§ 58‑50‑125. Health care plans; formation; approval; offerings.
(a) To improve theavailability and affordability of health benefits coverage for small employers,the Committee shall recommend to the Commissioner two plans of coverage, one ofwhich shall be a basic health care plan and the second of which shall be astandard health care plan. Each plan of coverage shall be in two forms, one ofwhich shall be in the form of insurance and the second of which shall beconsistent with the basic method of operation and benefit plans of HMOs,including federally qualified HMOs. On or before January 1, 1992, the Committeeshall file a progress report with the Commissioner. The Committee shall submitthe recommended plans to the Commissioner for approval within 180 days afterthe appointment of the Committee under G.S. 58‑50‑120. TheCommittee shall take into consideration the levels of health benefit plansprovided in North Carolina, and appropriate medical and economic factors, andshall establish benefit levels, cost sharing, exclusions, and limitations.Notwithstanding subsection (c) of this section, in developing and approving theplans, the Committee and the Commissioner shall give due consideration to cost‑effectiveand life‑saving health care services and to cost‑effective healthcare providers. The Committee shall file with the Commissioner its findings andrecommendations, and reasons for the findings and recommendations, if it doesnot provide for coverage by any type of health care provider specified in G.S.58‑50‑30. The recommended plans may include cost containmentfeatures such as, but not limited to: preferred provider provisions;utilization review of medical necessity of hospital and physician services;case management benefit alternatives; or other managed care provisions.
(a1) Both the basichealth care plan and the standard health care plan provided for in subsection(a) of this section may have optional deductible and co‑payment levels asmay be determined by the small employer carrier, including high deductibleoptions. A small employer carrier shall file any changes in deductibles or co‑paymentlevels with the Commissioner for the Commissioner's approval prior toimplementing the changes in this State. The Commissioner may periodicallyreview and update the benefits provided by these plans to address trends in thesmall group market. The Commissioner shall consult with small employer carriersand representatives of the insurance agent and small employer communities aspart of that periodic review.
(b) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(c) Except as providedunder Article 68 of this Chapter, the plans developed under this section arenot required to provide coverage that meets the requirements of otherprovisions of this Chapter that mandate either coverage or the offer ofcoverage by the type or level of health care services or health care provider.
(d) As a condition oftransacting business as a small employer carrier in this State, the carriershall either offer small employers at least one basic and one standard healthcare plan or the alternative coverages provided in G.S. 58‑50‑126.Every small employer that elects to be covered under such a plan and agrees tomake the required premium payments and to satisfy the other provisions of theplan shall be issued such a plan by the small employer carrier. The premiumpayment requirements used in connection with basic and standard health careplans may address the potential credit risk of small employers that elect coveragein accordance with this subsection by means of payment security provisions thatare reasonably related to the risk and are uniformly applied.
If a small employer carrieroffers coverage to a small employer, the small employer carrier shall offercoverage to all eligible employees of a small employer and their dependents. Asmall employer carrier shall not offer coverage to only certain individuals ina small employer group except in the case of late enrollees as provided in G.S.58‑50‑130(a)(4b). A small employer carrier shall not modify anyhealth benefit plan with respect to a small employer, any eligible employee, ordependent through riders, endorsements, or otherwise, in order to restrict orexclude coverage for certain diseases or medical conditions otherwise coveredby the health benefit plan. In the case of an eligible employee or dependent ofan eligible employee who, before the effective date of the plan, was excludedfrom coverage or denied coverage by a small employer carrier in the process of providinga health benefit plan to an eligible small employer, the small employer carriershall provide an opportunity for the eligible employee or dependent of aneligible employee to enroll in the health benefit plan currently held by thesmall employer.
(e) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(f) To the extent itis required under this section and G.S. 58‑68‑40, every smallemployer carrier shall fairly market all of its small group health benefitplans it offers on a guaranteed issue basis to all small employers in thegeographic areas in which the carrier makes coverage available or providesbenefits.
(g) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(h) The provisions ofsubsection (d) of this section apply to every health benefit plan delivered,issued for delivery, renewed, or continued in this State or covering personsresiding in this State on or after the date the plan becomes operational, asdetermined by the Commissioner. For purposes of this subsection, the date ahealth benefit plan is continued is the anniversary date of the issuance of thehealth benefit plan. (1991, c. 630, s. 1; c. 761, s. 10; 1993, c. 529, s. 3.6; 1997‑259,ss. 3, 4; 2006‑154, ss. 1, 2, 9, 10, 14.)
