Includes whereas clauses.

Part I.

Sets out NCGA findings on healthcare costs.

Adds new Article 94, Low-Cost Health Plan Option, to GS Chapter 58, providing as follows.

Defines low-cost health plan option as a qualified health plan, or group of qualified health plans, made available through a State-facilitated arrangement and ordered on the Exchange in accordance with this Article for the purpose of increasing competition, improving affordability, and expanding consumer choice. Defines reference-based rate as a reimbursement rate benchmarked to Medicare or another objective schedule adopted under the Article.

Requires the Department of Health and Human Services (DHHS) to consult with the Department of Insurance (DOI) and State Treasurer in establishing and administering the North Carolina Low-Cost Health Plan Option (Option). Requires the Option to be offered on the Exchange statewide. Allows using one or more participating carriers or third-party administrators to underwrite, administer, and operate the Option.

Requires DHHS to set procurement requirements to reduce premiums and out-of-pocket costs. Allows DHHS to require participating carriers to use value-based payment, tiered networks, advanced primary care models, or other designs consistent with affordability and quality. Allows DHHS to set reference-based rates for provider reimbursement under the Option, including rates expressed as a percentage of Medicare, with adjustments for rural access, critical access hospitals, and other essential providers. Requires that DHHS, beginning with the initial plan year and for each plan year thereafter, ensure that the Option meets specified affordability outcomes for premiums, administrative expenses, and out-of-pocket costs. Sets out steps that must be taken when DHHS determines that an affordability outcome cannot be met due to network adequacy requirements, provider participation, federal restrictions, or other constraints outside of DHHS control.

Requires that the Option be financed primarily through premiums and other revenues associated with plan operations. Allows requesting appropriations for specified functions and expenses.

Requires DHHS to report annually to the specified NCGA committee and division on enrollment, premiums, claims, administrative costs, network adequacy, consumer satisfaction, quality outcomes, and any recommended statutory changes.

Requires that the Option be offered on the Federally Facilitated Marketplace, or Exchange, beginning with the plan year 2028, unless DHHS certifies in writing to the Joint Legislative Oversight Committee on Health and Human Services that an earlier plan year is feasible.

Requires DHHS to begin planning, procurement, and implementation of this Part when this Part becomes effective.

Part II.

Adds new Article 85, Public Health Consortium, to GS Chapter 143, providing as follows.

Establishes the Public Health Purchasing Consortium (Consortium) to coordinate, aggregate, and strategically align the healthcare purchasing power of public entities in the state. Makes the State Treasurer the chair of the Consortium and sets out membership requirements. Sets out the Consortium’s six duties, including developing model procurement standards for carriers, Third-Party Administrators, Pharmacy Benefit Managers, and other vendors; coordinating strategies to improve competition, transparency, and affordability; and supporting implementation of the Option created under Article 94 of GS Chapter 58. Allows establishing a secure data- sharing framework, with data disclosed only for public purchasing purposes. Allows a county, municipality, or other political subdivision to participate in Consortium initiatives upon approval by its governing board and execution of a participation agreement, which may address specified topics. Requires an annual report to the specified NCGA committees.

Part III.

Requires that DHHS, the Department of Insurance, and the Department of State Treasurer enter into interagency agreements to implement Parts I and II. Allows DHHS to issue requests for information and requests for proposals and take actions necessary to ensure that the Option is operational by the date required.

Effective July 1, 2026, appropriates $25 million in recurring funds from the General Fund to DHHS and $10 million in nonrecurring funds for 2026-27 to implement the Plan and Consortium.

Part IV.

Appropriates $175 million in recurring funds and associated receipts for 2026-27 from the General Fund to DHHS, Division of Health Benefits (DHB), to continue and expand Health Opportunities Pilots activities to promote chronic disease prevention, reduce avoidable healthcare utilization, and improve health outcomes through interventions addressing health-related social needs. Sets out for allowable uses of the funds, with priority given to interventions and program designs expected to reduce the incidence or severity of chronic disease. Prohibits using funds to supplant existing state funding for similar purposes, unless expressly authorized by the NCGA.

