§ 108A‑70.21. Programeligibility; benefits; enrollment fee and other cost‑sharing; coveragefrom private plans; purchase of extended coverage.
(a) Eligibility. TheDepartment may enroll eligible children based on availability of funds.Following are eligibility and other requirements for participation in theProgram:
(1) Children must:
a. Be between the agesof 6 through 18;
b. Be ineligible forMedicaid, Medicare, or other federal government‑sponsored healthinsurance;
c. Be uninsured;
d. Be in a family whosefamily income is above one hundred percent (100%) through two hundred percent(200%) of the federal poverty level;
e. Be a resident ofthis State and eligible under federal law; and
f. Have paid theProgram enrollment fee required under this Part.
(2) Proof of familyincome and residency and declaration of uninsured status shall be provided bythe applicant at the time of application for Program coverage. The familymember who is legally responsible for the children enrolled in the Program hasa duty to report any change in the enrollee's status within 60 days of thechange of status.
(3) If a responsibleparent is under a court order to provide or maintain health insurance for achild and has failed to comply with the court order, then the child is deemeduninsured for purposes of determining eligibility for Program benefits if atthe time of application the custodial parent shows proof of agreement to notifyand cooperate with the child support enforcement agency in enforcing the order.
Ifhealth insurance other than under the Program is provided to the child afterenrollment and prior to the expiration of the eligibility period for which thechild is enrolled in the Program, then the child is deemed to be insured andineligible for continued coverage under the Program. The custodial parent has aduty to notify the Department within 10 days of receipt of the other healthinsurance, and the Department, upon receipt of notice, shall disenroll thechild from the Program. As used in this paragraph, the term "responsibleparent" means a person who is under a court order to pay child support.
(4) Except as otherwiseprovided in this section, enrollment shall be continuous for one year. At theend of each year, applicants may reapply for Program benefits.
(b) Benefits. Exceptas otherwise provided for eligibility, fees, deductibles, copayments, and othercost sharing charges, health benefits coverage provided to children eligibleunder the Program shall be equivalent to coverage provided for dependents underthe Predecessor Plan.
In addition to the benefitsprovided under the Predecessor Plan, the following services and supplies arecovered under the Health Insurance Program for Children established under thisPart:
(1) Oral examinations,teeth cleaning, and topical fluoride treatments twice during a 12‑monthperiod, full mouth X‑rays once every 60 months, supplemental bitewing X‑raysshowing the back of the teeth once during a 12‑month period, sealants,extractions, other than impacted teeth or wisdom teeth, therapeuticpulpotomies, space maintainers, root canal therapy for permanent anterior teethand permanent first molars, prefabricated stainless steel crowns, and routinefillings of amalgam or other tooth colored filling material to restore diseasedteeth.
(1a) Orthognathic surgeryto correct functionally impairing malocclusions when orthodontics was approvedand initiated while the child was covered by Medicaid and the need fororthognathic surgery was documented in the orthodontic treatment plan.
(2) Vision: Scheduledroutine eye examinations once every 12 months, eyeglass lenses or contactlenses once every 12 months, routine replacement of eyeglass frames once every24 months, and optical supplies and solutions when needed. Optical services,supplies, and solutions must be obtained from licensed or certifiedophthalmologists, optometrists, or optical dispensing laboratories. Eyeglasslenses are limited to single vision, bifocal, trifocal, or other complex lensesnecessary for a Plan enrollee's visual welfare. Coverage for oversized lensesand frames, designer frames, photosensitive lenses, tinted contact lenses,blended lenses, progressive multifocal lenses, coated lenses, and laminatedlenses is limited to the coverage for single vision, bifocal, trifocal, orother complex lenses provided by this subsection. Eyeglass frames are limitedto those made of zylonite, metal, or a combination of zylonite and metal. Allvisual aids covered by this subsection require prior approval. Upon priorapproval refractions may be covered more often than once every 12 months.
(3) Hearing: Auditorydiagnostic testing services and hearing aids and accessories when provided by alicensed or certified audiologist, otolaryngologist, or other approved hearingaid specialist. Prior approval is required for hearing aids, accessories,earmolds, repairs, loaners, and rental aids.
(4) Over the countermedications: Selected over the counter medications provided the medication iscovered under the State Medical Assistance Plan. Coverage shall be subject tothe same policies and approvals as required under the Medicaid program.
