the Senate for three year terms, with appointments made within 30 days after enactment; (2) four members appointed by the Speaker of the House of Representatives for three year terms, with appointments made within 30 days after enactment; and (3) three members appointed by the Governor for two year terms, within 30 days after enactment. Includes additional appointee qualifications and requirements. Details additional powers and duties of the Board.
Requires the Commissioner to review and approve or disapprove the Plan of Operation submitted by the Board within 90 days. Deems the Plan approved if the Commissioner fails to act within 90 days. Allows for resubmission upon disapproval and outlines other procedures related to Plan submission. Clarifies and adds to the list of components included in the Plan of Operation. Clarifies that the Exchange Authority has the authority to contract with an eligible entity, as defined, to perform any functions described in Part 8, take legal action, and enter into information-sharing agreements with federal and state agencies and other state exchanges as specified. Authorizes the Exchange Authority to make a Qualified Health Plan available that may require benefits other than the Essential Health Benefits, as specified. Directs the Executive Director of the Exchange Authority to make an annual report by March 1 of each year to listed parties, summarizing the activities of the Exchange Authority during the preceding calendar year. Makes the Exchange Authority, the Board, and employees, subject to Article 33C of GS Chapter 143 (provisions for meetings of public bodies). Makes all information in the possession of the Exchange Authority, regardless of physical form, subject to GS Chapter 132 (public records), except protected and confidential information. Clarifies other requirements of the Exchange Authority. Provides additional duties for the Exchange Authority, including the duty to establish an Individual Exchange, to meet specified financial integrity requirements, and to conduct a review of the costs and benefits of collecting and distributing premiums for small businesses. Details reporting requirements.
Health Benefit Plan Certification. Clarifies that the Exchange Authority will certify a Health Benefit Plan as a Qualified Health Plan if the Department of Insurance determines the plan satisfies the enumerated requirements, unless the Exchange Authority determines the plan is not in the interest of Qualified Individuals and Employers. Directs the Exchange to establish and publish a transparent, objective process for denying certification or decertifying Qualified Health Plans, as described. Makes other clarifying changes.
Additional Provisions. Permits a Qualified Employer to either designate one or more Qualified Health Plans from which its employees may choose or designate any level of coverage to be made available to employees through the SHOP Exchange. Permits a Qualified Individual enrolled in any Qualified Health Plan to pay any applicable premium owed to the Health Insurer issuing the plan. Establishes the Individual Exchange and the SHOP Exchange risk pools, as detailed. Provides that the statute does not: prohibit a Health Insurer from offering outside of the Individual Exchange or the SHOP Exchange a health plan to a Qualified Individual or Employer; prohibit a Qualified Individual from enrolling in, or a Qualified Employer from selecting, a health plan outside of the Exchange Authority; limit the operation of any state law for any policy or plan outside the Exchange Authority; or otherwise restrict the choice of any individual to enroll or not enroll. Details circumstances under which a Qualified Individual may enroll in a catastrophic plan. Allows Agents and Brokers to enroll and assist Qualified Individuals and Employers, as described. Requires Agent and Broker compensation to be determined by the insurer.
Codifies the utilization of the funding stream from the NC Health Insurance Risk Pool to support the Exchange Authority. Adds that, beginning in 2015, the funding stream supporting the NC Health Insurance Risk Pool will support those operations of the Exchange Authority that serve individuals with incomes less than or equal to 400% of the federal poverty level and Qualified Employers receiving a tax credit for the purchase of insurance under federal law. Requires other costs to be funded by an annual user fee paid by the individual or employer to the Exchange Authority, as specified. Requires the Exchange Authority to examine its potential operating costs and propose any additional funding stream changes before the 2013 General Assembly commences. Directs the Exchange Authority to be self-sustaining by January 1, 2015, as required by federal law. Details additional funding criteria and exempts the Exchange Authority from all state taxes. Directs the Commissioner to promulgate necessary regulations. Requires an annual audit of the Exchange Authority. Makes additional clarifying changes.
Changes the title of the act to AN ACT TO PRESERVE STATE-BASED AUTHORITY TO REGULATE THE NORTH CAROLINA HEALTH INSURANCE MARKET AND TO PREVENT FEDERAL ENCROACHMENT ON STATE AUTHORITY BY ESTABLISHING THE NORTH CAROLINA BENEFIT EXCHANGE.