Requires DHB to report annually, beginning in 2027, while funds remain available to the specified NCGA committees and division on the specified items related to the Healthy Opportunities Pilots.

Effective July 1, 2026.

Part V.

Adds Parts to Article 11B, Transparency in Health Care Costs, of GS Chapter 131E and makes the following changes.

Amends GS 131E-214.13 governing pricing disclosure for frequently reported Diagnostic Related Group (DRG), Current Procedural Technology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Adds CPT, DRG, HCPCS, and statewide data processor to the defined terms. Changes the reporting requirements in subsections (b) and (d) to now require hospitals to quarterly (was, annually) report to the statewide data processor (was, the Department of Health and Human Services (DHHS)) specified information about (1) the 100 most frequently reported admissions by DRG for inpatients and (2) total costs for the 20 most common surgical procedures and the 20 most common imaging procedures performed in outpatient settings or ambulatory surgical facilities (facilities) along with CPT and HCPCS codes. Specifies that when calculating the amount, each hospital or facility must include charges for each billable item and service associated with the DRG or procedure regardless of whether a physician or nonphysician practitioner performed the service. Reorganizes the rulemaking provisions and adds that the Medicare Care Commission (Commission) must establish procedures for the statewide data processor to receive and submit data reported to DHHS for publication on its website. Makes conforming changes.

Enacts GS 131E-214.18 to authorize DHHS to assess civil penalties for violations of Article 11B in addition to any federal penalty. Sets the daily penalty at no less than .01% of the annual salary of the CEO of the noncompliant hospital or facility or more than $2,000.

Adds receipt of data from hospitals and facilities reported pursuant to GS 131E-214.13, as amended, to the duties of a statewide data processor set forth in GS 131E-214.4 and requires submitting the data to DHHS.

Makes the above changes effective on the later of January 1, 2027, or the date rules adopted by the Commission regarding uniform reporting pursuant to GS 131E-214.13(d) becomes effective. Directs the Commission to notify the Revisor of Statutes when rules pursuant to GS 131E-214.13(f1)(1) and (2) become effective. 

Part VI.

Enacts GS 131E-214.30, as follows. Requires at the time a health service facility participating in an insurer's healthcare provider network (1) treats an insured individual for anything other than screening and stabilization; (2) admits an insured individual to receive emergency services; (3) schedules a procedure for non-emergency services for an insured individual; or (4) seeks prior authorization from an insurer for the provision of nonemergency services to an insured individual, to provide the insured individual with a written disclosure pertaining to billing, out-of-network services, and consumer protections, as described.  Requires emergency services facilities to disclose to an insured individual if it does not have a contract for services with the insured’s insurer, and to provide information about consumer protections, as described, as soon as practicable after the facility begins providing emergency services.

Enacts GS 131E-214.31, as follows. Requires at the time a healthcare provider not participating in the insured’s network (1) treats an insured individual for anything other than screening and stabilization; (2) schedules a procedure for non-emergency services for an insured individual; or (3) seeks prior authorization from an insurer for the provision of non-emergency services to an insured individual, to provide the insured individual with a written disclosure that warns the insured that the healthcare provider is not in the insured’s healthcare provider network and provides consumer protection information, as described.

Designates failure to comply with the above requirements as an unfair and deceptive trade practice. Clarifies that nothing in Article 11B of GS Chapter 131E forecloses other remedies available under law or equity.

Repeals the definition of health benefit plan in GS 58-3-200(a)(1) and insurer in GS 58-3-200(a)(2) (definitions section of provisions pertaining to miscellaneous insurance and managed care coverages and networks). Adds definition of terms clinical laboratory, and healthcare provider.

Requires an insurer upon request under GS 58-3-200(d) (services outside provider networks), to determine whether a healthcare provider able to meet the needs of the insured is available to the insured without unreasonable delay by reference to the insured's location and the specific medical needs of the insured.

Applies to healthcare services provided on or after October 1, 2026, and to contracts issued, renewed, or amended or after that date.

Part VII.