(5) Routine diagnosticexaminations and tests: annual routine diagnostic examinations and tests,including x‑rays, blood and blood pressure checks, urine tests, tuberculosistests, and general health check‑ups that are medically necessary for themaintenance and improvement of individual health are covered.
No benefits are to be providedfor services and materials under this subsection that do not meet the standardsaccepted by the American Dental Association.
The Department shall provideservices to children enrolled in the NC Health Choice Program through CommunityCare of North Carolina (CCNC) and shall pay Community Care of North Carolinaproviders for these services as allowed under Medicaid. The Department shallpay for these services only if sufficient information is available to theDepartment for utilization management of the services provided through CCNC.
(b1) Payments. Prescriptiondrug providers shall accept as payment in full, for outpatient prescriptionsfilled, amounts allowable for prescription drugs under Medicaid. For all otherproviders, services provided to children enrolled in the Program shall beprovided at rates equivalent to one hundred percent (100%) of Medicaid rates,less any co‑payments assessed to enrollees under this Part.
(c) Annual EnrollmentFee. There shall be no enrollment fee for Program coverage for enrolleeswhose family income is at or below one hundred fifty percent (150%) of thefederal poverty level. The enrollment fee for Program coverage for enrolleeswhose family income is above one hundred fifty percent (150%) through twohundred percent (200%) of the federal poverty level shall be fifty dollars($50.00) per year per child with a maximum annual enrollment fee of one hundreddollars ($100.00) for two or more children. The enrollment fee shall becollected by the county department of social services and retained to cover thecost of determining eligibility for services under the Program. Countydepartments of social services shall establish procedures for the collection ofenrollment fees.
(d) (See note)Cost‑Sharing. There shall be no deductibles, copayments, or other cost‑sharingcharges for families covered under the Program whose family income is at orbelow one hundred fifty percent (150%) of the federal poverty level, exceptthat fees for outpatient prescription drugs are applicable and shall be onedollar ($1.00) for each outpatient generic prescription drug, for each outpatientbrand‑name prescription drug for which there is no generic substitutionavailable, and for each covered over‑the‑counter medication. Thefee for each outpatient brand‑name prescription drug for which there is ageneric substitution available is three dollars ($3.00). Families covered underthe Program whose family income is above one hundred fifty percent (150%) ofthe federal poverty level shall be responsible for copayments to providers asfollows:
(1) Five dollars ($5.00)per child for each visit to a provider, except that there shall be no copaymentrequired for well‑baby, well‑child, or age‑appropriateimmunization services;
(2) Five dollars ($5.00)per child for each outpatient hospital visit;
(3) A one dollar ($1.00)fee for each outpatient generic prescription drug, for each outpatient brand‑nameprescription drug for which there is no generic substitution available, and foreach covered over‑the‑counter medication. The fee for eachoutpatient brand‑name prescription drug for which there is a genericsubstitution available is ten dollars ($10.00).
(4) Twenty dollars($20.00) for each emergency room visit unless:
a. The child isadmitted to the hospital, or
b. No other reasonablecare was available as determined by the Department.
Copayments required under thissubsection for prescription drugs apply only to prescription drugs prescribedon an outpatient basis.
(e) Cost‑SharingLimitations. The department shall establish maximum annual cost‑sharinglimits per individual or family, provided that the total annual aggregate cost‑sharing,including enrollment fees, with respect to all children in a family receivingbenefits under this section shall not exceed five percent (5%) of the family'sincome for the year involved.
(f) Coverage FromPrivate Plans. The Department shall, from funds available for the Program,pay the cost for dependent coverage provided under a private insurance plan forpersons eligible for coverage under the Program if all of the followingconditions are met:
(1) The person eligiblefor Program coverage requests to obtain dependent coverage from a privateinsurer in lieu of coverage under the Program and shows proof that coverageunder the private plan selected meets the requirements of this subsection;
(2) The dependent coverageunder the private plan is actuarially equivalent to the coverage provided underthe Program and the private plan does not engage in the exclusive enrollment ofchildren with favorable health care risks;
(3) The cost ofdependent coverage under the private plan is the same as or less than the costof coverage under the Program; and
(4) The total annualaggregate cost‑sharing, including fees, paid by the enrollee under theprivate plan for all dependents covered by the plan, do not exceed five percent(5%) of the enrollee's family income for the year involved.
The Department may reimbursean enrollee for private coverage under this subsection upon a showing of proofthat the dependent coverage is in effect for the period for which the enrolleeis eligible for the Program.