§ 58‑50‑125. Health care plans; formation; approval; offerings.
(a) To improve theavailability and affordability of health benefits coverage for small employers,the Committee shall recommend to the Commissioner two plans of coverage, one ofwhich shall be a basic health care plan and the second of which shall be astandard health care plan. Each plan of coverage shall be in two forms, one ofwhich shall be in the form of insurance and the second of which shall beconsistent with the basic method of operation and benefit plans of HMOs,including federally qualified HMOs. On or before January 1, 1992, the Committeeshall file a progress report with the Commissioner. The Committee shall submitthe recommended plans to the Commissioner for approval within 180 days afterthe appointment of the Committee under G.S. 58‑50‑120. TheCommittee shall take into consideration the levels of health benefit plansprovided in North Carolina, and appropriate medical and economic factors, andshall establish benefit levels, cost sharing, exclusions, and limitations.Notwithstanding subsection (c) of this section, in developing and approving theplans, the Committee and the Commissioner shall give due consideration to cost‑effectiveand life‑saving health care services and to cost‑effective healthcare providers. The Committee shall file with the Commissioner its findings andrecommendations, and reasons for the findings and recommendations, if it doesnot provide for coverage by any type of health care provider specified in G.S.58‑50‑30. The recommended plans may include cost containmentfeatures such as, but not limited to: preferred provider provisions;utilization review of medical necessity of hospital and physician services;case management benefit alternatives; or other managed care provisions.
(a1) Both the basichealth care plan and the standard health care plan provided for in subsection(a) of this section may have optional deductible and co‑payment levels asmay be determined by the small employer carrier, including high deductibleoptions. A small employer carrier shall file any changes in deductibles or co‑paymentlevels with the Commissioner for the Commissioner's approval prior toimplementing the changes in this State. The Commissioner may periodicallyreview and update the benefits provided by these plans to address trends in thesmall group market. The Commissioner shall consult with small employer carriersand representatives of the insurance agent and small employer communities aspart of that periodic review.
(b) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(c) Except as providedunder Article 68 of this Chapter, the plans developed under this section arenot required to provide coverage that meets the requirements of otherprovisions of this Chapter that mandate either coverage or the offer ofcoverage by the type or level of health care services or health care provider.
(d) As a condition oftransacting business as a small employer carrier in this State, the carriershall either offer small employers at least one basic and one standard healthcare plan or the alternative coverages provided in G.S. 58‑50‑126.Every small employer that elects to be covered under such a plan and agrees tomake the required premium payments and to satisfy the other provisions of theplan shall be issued such a plan by the small employer carrier. The premiumpayment requirements used in connection with basic and standard health careplans may address the potential credit risk of small employers that elect coveragein accordance with this subsection by means of payment security provisions thatare reasonably related to the risk and are uniformly applied.
If a small employer carrieroffers coverage to a small employer, the small employer carrier shall offercoverage to all eligible employees of a small employer and their dependents. Asmall employer carrier shall not offer coverage to only certain individuals ina small employer group except in the case of late enrollees as provided in G.S.58‑50‑130(a)(4b). A small employer carrier shall not modify anyhealth benefit plan with respect to a small employer, any eligible employee, ordependent through riders, endorsements, or otherwise, in order to restrict orexclude coverage for certain diseases or medical conditions otherwise coveredby the health benefit plan. In the case of an eligible employee or dependent ofan eligible employee who, before the effective date of the plan, was excludedfrom coverage or denied coverage by a small employer carrier in the process of providinga health benefit plan to an eligible small employer, the small employer carriershall provide an opportunity for the eligible employee or dependent of aneligible employee to enroll in the health benefit plan currently held by thesmall employer.
(e) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(f) To the extent itis required under this section and G.S. 58‑68‑40, every smallemployer carrier shall fairly market all of its small group health benefitplans it offers on a guaranteed issue basis to all small employers in thegeographic areas in which the carrier makes coverage available or providesbenefits.
(g) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(h) The provisions ofsubsection (d) of this section apply to every health benefit plan delivered,issued for delivery, renewed, or continued in this State or covering personsresiding in this State on or after the date the plan becomes operational, asdetermined by the Commissioner. For purposes of this subsection, the date ahealth benefit plan is continued is the anniversary date of the issuance of thehealth benefit plan. (1991, c. 630, s. 1; c. 761, s. 10; 1993, c. 529, s. 3.6; 1997‑259,ss. 3, 4; 2006‑154, ss. 1, 2, 9, 10, 14.)
§ 58‑50‑125. Health care plans; formation; approval; offerings.