Adds new Article 11C to GS Chapter 131E, entitled “Fair Billing and Collection Practices for Hospitals and Ambulatory Surgical Facilities," as follows. Recodifies GS 131E-91(fair billing and collections practices for hospitals and ambulatory surgical facilities) as GS 131E-214.50, and reorganizes that provision into new Article 11C. Requires a hospital or ambulatory surgical facility to first present an itemized list of charges to the patient detailing the specific nature of the charges or expenses incurred by the patient before referring the bill to collection as another required collections practice under new GS 131E-214.50. Enacts new GS 131E-214.52 (patient’s right to a good faith estimate) as part of new Article 11C, as follows. Defines CMS, facility (licensed hospital or ambulatory surgical facility), items and services, service package, and shoppable service (a non-urgent service that can be scheduled by the patient in advance). Requires a facility to provide, upon a patient's request, a good faith estimate for a shoppable service as described. Limits a patient’s final bill from exceeding more than 5% of the good faith estimate. Requires DHHS to adopt rules to implement the statute. Directs DHHS to notify the Revisor when the rules required under GS 131A-214.52 take effect.

Effective on the later of January 1, 2027, or the date the rules adopted by DHHS become effect. Applies to acts occurring after the effective date. 

Part VIII.

Adds new GS 131E-214.54 (concerning facility fees) to Article 11C, as follows. Defines ambulatory surgical facility, campus, facility fee (any fee charged or billed by a health care provider for outpatient services provided in a hospital-based facility that is (i) intended to compensate the health care provider for the operational expenses of the health care provider, (ii) separate and distinct from a professional fee, and (iii) charged regardless of the modality through which the health care services were provided), health care provider, health systems, hospital, hospital-based facility, professional fee, and remote location of a hospital.

Places the following limits on facility fees: (1) prevents a health care provider from assessing a charge, bill, or collecting a facility fee unless the services are provided on a hospital's main campus, at a remote location of a hospital, or at a facility that includes an emergency department or ambulatory surgical center and (2) regardless of where the services are provided, no health care provider can assess a charge, bill, or collect a facility fee for outpatient evaluation and management services, or any other outpatient, diagnostic, or imaging services identified by DHHS. Requires DHHS to annually identify those services. 

Requires each hospital and health system to submit a report annually to DHHS by July 1st on the six specified matters. Specifies that all violations of the statute are an unfair trade practice. Subjects health care providers that violate the statute to a civil penalty of not more than $1,000 per occurrence.

Requires DHHS to adopt rules to implement new GS 131E-214.54. Effective on the later of January 1, 2027 or the date DHHS adopts the rules discussed above. Requires DHHS to notify the Revisor when the rules adopted under GS 131E-214.54 take effect.

Part IX.

Expands the State Auditor’s responsibilities under GS 147-64.6 to include a periodic review of health service facilities that: (1) receive State funds and (2) are licensed under GS Chapter 122C that are recipients of State funds for information on the prices these facilities charge out-of-network or uninsured patients and their transparency about those prices. Requires that the State Auditor report findings to the specified NCGA committee by April 1, 2027, and periodically thereafter as specified.

Part X.

Expands the obligations pertaining to non-expedited appeals under GS 58-50-61(k) to include utilization review organizations (currently just insurers). Requires providing contact information for the insurer instead of the coordinator. Makes clarifying and technical changes. Requires an insurer to provide their contact information as part of the written information they `must provide as part of a first-level grievance review (currently have to provide review contact information for the coordinator) and makes technical changes to GS 58-50-62(e) (concerning first-level grievance reviews). Requires the insurer to provide information on how and where to submit written material for a second-level grievance review and contact information for the insurer (currently, just have to provide the coordinator's contact information) in GS 58-50-62(f) (second-level grievance reviews).

Part XI-A.

Amends GS 131E-176 (the definitions pertaining to certificates of need) so that rehabilitative health services; rehabilitation health service facilities; rehabilitation health service facility beds; rehabilitation facility hospitals for rehabilitation of injured, disabled, or sick persons and nursing provided at a non-inpatient rehabilitation facility for the rehabilitation of sick, injured, or disabled individuals are no longer included in the definitions. Amends term rehabilitation facility so that it means a facility that has been classified and designated as an inpatient rehabilitation facility by the Centers for Medicare and Medicaid Services (currently, means a public or private inpatient facility which is operated for the primary purpose of assisting in the rehabilitation of individuals with disabilities through an integrated program of medical and other services which are provided under competent, professional supervision).