(g) Purchase ofExtended Coverage. An enrollee in the Program who loses eligibility due to anincrease in family income above two hundred percent (200%) of the federalpoverty level and up to and including two hundred twenty‑five percent(225%) of the federal poverty level may purchase at full premium cost continuedcoverage under the Program for a period not to exceed one year beginning on thedate the enrollee becomes ineligible under the income requirements for theProgram. The benefits, copayments, and other conditions of enrollment under theProgram applicable to extended coverage purchased under this subsection shallbe the same as those applicable to an NC Kids' Care enrollee whose familyincome equals two hundred percent (200%) of the federal poverty level.
(h) No State Funds forVoluntary Participation. No State or federal funds shall be used to cover,subsidize, or otherwise offset the cost of coverage obtained under subsection(g) of this section.
(i) No LifetimeMaximum Benefit Limit. Benefits provided to an enrollee in the Program shallnot be subject to a maximum lifetime limit. (1998‑1, s. 1; 1999‑237, s. 11.9; 2002‑126,s. 10.20(a); 2003‑284, s. 10.29(a); 2005‑276, ss. 10.22(b),10.22(c), 10.22(d); 2007‑323, s. 28.22A(o); 2007‑345, s. 12; 2008‑107,ss. 10.12(b), (c), 10.13(f), (k); 2008‑118, s. 1.6(b), (c); 2009‑16,s. 4(d); 2009‑451, s. 10.35(a).)
§ 108A‑70.21. Programeligibility; benefits; enrollment fee and other cost‑sharing; coveragefrom private plans; purchase of extended coverage.
(a) Eligibility. TheDepartment may enroll eligible children based on availability of funds.Following are eligibility and other requirements for participation in theProgram:
(1) Children must:
a. Be between the agesof 6 through 18;
b. Be ineligible forMedicaid, Medicare, or other federal government‑sponsored healthinsurance;
c. Be uninsured;
d. Be in a family whosefamily income is above one hundred percent (100%) through two hundred percent(200%) of the federal poverty level;
e. Be a resident ofthis State and eligible under federal law; and
f. Have paid theProgram enrollment fee required under this Part.
(2) Proof of familyincome and residency and declaration of uninsured status shall be provided bythe applicant at the time of application for Program coverage. The familymember who is legally responsible for the children enrolled in the Program hasa duty to report any change in the enrollee's status within 60 days of thechange of status.
(3) If a responsibleparent is under a court order to provide or maintain health insurance for achild and has failed to comply with the court order, then the child is deemeduninsured for purposes of determining eligibility for Program benefits if atthe time of application the custodial parent shows proof of agreement to notifyand cooperate with the child support enforcement agency in enforcing the order.
Ifhealth insurance other than under the Program is provided to the child afterenrollment and prior to the expiration of the eligibility period for which thechild is enrolled in the Program, then the child is deemed to be insured andineligible for continued coverage under the Program. The custodial parent has aduty to notify the Department within 10 days of receipt of the other healthinsurance, and the Department, upon receipt of notice, shall disenroll thechild from the Program. As used in this paragraph, the term "responsibleparent" means a person who is under a court order to pay child support.
(4) Except as otherwiseprovided in this section, enrollment shall be continuous for one year. At theend of each year, applicants may reapply for Program benefits.
(b) Benefits. Exceptas otherwise provided for eligibility, fees, deductibles, copayments, and othercost sharing charges, health benefits coverage provided to children eligibleunder the Program shall be equivalent to coverage provided for dependents underthe Predecessor Plan.
In addition to the benefitsprovided under the Predecessor Plan, the following services and supplies arecovered under the Health Insurance Program for Children established under thisPart:
(1) Oral examinations,teeth cleaning, and topical fluoride treatments twice during a 12‑monthperiod, full mouth X‑rays once every 60 months, supplemental bitewing X‑raysshowing the back of the teeth once during a 12‑month period, sealants,extractions, other than impacted teeth or wisdom teeth, therapeuticpulpotomies, space maintainers, root canal therapy for permanent anterior teethand permanent first molars, prefabricated stainless steel crowns, and routinefillings of amalgam or other tooth colored filling material to restore diseasedteeth.
(1a) Orthognathic surgeryto correct functionally impairing malocclusions when orthodontics was approvedand initiated while the child was covered by Medicaid and the need fororthognathic surgery was documented in the orthodontic treatment plan.