(a) To improve theavailability and affordability of health benefits coverage for small employers,the Committee shall recommend to the Commissioner two plans of coverage, one ofwhich shall be a basic health care plan and the second of which shall be astandard health care plan. Each plan of coverage shall be in two forms, one ofwhich shall be in the form of insurance and the second of which shall beconsistent with the basic method of operation and benefit plans of HMOs,including federally qualified HMOs. On or before January 1, 1992, the Committeeshall file a progress report with the Commissioner. The Committee shall submitthe recommended plans to the Commissioner for approval within 180 days afterthe appointment of the Committee under G.S. 58‑50‑120. TheCommittee shall take into consideration the levels of health benefit plansprovided in North Carolina, and appropriate medical and economic factors, andshall establish benefit levels, cost sharing, exclusions, and limitations.Notwithstanding subsection (c) of this section, in developing and approving theplans, the Committee and the Commissioner shall give due consideration to cost‑effectiveand life‑saving health care services and to cost‑effective healthcare providers. The Committee shall file with the Commissioner its findings andrecommendations, and reasons for the findings and recommendations, if it doesnot provide for coverage by any type of health care provider specified in G.S.58‑50‑30. The recommended plans may include cost containmentfeatures such as, but not limited to: preferred provider provisions;utilization review of medical necessity of hospital and physician services;case management benefit alternatives; or other managed care provisions.
(a1) Both the basichealth care plan and the standard health care plan provided for in subsection(a) of this section may have optional deductible and co‑payment levels asmay be determined by the small employer carrier, including high deductibleoptions. A small employer carrier shall file any changes in deductibles or co‑paymentlevels with the Commissioner for the Commissioner's approval prior toimplementing the changes in this State. The Commissioner may periodicallyreview and update the benefits provided by these plans to address trends in thesmall group market. The Commissioner shall consult with small employer carriersand representatives of the insurance agent and small employer communities aspart of that periodic review.
(b) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(c) Except as providedunder Article 68 of this Chapter, the plans developed under this section arenot required to provide coverage that meets the requirements of otherprovisions of this Chapter that mandate either coverage or the offer ofcoverage by the type or level of health care services or health care provider.
(d) As a condition oftransacting business as a small employer carrier in this State, the carriershall either offer small employers at least one basic and one standard healthcare plan or the alternative coverages provided in G.S. 58‑50‑126.Every small employer that elects to be covered under such a plan and agrees tomake the required premium payments and to satisfy the other provisions of theplan shall be issued such a plan by the small employer carrier. The premiumpayment requirements used in connection with basic and standard health careplans may address the potential credit risk of small employers that elect coveragein accordance with this subsection by means of payment security provisions thatare reasonably related to the risk and are uniformly applied.
If a small employer carrieroffers coverage to a small employer, the small employer carrier shall offercoverage to all eligible employees of a small employer and their dependents. Asmall employer carrier shall not offer coverage to only certain individuals ina small employer group except in the case of late enrollees as provided in G.S.58‑50‑130(a)(4b). A small employer carrier shall not modify anyhealth benefit plan with respect to a small employer, any eligible employee, ordependent through riders, endorsements, or otherwise, in order to restrict orexclude coverage for certain diseases or medical conditions otherwise coveredby the health benefit plan. In the case of an eligible employee or dependent ofan eligible employee who, before the effective date of the plan, was excludedfrom coverage or denied coverage by a small employer carrier in the process of providinga health benefit plan to an eligible small employer, the small employer carriershall provide an opportunity for the eligible employee or dependent of aneligible employee to enroll in the health benefit plan currently held by thesmall employer.
(e) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(f) To the extent itis required under this section and G.S. 58‑68‑40, every smallemployer carrier shall fairly market all of its small group health benefitplans it offers on a guaranteed issue basis to all small employers in thegeographic areas in which the carrier makes coverage available or providesbenefits.
(g) Repealed by SessionLaws 2006‑154, s. 9, effective July 23, 2006.
(h) The provisions ofsubsection (d) of this section apply to every health benefit plan delivered,issued for delivery, renewed, or continued in this State or covering personsresiding in this State on or after the date the plan becomes operational, asdetermined by the Commissioner. For purposes of this subsection, the date ahealth benefit plan is continued is the anniversary date of the issuance of thehealth benefit plan. (1991, c. 630, s. 1; c. 761, s. 10; 1993, c. 529, s. 3.6; 1997‑259,ss. 3, 4; 2006‑154, ss. 1, 2, 9, 10, 14.)