Part XI-B.

Adds new Article 9B, Essential Rural Health Services Protection Act, to GS Chapter 131E, providing as follows. Defines essential rural health services as any of the following services when provided in a rural county or when reasonably necessary to maintain access for residents of a rural county: emergency services; obstetrical services, including labor and delivery; inpatient services; surgical services necessary for emergency stabilization or urgent intervention; behavioral health services, including inpatient psychiatric services; dialysis services; diagnostic imaging or laboratory services necessary for emergency diagnosis or treatment; primary care services, if the Department determines that loss or material reduction of the service would likely leave a rural county without reasonable local access; and any other service designated by the Department by rules adopted pursuant to this Article as essential to preserving access to care in rural counties. Defines rural county as one with a population density of 250 or fewer persons per square mile. Defines additional terms used in the Article.

Prohibits implementing a material change (as defined, including closure of an essential rural health service, reduction in hours or capacity, or relocation of essential services) affecting essential rural health services unless notice is given to DHHS at least 120 days before the proposed effective date of the material change. Sets out what must be included in the notice.

After receiving a notice, DHHS must evaluate whether the proposed material change is reasonably likely to do one or more of the seven listed scenarios, including materially reducing access to an essential rural health service for residents of a rural county; reduce the availability of emergency services, obstetrical services, behavioral health services, primary care, inpatient services, or other essential rural health services in a rural county; increase patient travel times or care delays beyond levels reasonably consistent with maintaining meaningful rural access; or create or worsen discriminatory admission, transfer, referral, staffing, or contracting practices that shift disproportionate burdens to essential rural providers. Sets out issues DHHS must consider in conducting the review and requires getting public input when DHHS determines it is necessary to complete its evaluation.

Requires DHHS to adopt rules establishing one or more financial viability thresholds for essential rural providers. If an essential rural provider falls below those thresholds, requires DHHS to initiate a rural financial viability review, reviewing specified issues. Allows DHHS, upon finding that continued access to essential rural health services is reasonably likely to be materially impaired as a result of an essential rural provider's financial viability status, to impose reporting requirements on the essential rural provider, impose a mitigation plan, or take other enforcement action.

Requires DHHS to do one of the following within 60 days of determining that a notice meets the statutory requirements: (1) issue a written notice that no further action is required; (2) approve the proposed material change subject to a mitigation plan that satisfies this statute’s criteria; or (3) issue a written determination prohibiting the proposed material change if DHHS finds that, even with a mitigation plan, (i) essential rural health services would not be adequately protected in the affected service area or (ii) the proposed material change is reasonably likely to materially destabilize the financial viability of an essential rural provider. Sets out actions that may be included in a mitigation plan, including a requirement to phase in proposed material changes over time, requirement to maintain a financial assistance polity for uninsured and underinsured patients, and reporting and monitoring requirements. Allows extending the time for making the determination on the notice as long as specified notice is given to the person when public input or additional information is necessary. Prohibits a person from implementing a material change while a review is pending.

Requires an opportunity for public comment when a proposed material change (1) involves a hospital or hospital authority or (2) is reasonably likely to materially affect essential rural health services in a rural county.

Prohibits a person subject to the Article from: (1) engaging in any pattern or practice of admission, transfer, referral, staffing, contracting, or operational behavior that has the purpose or effect of materially undermining an essential rural provider's ability to maintain essential rural health services; (2) selectively retaining lower-acuity or better-insured patients, or shift disproportionate numbers of higher-acuity, uninsured, underinsured, or Medicaid patients, in a manner reasonably likely to materially destabilize access to essential rural health services in a rural county; (3) knowingly failing to provide the notice required; or (4) knowingly submitting materially false information to the DHHS.