(2) Vision: Scheduledroutine eye examinations once every 12 months, eyeglass lenses or contactlenses once every 12 months, routine replacement of eyeglass frames once every24 months, and optical supplies and solutions when needed. Optical services,supplies, and solutions must be obtained from licensed or certifiedophthalmologists, optometrists, or optical dispensing laboratories. Eyeglasslenses are limited to single vision, bifocal, trifocal, or other complex lensesnecessary for a Plan enrollee's visual welfare. Coverage for oversized lensesand frames, designer frames, photosensitive lenses, tinted contact lenses,blended lenses, progressive multifocal lenses, coated lenses, and laminatedlenses is limited to the coverage for single vision, bifocal, trifocal, orother complex lenses provided by this subsection. Eyeglass frames are limitedto those made of zylonite, metal, or a combination of zylonite and metal. Allvisual aids covered by this subsection require prior approval. Upon priorapproval refractions may be covered more often than once every 12 months.
(3) Hearing: Auditorydiagnostic testing services and hearing aids and accessories when provided by alicensed or certified audiologist, otolaryngologist, or other approved hearingaid specialist. Prior approval is required for hearing aids, accessories,earmolds, repairs, loaners, and rental aids.
(4) Over the countermedications: Selected over the counter medications provided the medication iscovered under the State Medical Assistance Plan. Coverage shall be subject tothe same policies and approvals as required under the Medicaid program.
(5) Routine diagnosticexaminations and tests: annual routine diagnostic examinations and tests,including x‑rays, blood and blood pressure checks, urine tests, tuberculosistests, and general health check‑ups that are medically necessary for themaintenance and improvement of individual health are covered.
No benefits are to be providedfor services and materials under this subsection that do not meet the standardsaccepted by the American Dental Association.
The Department shall provideservices to children enrolled in the NC Health Choice Program through CommunityCare of North Carolina (CCNC) and shall pay Community Care of North Carolinaproviders for these services as allowed under Medicaid. The Department shallpay for these services only if sufficient information is available to theDepartment for utilization management of the services provided through CCNC.
(b1) Payments. Prescriptiondrug providers shall accept as payment in full, for outpatient prescriptionsfilled, amounts allowable for prescription drugs under Medicaid. For all otherproviders, services provided to children enrolled in the Program shall beprovided at rates equivalent to one hundred percent (100%) of Medicaid rates,less any co‑payments assessed to enrollees under this Part.
(c) Annual EnrollmentFee. There shall be no enrollment fee for Program coverage for enrolleeswhose family income is at or below one hundred fifty percent (150%) of thefederal poverty level. The enrollment fee for Program coverage for enrolleeswhose family income is above one hundred fifty percent (150%) through twohundred percent (200%) of the federal poverty level shall be fifty dollars($50.00) per year per child with a maximum annual enrollment fee of one hundreddollars ($100.00) for two or more children. The enrollment fee shall becollected by the county department of social services and retained to cover thecost of determining eligibility for services under the Program. Countydepartments of social services shall establish procedures for the collection ofenrollment fees.
(d) (See note)Cost‑Sharing. There shall be no deductibles, copayments, or other cost‑sharingcharges for families covered under the Program whose family income is at orbelow one hundred fifty percent (150%) of the federal poverty level, exceptthat fees for outpatient prescription drugs are applicable and shall be onedollar ($1.00) for each outpatient generic prescription drug, for each outpatientbrand‑name prescription drug for which there is no generic substitutionavailable, and for each covered over‑the‑counter medication. Thefee for each outpatient brand‑name prescription drug for which there is ageneric substitution available is three dollars ($3.00). Families covered underthe Program whose family income is above one hundred fifty percent (150%) ofthe federal poverty level shall be responsible for copayments to providers asfollows:
(1) Five dollars ($5.00)per child for each visit to a provider, except that there shall be no copaymentrequired for well‑baby, well‑child, or age‑appropriateimmunization services;
(2) Five dollars ($5.00)per child for each outpatient hospital visit;
(3) A one dollar ($1.00)fee for each outpatient generic prescription drug, for each outpatient brand‑nameprescription drug for which there is no generic substitution available, and foreach covered over‑the‑counter medication. The fee for eachoutpatient brand‑name prescription drug for which there is a genericsubstitution available is ten dollars ($10.00).
(4) Twenty dollars($20.00) for each emergency room visit unless:
a. The child isadmitted to the hospital, or
b. No other reasonablecare was available as determined by the Department.
