(a) In General. Inthe case of health insurance coverage offered in this State, a small employercarrier may elect to limit the coverage offered under G.S. 58‑50‑125(d)if the carrier offers at least two different policy forms of health insurancecoverage and both policy forms meet all of the following:
(1) The policy forms aredesigned for, made available or actively marketed to, and actually enroll self‑employedindividuals and other small employer groups.
(2) The policy formsmeet the requirements of either subsections (b) or (c) of this section, aselected by the small employer carrier.
(b) Choice of MostPopular Policy Forms. The requirements of this section are met for healthinsurance coverage policy forms offered by a small employer carrier if thecarrier offers the policy forms for small group health insurance coverage withthe two highest premium volume numbers of all the policy forms offered by thecarrier in this State or in applicable marketing or service areas in the periodinvolved.
(c) Choice of TwoPolicy Forms with Representative Coverage. The requirements of this sectionare met for health insurance coverage policy forms offered by a small employercarrier in the small group market if the small employer carrier offers bothpolicy forms described in this subsection and each policy form includesbenefits substantially similar to other small group health insurance coverageoffered by the small employer carrier in this State.
(1) Lower‑levelcoverage policy form. A policy form is deemed a lower‑level coveragepolicy form if the actuarial value of the benefits under the coverage is atleast eighty‑five percent (85%), but not greater than one hundred percent(100%) of a weighted average, as described in subdivision (3) of thissubsection.
(2) Higher‑levelcoverage policy form. A policy form is deemed a higher‑level coveragepolicy form if all of the following apply:
a. The actuarial valueof the benefits under the coverage is at least fifteen percent (15%) greaterthan the actuarial value of the coverage described in subdivision (1) of thissubsection offered by the small employer carrier.
b. The actuarial valueof the benefits under the coverage is at least one hundred percent (100%), butnot greater than one hundred twenty percent (120%) of a weighted average, asdescribed in subdivision (3) of this subsection.
(3) Weighted average. Forthe purposes of this subsection, a weighted average is the average actuarialvalue of the benefits provided by all the health insurance coverage issued, aselected by the small employer carrier, either by that small employer carrier orall small employer carriers in this State in the small group market during theprevious year, not including coverage issued under this section, weighted byenrollment for the different coverage.
(d) Election. Thesmall employer carrier elections of the policies to be offered under thissection shall apply uniformly to all small employers in this State for thatsmall employer carrier. The election shall be effective for a period of notless than two years. An election under this section shall be made in accordancewith G.S. 58‑50‑127.
(e) Assumptions. Forthe purposes of subsection (c) of this section, the actuarial value of benefitsprovided under small group insurance coverage shall be calculated based on astandardized population and a set of standardized utilization and cost factors.
(f) Discontinuation ofBasic or Standard Plans. If a small employer carrier chooses to offer theplans under this section and discontinues coverage under the basic or standardhealth benefit plans provided for in G.S. 58‑50‑125, the carriershall make available to the insured employer whose coverage is to bediscontinued both of the plans offered under this section. New coverage madeavailable under this section shall constitute replacement coverage and shall berated in accordance with G.S. 58‑50‑130(b)(3).
(g) Different PolicyForms. For purposes of this section only, policy forms that have differentcost‑sharing arrangements or different riders shall be considered to bedifferent policy forms. (2006‑154, s. 3; 2007‑298, s. 5.1.)
(a) In General. Inthe case of health insurance coverage offered in this State, a small employercarrier may elect to limit the coverage offered under G.S. 58‑50‑125(d)if the carrier offers at least two different policy forms of health insurancecoverage and both policy forms meet all of the following:
(1) The policy forms aredesigned for, made available or actively marketed to, and actually enroll self‑employedindividuals and other small employer groups.
(2) The policy formsmeet the requirements of either subsections (b) or (c) of this section, aselected by the small employer carrier.
(b) Choice of MostPopular Policy Forms. The requirements of this section are met for healthinsurance coverage policy forms offered by a small employer carrier if thecarrier offers the policy forms for small group health insurance coverage withthe two highest premium volume numbers of all the policy forms offered by thecarrier in this State or in applicable marketing or service areas in the periodinvolved.
(c) Choice of TwoPolicy Forms with Representative Coverage. The requirements of this sectionare met for health insurance coverage policy forms offered by a small employercarrier in the small group market if the small employer carrier offers bothpolicy forms described in this subsection and each policy form includesbenefits substantially similar to other small group health insurance coverageoffered by the small employer carrier in this State.
(1) Lower‑levelcoverage policy form. A policy form is deemed a lower‑level coveragepolicy form if the actuarial value of the benefits under the coverage is atleast eighty‑five percent (85%), but not greater than one hundred percent(100%) of a weighted average, as described in subdivision (3) of thissubsection.
(2) Higher‑levelcoverage policy form. A policy form is deemed a higher‑level coveragepolicy form if all of the following apply:
a. The actuarial valueof the benefits under the coverage is at least fifteen percent (15%) greaterthan the actuarial value of the coverage described in subdivision (1) of thissubsection offered by the small employer carrier.
b. The actuarial valueof the benefits under the coverage is at least one hundred percent (100%), butnot greater than one hundred twenty percent (120%) of a weighted average, asdescribed in subdivision (3) of this subsection.