Requires a person subject to a mitigation plan to report annually with DHHS for a period not to exceed five years. Requires DHHS to report annually, beginning November 1, 2027, to the specified NCGA committee and division notices, determination, mitigation plans, enforcement actions, and observed effects on rural access to essential health services.

Allows DHHS to assess civil penalties not to exceed $10,000 per day for each violation of the Article, an order, or mitigation plan. Proceeds of the penalties are to be remitted to the Civil Penalty and Forfeiture Fund. Allows DHHS to seek injunctive relief in Wake County or a county affected by a violation.

Allows DHHS to adopt rules necessary to implement the Article.

Effective January 1, 2027, and applies to material changes affecting essential rural health services proposed, announced, or implemented on or after that date.

Part XII.

Amends GS 58-50-61 (concerning utilization reviews), as follows. Defines an urgent health care service to mean a health care service (including mental or behavioral health services) with respect to which the application of the time periods for making an urgent care determination that, in the opinion of a healthcare provider with knowledge of the covered person's medical condition, either: (1) could seriously jeopardize the person's life or health or their ability to regain maximum function or (2) would subject the person to severe pain that can't be adequately managed without the care or treatment that is subject to utilization review. Defines prior authorization (process by which insurers and utilization review organizations (URO) determine coverage on the basis of medical necessity and/or covered benefits prior to the rendering of those services) and course of treatment. Now defines health care provider as it defined in GS 90-410.

Creates two different timelines for prospective and concurrent utilization reviews based on the urgency of the healthcare service. Specifies that the current three-business day deadline is for nonurgent healthcare services. For urgent healthcare services, requires the insurer or its utilization review organization (URO) to conduct the review and make the determination or noncertification by not later than 24 hours after receiving the necessary information to conduct the review, unless the provider and the insurer or the insurer’s URO does not have access to the electronic health records of the covered person. Extends the notice obligations pertaining to utilization reviews to URO’s that conduct utilization reviews.   

Sets forth three requirements that apply to an appeals review, including that any appeal not involving a mental health matter be reviewed by a licensed physician meeting the specified criteria, that appeals initiated by a licensed mental health professional be reviewed by a licensed mental health professional rather than a licensed physician and the licensed physician or licensed mental health professional consider all known clinical aspects of the healthcare service under review.  

Requires an insurer to make any current utilization review requirements and restrictions available on its website. Specifies that any new prior authorization requirements or restrictions amendments thereof are not in effect unless and until the insurer’s website has been updated to reflect the new/amended requirements or restrictions. Directs that a claim cannot be denied for failure to obtain a prior authorization if the prior authorization requirement or amended requirement was not in effect on the date of service of the claim.

Sets forth the following requirements that apply to the length of time an approved prior authorization remains valid in certain circumstances:

• If a covered person enrolls in a new health benefit plan offered by the same insurer under which the prior authorization was approved, then the previously approved prior authorization remains valid for the initial 90 days of coverage under the new heath benefit plan. Clarifies that this does not require coverage of a service if it is not a covered service under the new health benefit plan.
• If a healthcare service, other than for in-patient care, requires prior authorization and is for the treatment of a covered person's chronic condition, then the prior authorization shall remain valid for no less than six months from the date the healthcare provider receives notification of the prior authorization approval.

Requires, by January 1, 2028, insurers offering a health benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit plan, to implement and maintain a prior authorization application programming interface meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025.

Extends liability for violations of GS 58-50-61 to agents of the insurer. Prevents an insurer from using an artificial intelligence-based algorithm as the sole basis for a utilization review determination.

Makes additional technical and clarifying changes.

Applies to insurance contracts, including contracts with URO’s, issued, renewed, or amended on or after October 1, 2026.

Directs the State Treasurer and the Executive Administrator of the State Health Plan to review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with GS 58-50-61, as amended by the act. 

Makes conforming changes to GS 58-50-75 and GS 90-21.52.

Part XIII.