Copayments required under thissubsection for prescription drugs apply only to prescription drugs prescribedon an outpatient basis.
(e) Cost‑SharingLimitations. The department shall establish maximum annual cost‑sharinglimits per individual or family, provided that the total annual aggregate cost‑sharing,including enrollment fees, with respect to all children in a family receivingbenefits under this section shall not exceed five percent (5%) of the family'sincome for the year involved.
(f) Coverage FromPrivate Plans. The Department shall, from funds available for the Program,pay the cost for dependent coverage provided under a private insurance plan forpersons eligible for coverage under the Program if all of the followingconditions are met:
(1) The person eligiblefor Program coverage requests to obtain dependent coverage from a privateinsurer in lieu of coverage under the Program and shows proof that coverageunder the private plan selected meets the requirements of this subsection;
(2) The dependent coverageunder the private plan is actuarially equivalent to the coverage provided underthe Program and the private plan does not engage in the exclusive enrollment ofchildren with favorable health care risks;
(3) The cost ofdependent coverage under the private plan is the same as or less than the costof coverage under the Program; and
(4) The total annualaggregate cost‑sharing, including fees, paid by the enrollee under theprivate plan for all dependents covered by the plan, do not exceed five percent(5%) of the enrollee's family income for the year involved.
The Department may reimbursean enrollee for private coverage under this subsection upon a showing of proofthat the dependent coverage is in effect for the period for which the enrolleeis eligible for the Program.
(g) Purchase ofExtended Coverage. An enrollee in the Program who loses eligibility due to anincrease in family income above two hundred percent (200%) of the federalpoverty level and up to and including two hundred twenty‑five percent(225%) of the federal poverty level may purchase at full premium cost continuedcoverage under the Program for a period not to exceed one year beginning on thedate the enrollee becomes ineligible under the income requirements for theProgram. The benefits, copayments, and other conditions of enrollment under theProgram applicable to extended coverage purchased under this subsection shallbe the same as those applicable to an NC Kids' Care enrollee whose familyincome equals two hundred percent (200%) of the federal poverty level.
(h) No State Funds forVoluntary Participation. No State or federal funds shall be used to cover,subsidize, or otherwise offset the cost of coverage obtained under subsection(g) of this section.
(i) No LifetimeMaximum Benefit Limit. Benefits provided to an enrollee in the Program shallnot be subject to a maximum lifetime limit. (1998‑1, s. 1; 1999‑237, s. 11.9; 2002‑126,s. 10.20(a); 2003‑284, s. 10.29(a); 2005‑276, ss. 10.22(b),10.22(c), 10.22(d); 2007‑323, s. 28.22A(o); 2007‑345, s. 12; 2008‑107,ss. 10.12(b), (c), 10.13(f), (k); 2008‑118, s. 1.6(b), (c); 2009‑16,s. 4(d); 2009‑451, s. 10.35(a).)
§ 108A‑70.21. Programeligibility; benefits; enrollment fee and other cost‑sharing; coveragefrom private plans; purchase of extended coverage.
(a) Eligibility. TheDepartment may enroll eligible children based on availability of funds.Following are eligibility and other requirements for participation in theProgram:
(1) Children must:
a. Be between the agesof 6 through 18;
b. Be ineligible forMedicaid, Medicare, or other federal government‑sponsored healthinsurance;
c. Be uninsured;
d. Be in a family whosefamily income is above one hundred percent (100%) through two hundred percent(200%) of the federal poverty level;
e. Be a resident ofthis State and eligible under federal law; and
f. Have paid theProgram enrollment fee required under this Part.
(2) Proof of familyincome and residency and declaration of uninsured status shall be provided bythe applicant at the time of application for Program coverage. The familymember who is legally responsible for the children enrolled in the Program hasa duty to report any change in the enrollee's status within 60 days of thechange of status.
(3) If a responsibleparent is under a court order to provide or maintain health insurance for achild and has failed to comply with the court order, then the child is deemeduninsured for purposes of determining eligibility for Program benefits if atthe time of application the custodial parent shows proof of agreement to notifyand cooperate with the child support enforcement agency in enforcing the order.
