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 requirements.
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 and criteria in GS 58-50-340 (health benefit plan certification requirements in proposed Part 8). A qualified employer is a small employer that elects to make (1) its full-time employees eligible for one or more qualified health plans offered through the SHOP exchange and (2) at the employer’s option, some, or all of its part-time employees eligible. 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) resides in NC; (3) is not incarcerated at the time of enrollment, other than incarceration pending disposition of charges; and (4) is, and is reasonably expected to be, for the entire period for which enrollment is sought, a citizen or national of the U.S. or an alien lawfully present in the U.S.
Exchange. Provides that the Exchange, established under Part 8, is not an instrumentality of North Carolina. Provides that the Exchange will operate under the Exchange Board of Directors until the General Assembly determines that it is no longer in the interest of the people of the state to maintain state-based authority of the Exchange and enacts legislation to allow for federal control of this segment of the state insurance market. Requires the Exchange to make only qualified health plans available to qualified individuals and qualified employers beginning with effective dates on January 1, 2014. Permits the Exchange to allow a health carrier to offer limited dental benefits, as indicated, if the plan also provides pediatric dental benefits, as specified. 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) and the Director of the Division of Medical Assistance or the Director’s designee, as ex-officio nonvoting members of the Board. Provides for seven voting members of the Board with four members appointed by the Commissioner, one appointed by the Governor, one by the General Assembly on the recommendation of the Speaker of the House of Representatives, and one member appointed by the General Assembly on the recommendation of the President Pro Tempore of the Senate. Requires that each of the appointed voting members of the Board have expertise in at least two of eleven specified areas relating to health care coverage, finance, and administration. Directs each of the appointing authorities to consult with all other appointing authorities with the goal of making the Board’s composition reflect a diversity of expertise.
Directs the establishment of Five Board Advisory Committees, with a minimum of five members each, to provide technical assistance concerning the operations of the Exchange: (1) Health Carrier Advisory Committee, (2) Employer Advisory Committee, (3) Consumer Advisory Committee, (4) Producer and Navigator Advisory Committee, and (5) Provider Advisory Committee. Provides that the Commissioner select initial members to serve on each of the five Board Advisory Committees based on recommendations from stakeholder groups representing the five subject areas of interest represented by the Board Advisory Committees.
Details term lengths, the filling of vacancies, and meeting guidelines. Includes an indemnification provision for the Board and employees of the Exchange. Classifies members of the Board as public servants under GS Chapter 138A and classifies the Board as a public body under GS 143-318.10(b). Provides ethics guidelines and specifies that each Board member is to comply with all conflict of interest rules and recusal procedures set out in the Board’s Plan of Operation. Declares that each Board member has the responsibility and duty to meet the requirements of (1) proposed Part 8, (2) the Affordable Care Act, and (3) all applicable state and federal laws, rules, and regulations. Enumerates the general powers and authority of the Exchange, including the power to enter into contracts to carry out the provisions of Part 8. Lists the duties and operational requirements of the Exchange, including the directive 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 Executive Director of the Exchange. Requires the Board to submit a Plan of Operation for the Exchange to the Commissioner containing specified information.
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 unless the Board determines that the health benefit plan is not in the public interest. 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.
Additional Provisions. Requires an annual audit of the exchange under the oversight of the State Auditor, with the audit costs reimbursed to the State Auditor from Exchange funds. Directs the Commissioner and the Board to adopt rules under GS Chapter 150B, including temporary rules, as necessary or proper to implement the provisions of proposed Part 8. Provides that rules adopted by the Board under this section are not to conflict with or prevent the application of rules adopted by the Commissioner under proposed Part 8 or under GS Chapter 58.
Reserves GS 58-50-351 through GS 58-50-349 for future codification purposes. Diverts the funding stream currently supporting the North Carolina Health Insurance Risk Pool to support the Exchange, beginning in 2014. Requires the Exchange to publish on the internet the average costs of licensing and regulatory fees, administrative costs, monies lost to fraud and waste, and any other payments. States that nothing in the act 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. Includes a severability clause.