Enacts new Article 11D, Preserving Competition in Healthcare Act, to GS Chapter 131E. Sets forth defined terms. Defines hospital entity to include any licensed hospital, whether corporate or governmental, and any affiliated entity. Defines transaction to include all of the following, so long as the value of the assets, control, or governance interest equals or exceeds $5 million:

1. The sale, transfer, lease, exchange, optioning, conveyance, or other disposition of no less than 50% of the assets or operations of any hospital entity to any person or entity other than another hospital entity that controls, is controlled by, or is under common control with such hospital entity;
2. the transfer of control or governance of a hospital entity to a person or entity other than another hospital entity that controls, is controlled by, or is under common control with such hospital entity;
3. any binding legal obligation between two or more persons that results in a transfer of control, responsibility, or governance of no less than 50% of a hospital entity's assets to an acquiring entity;
4. any transaction, regardless of its exact form, that would be subject to review under the Article if it was structured as a purchase, merger, or joint venture;
5. any of the above transactions that is entered into by a hospital entity or by any person or entity that controls, is controlled by, or is under common control with such hospital entity; or
6. dispositions of no less than 50% of a hospital entity's assets made in the course of a bankruptcy proceeding.

Enacts GS 131E-214.61, requiring the State Auditor (Auditor), the Attorney General (AG), and the State Treasurer (Treasurer) (collectively, the Governing Actors) to collectively act or decide together on any or decision that is required by them under the Article. Excludes from the Article's scope in GS 131E-214.62 those transactions that are in the usual and regular course of a hospital entity's activities which the Governing Parties have provided a written waiver for the transaction. Deems the Governing Parties’ determination final and not subject to judicial review unless found to be arbitrary and capricious.

Establishes, in GS 131E-214.64, a procedure for hospital entities to notify the Governing Parties of proposed transactions and for the Governing Parties to review and make determinations with respect to transactions subject to the Article, as described. Requires hospital entities subject to the Article to provide the Governing Parties with written notice of a proposed transaction and certification that a copy of the Article has been provided to each member of the governing board or board of trustees of the hospital entity. Allows for a single written notice to suffice for both the hospital entity and acquiring entity, subject to the Governing Parties requesting more information as needed. Provides for the effect of the notice and directs the Governing Parties to adopt rules regarding required content and manner of the written notice. Sets forth a 60-day timeline for the Governing Parties’ review in GS 131E-214.66, within which the Governing Parties must notify the hospital entity in writing of its decision to either object to or take no action regarding the proposed transaction. Provides for the Governing Parties to extend the review period for up to another 60 days. Prohibits the parties from consummating the transaction during the review period.

Additionally requires in GS 131E-214.68, for the hospital entity to give written notice of the proposed transaction by publication in at least one newspaper in general circulation in each relevant county, as specified, within ten days after providing written notice to the Governing Parties. Details requirements of the published written notice and deems failure to provide this notice as sufficient grounds for the Governing Parties to object to the proposed transaction.

Requires in GS 131E-214.70, for the hospital entity and acquiring entity to hold at least one public hearing within 30 days after providing written notice to the Governing Parties, but not within 14 days after publication of written notice. Details hearing requirements, including seven days' written notice to the Governing Parties of the time, date, and location of the public hearing. Also requires the hospital entity and acquiring entity to give written notice to the relevant local governing bodies, as specified. Requires the Governing Parties’ approval to conduct the public hearing electronically. Provides specific hearing requirements for hospital entities that are nonprofits or publicly owned entities. Allows the Governing Parties to conduct an additional public hearing, subject to similar notice requirements. Deems the parties to the proposed transaction responsible for the costs of all public hearings. Excludes dispositions made in the course of a bankruptcy proceeding.

Lists eight general considerations the Governing Parties must address in making a determination about the proposed transaction in GS 131E-214.72, including (1) whether the fair market value of any asset to be transferred from the hospital entity to the acquiring entity has been manipulated by the actions of the parties in a manner that causes the fair market value of the asset to decrease; (2) whether the proposed transaction may have a significant effect on the cost, availability, accessibility, or quality of healthcare services for any affected community by considering six required factors; (3) any objections raised in the comments submitted to the AG; and (4) whether the proposed transaction complies with all applicable State and federal laws and regulations, including antitrust laws. Lists eight additional considerations the Governing Parties must take into account in making a decision about any proposed transaction subject to the provisions of the Article that would alter the control or governance of a tax-exempt or publicly owned hospital entity. Finally, for any proposed transaction subject to the provisions of the Article that involves a hospital owned by a municipality or a hospital authority, requires the Governing Parties to determine whether the transaction complies with the provisions of Article 2 of GS Chapter 131E governing the sale or conveyance of any rights of ownership the municipality or hospital authority has in a hospital entity.