Ifhealth insurance other than under the Program is provided to the child afterenrollment and prior to the expiration of the eligibility period for which thechild is enrolled in the Program, then the child is deemed to be insured andineligible for continued coverage under the Program. The custodial parent has aduty to notify the Department within 10 days of receipt of the other healthinsurance, and the Department, upon receipt of notice, shall disenroll thechild from the Program. As used in this paragraph, the term "responsibleparent" means a person who is under a court order to pay child support.
(4) Except as otherwiseprovided in this section, enrollment shall be continuous for one year. At theend of each year, applicants may reapply for Program benefits.
(b) Benefits. Exceptas otherwise provided for eligibility, fees, deductibles, copayments, and othercost sharing charges, health benefits coverage provided to children eligibleunder the Program shall be equivalent to coverage provided for dependents underthe Predecessor Plan.
In addition to the benefitsprovided under the Predecessor Plan, the following services and supplies arecovered under the Health Insurance Program for Children established under thisPart:
(1) Oral examinations,teeth cleaning, and topical fluoride treatments twice during a 12‑monthperiod, full mouth X‑rays once every 60 months, supplemental bitewing X‑raysshowing the back of the teeth once during a 12‑month period, sealants,extractions, other than impacted teeth or wisdom teeth, therapeuticpulpotomies, space maintainers, root canal therapy for permanent anterior teethand permanent first molars, prefabricated stainless steel crowns, and routinefillings of amalgam or other tooth colored filling material to restore diseasedteeth.
(1a) Orthognathic surgeryto correct functionally impairing malocclusions when orthodontics was approvedand initiated while the child was covered by Medicaid and the need fororthognathic surgery was documented in the orthodontic treatment plan.
(2) Vision: Scheduledroutine eye examinations once every 12 months, eyeglass lenses or contactlenses once every 12 months, routine replacement of eyeglass frames once every24 months, and optical supplies and solutions when needed. Optical services,supplies, and solutions must be obtained from licensed or certifiedophthalmologists, optometrists, or optical dispensing laboratories. Eyeglasslenses are limited to single vision, bifocal, trifocal, or other complex lensesnecessary for a Plan enrollee's visual welfare. Coverage for oversized lensesand frames, designer frames, photosensitive lenses, tinted contact lenses,blended lenses, progressive multifocal lenses, coated lenses, and laminatedlenses is limited to the coverage for single vision, bifocal, trifocal, orother complex lenses provided by this subsection. Eyeglass frames are limitedto those made of zylonite, metal, or a combination of zylonite and metal. Allvisual aids covered by this subsection require prior approval. Upon priorapproval refractions may be covered more often than once every 12 months.
(3) Hearing: Auditorydiagnostic testing services and hearing aids and accessories when provided by alicensed or certified audiologist, otolaryngologist, or other approved hearingaid specialist. Prior approval is required for hearing aids, accessories,earmolds, repairs, loaners, and rental aids.
(4) Over the countermedications: Selected over the counter medications provided the medication iscovered under the State Medical Assistance Plan. Coverage shall be subject tothe same policies and approvals as required under the Medicaid program.
(5) Routine diagnosticexaminations and tests: annual routine diagnostic examinations and tests,including x‑rays, blood and blood pressure checks, urine tests, tuberculosistests, and general health check‑ups that are medically necessary for themaintenance and improvement of individual health are covered.
No benefits are to be providedfor services and materials under this subsection that do not meet the standardsaccepted by the American Dental Association.
The Department shall provideservices to children enrolled in the NC Health Choice Program through CommunityCare of North Carolina (CCNC) and shall pay Community Care of North Carolinaproviders for these services as allowed under Medicaid. The Department shallpay for these services only if sufficient information is available to theDepartment for utilization management of the services provided through CCNC.
(b1) Payments. Prescriptiondrug providers shall accept as payment in full, for outpatient prescriptionsfilled, amounts allowable for prescription drugs under Medicaid. For all otherproviders, services provided to children enrolled in the Program shall beprovided at rates equivalent to one hundred percent (100%) of Medicaid rates,less any co‑payments assessed to enrollees under this Part.
(c) Annual EnrollmentFee. There shall be no enrollment fee for Program coverage for enrolleeswhose family income is at or below one hundred fifty percent (150%) of thefederal poverty level. The enrollment fee for Program coverage for enrolleeswhose family income is above one hundred fifty percent (150%) through twohundred percent (200%) of the federal poverty level shall be fifty dollars($50.00) per year per child with a maximum annual enrollment fee of one hundreddollars ($100.00) for two or more children. The enrollment fee shall becollected by the county department of social services and retained to cover thecost of determining eligibility for services under the Program. Countydepartments of social services shall establish procedures for the collection ofenrollment fees.