(3) Weighted average. Forthe purposes of this subsection, a weighted average is the average actuarialvalue of the benefits provided by all the health insurance coverage issued, aselected by the small employer carrier, either by that small employer carrier orall small employer carriers in this State in the small group market during theprevious year, not including coverage issued under this section, weighted byenrollment for the different coverage.
(d) Election. Thesmall employer carrier elections of the policies to be offered under thissection shall apply uniformly to all small employers in this State for thatsmall employer carrier. The election shall be effective for a period of notless than two years. An election under this section shall be made in accordancewith G.S. 58‑50‑127.
(e) Assumptions. Forthe purposes of subsection (c) of this section, the actuarial value of benefitsprovided under small group insurance coverage shall be calculated based on astandardized population and a set of standardized utilization and cost factors.
(f) Discontinuation ofBasic or Standard Plans. If a small employer carrier chooses to offer theplans under this section and discontinues coverage under the basic or standardhealth benefit plans provided for in G.S. 58‑50‑125, the carriershall make available to the insured employer whose coverage is to bediscontinued both of the plans offered under this section. New coverage madeavailable under this section shall constitute replacement coverage and shall berated in accordance with G.S. 58‑50‑130(b)(3).
(g) Different PolicyForms. For purposes of this section only, policy forms that have differentcost‑sharing arrangements or different riders shall be considered to bedifferent policy forms. (2006‑154, s. 3; 2007‑298, s. 5.1.)
(a) In General. Inthe case of health insurance coverage offered in this State, a small employercarrier may elect to limit the coverage offered under G.S. 58‑50‑125(d)if the carrier offers at least two different policy forms of health insurancecoverage and both policy forms meet all of the following:
(1) The policy forms aredesigned for, made available or actively marketed to, and actually enroll self‑employedindividuals and other small employer groups.
(2) The policy formsmeet the requirements of either subsections (b) or (c) of this section, aselected by the small employer carrier.
(b) Choice of MostPopular Policy Forms. The requirements of this section are met for healthinsurance coverage policy forms offered by a small employer carrier if thecarrier offers the policy forms for small group health insurance coverage withthe two highest premium volume numbers of all the policy forms offered by thecarrier in this State or in applicable marketing or service areas in the periodinvolved.
(c) Choice of TwoPolicy Forms with Representative Coverage. The requirements of this sectionare met for health insurance coverage policy forms offered by a small employercarrier in the small group market if the small employer carrier offers bothpolicy forms described in this subsection and each policy form includesbenefits substantially similar to other small group health insurance coverageoffered by the small employer carrier in this State.
(1) Lower‑levelcoverage policy form. A policy form is deemed a lower‑level coveragepolicy form if the actuarial value of the benefits under the coverage is atleast eighty‑five percent (85%), but not greater than one hundred percent(100%) of a weighted average, as described in subdivision (3) of thissubsection.
(2) Higher‑levelcoverage policy form. A policy form is deemed a higher‑level coveragepolicy form if all of the following apply:
a. The actuarial valueof the benefits under the coverage is at least fifteen percent (15%) greaterthan the actuarial value of the coverage described in subdivision (1) of thissubsection offered by the small employer carrier.
b. The actuarial valueof the benefits under the coverage is at least one hundred percent (100%), butnot greater than one hundred twenty percent (120%) of a weighted average, asdescribed in subdivision (3) of this subsection.
(3) Weighted average. Forthe purposes of this subsection, a weighted average is the average actuarialvalue of the benefits provided by all the health insurance coverage issued, aselected by the small employer carrier, either by that small employer carrier orall small employer carriers in this State in the small group market during theprevious year, not including coverage issued under this section, weighted byenrollment for the different coverage.
(d) Election. Thesmall employer carrier elections of the policies to be offered under thissection shall apply uniformly to all small employers in this State for thatsmall employer carrier. The election shall be effective for a period of notless than two years. An election under this section shall be made in accordancewith G.S. 58‑50‑127.
(e) Assumptions. Forthe purposes of subsection (c) of this section, the actuarial value of benefitsprovided under small group insurance coverage shall be calculated based on astandardized population and a set of standardized utilization and cost factors.
(f) Discontinuation ofBasic or Standard Plans. If a small employer carrier chooses to offer theplans under this section and discontinues coverage under the basic or standardhealth benefit plans provided for in G.S. 58‑50‑125, the carriershall make available to the insured employer whose coverage is to bediscontinued both of the plans offered under this section. New coverage madeavailable under this section shall constitute replacement coverage and shall berated in accordance with G.S. 58‑50‑130(b)(3).
(g) Different PolicyForms. For purposes of this section only, policy forms that have differentcost‑sharing arrangements or different riders shall be considered to bedifferent policy forms. (2006‑154, s. 3; 2007‑298, s. 5.1.)