Enacts GS 131E-214.76, granting the Governing Parties authority to contract, consult and receive advice from any State or US agency, or contract with experts or consultants, to assist in transaction review. Allows the Governing Parties to request from the Department of Health and Human Services (DHHS) a report of the anticipated effects of any proposed transaction on access to, or the pricing of, healthcare services in any part of the State; allows extension of the review period upon requests of such reports so long as the total review period does not exceed 180 days from the Governing Parties’ notice that the parties have submitted a complete notice. Authorizes the Governing Parties to impose specified fees upon the acquiring entity of up to $50,000 for the cost of all the contracts entered into by the Governing Parties, the Governing Parties’ actual review costs and DHHS's actual costs for report preparations. Allows the acquiring entity to seek an order from a court to limit its liability for imposed fees. Details procedures for such an objection and the effect of failing to pay imposed fees.

Establishes requirements for instances in which the Governing Parties objects to the proposed transaction in GS 131E-214.78. Requires the Governing Parties to file an action seeking injunctive relief in superior court, as described. Details procedures of such actions based on whether the hospital entity is a nonprofit or publicly owned entity, or a for-profit entity. In either instance, the court can issue a final determination approving the transaction, approving the transaction subject to modification, or disapproving the transaction. Allows appeal of the court's decision, except prohibits the Governing Parties from appealing a court's approval of the transaction subject to the same modification the Governing Parties initially sought. Allows any party to decline to enter into a transaction modified by court order. Deems modified transactions entered into not subject the renewed objections by the Governing Parties.

Following either the conclusion of the review process by the Governing Parties under GS 131E-214.72 or, if necessary, after a final decision of any judicial action authorized under GS 131E-214-78, requires the acquiring party to submit an annual report on its compliance with the terms of the purchase agreement for the transaction, including any representations made to, or modifications made by the Governing Parties. Directs the Governing Parties to adopt rules to specify the required contents of the annual report.  Requires entities that acquired a nonprofit or publicly owned hospital entities to also submit a report on its charitable activities and the disposition of its charitable assets. Authorizes the Governing Parties to file an action for relief as specified to restore the benefits of healthcare provider competition if the Governing Parties deem it reasonable and necessary to do so based on the acquiring entity’s failure to comply with the terms of the agreement either approved by the Governing Parties or issued by a court, including any modifications thereto.

Prohibits an acquiring entity from changing the financial assistance policy regarding uninsured or underinsured in effect immediately proceeding consummation of the transaction without first providing 120 days' written notice to the AG, its hospital staff, and patients who have previously benefited from the hospital entity's policy, with a limited exception for increases to applicable eligibility income limits. Clarifies that this provision does not prevent a hospital from increasing its applicable income limits used to determine patient eligibility for financial assistance at any time following consummation of the transaction, and it does not require an acquiring entity to provide prior notice to the Governing Parties. Details notice requirements for patients who previously benefited from the policy. Includes education requirements for the acquiring entity's physicians regarding new financial assistance policies and verbally informing patients of the new policy during the notice period.

Enacts GS 131E-214.82, as follows. Deems any transaction in violation of the Article void. Subjects each member of the governing board and each chief financial officer of the transaction entered in violation of the Article up to $50,000 per transaction unless the violation was made in wanton disregard of the law, in which case the penalty may be up to $1 million per violation. Directs the Governing Parties to initiate an action for determination of the penalty amount in the Superior Court for Wake County. Prohibits DHHS from issuing hospital licensed to any party of a transaction entered in violation of the notice, public hearing, and review requirements of the Article. Specifies the effect of the Article on the Governing Parties’ authority and the effect of the Article's penalties and remedies.

Effective December 1, 2026, and applies to activities occurring on or after that date.