(d) (See note)Cost‑Sharing. There shall be no deductibles, copayments, or other cost‑sharingcharges for families covered under the Program whose family income is at orbelow one hundred fifty percent (150%) of the federal poverty level, exceptthat fees for outpatient prescription drugs are applicable and shall be onedollar ($1.00) for each outpatient generic prescription drug, for each outpatientbrand‑name prescription drug for which there is no generic substitutionavailable, and for each covered over‑the‑counter medication. Thefee for each outpatient brand‑name prescription drug for which there is ageneric substitution available is three dollars ($3.00). Families covered underthe Program whose family income is above one hundred fifty percent (150%) ofthe federal poverty level shall be responsible for copayments to providers asfollows:
(1) Five dollars ($5.00)per child for each visit to a provider, except that there shall be no copaymentrequired for well‑baby, well‑child, or age‑appropriateimmunization services;
(2) Five dollars ($5.00)per child for each outpatient hospital visit;
(3) A one dollar ($1.00)fee for each outpatient generic prescription drug, for each outpatient brand‑nameprescription drug for which there is no generic substitution available, and foreach covered over‑the‑counter medication. The fee for eachoutpatient brand‑name prescription drug for which there is a genericsubstitution available is ten dollars ($10.00).
(4) Twenty dollars($20.00) for each emergency room visit unless:
a. The child isadmitted to the hospital, or
b. No other reasonablecare was available as determined by the Department.
Copayments required under thissubsection for prescription drugs apply only to prescription drugs prescribedon an outpatient basis.
(e) Cost‑SharingLimitations. The department shall establish maximum annual cost‑sharinglimits per individual or family, provided that the total annual aggregate cost‑sharing,including enrollment fees, with respect to all children in a family receivingbenefits under this section shall not exceed five percent (5%) of the family'sincome for the year involved.
(f) Coverage FromPrivate Plans. The Department shall, from funds available for the Program,pay the cost for dependent coverage provided under a private insurance plan forpersons eligible for coverage under the Program if all of the followingconditions are met:
(1) The person eligiblefor Program coverage requests to obtain dependent coverage from a privateinsurer in lieu of coverage under the Program and shows proof that coverageunder the private plan selected meets the requirements of this subsection;
(2) The dependent coverageunder the private plan is actuarially equivalent to the coverage provided underthe Program and the private plan does not engage in the exclusive enrollment ofchildren with favorable health care risks;
(3) The cost ofdependent coverage under the private plan is the same as or less than the costof coverage under the Program; and
(4) The total annualaggregate cost‑sharing, including fees, paid by the enrollee under theprivate plan for all dependents covered by the plan, do not exceed five percent(5%) of the enrollee's family income for the year involved.
The Department may reimbursean enrollee for private coverage under this subsection upon a showing of proofthat the dependent coverage is in effect for the period for which the enrolleeis eligible for the Program.
(g) Purchase ofExtended Coverage. An enrollee in the Program who loses eligibility due to anincrease in family income above two hundred percent (200%) of the federalpoverty level and up to and including two hundred twenty‑five percent(225%) of the federal poverty level may purchase at full premium cost continuedcoverage under the Program for a period not to exceed one year beginning on thedate the enrollee becomes ineligible under the income requirements for theProgram. The benefits, copayments, and other conditions of enrollment under theProgram applicable to extended coverage purchased under this subsection shallbe the same as those applicable to an NC Kids' Care enrollee whose familyincome equals two hundred percent (200%) of the federal poverty level.
(h) No State Funds forVoluntary Participation. No State or federal funds shall be used to cover,subsidize, or otherwise offset the cost of coverage obtained under subsection(g) of this section.
(i) No LifetimeMaximum Benefit Limit. Benefits provided to an enrollee in the Program shallnot be subject to a maximum lifetime limit. (1998‑1, s. 1; 1999‑237, s. 11.9; 2002‑126,s. 10.20(a); 2003‑284, s. 10.29(a); 2005‑276, ss. 10.22(b),10.22(c), 10.22(d); 2007‑323, s. 28.22A(o); 2007‑345, s. 12; 2008‑107,ss. 10.12(b), (c), 10.13(f), (k); 2008‑118, s. 1.6(b), (c); 2009‑16,s. 4(d); 2009‑451, s. 10.35(a).)
