North Carolina Health Insurance (NC)

North Carolina (NC)
Individual Health Insurance Regulations

Learn more about North Carolina Individual Health Insurance

All health insurance companies offering individual/family health plans in North Carolina may medically underwrite new applications for insurance, with the exception of a few plans offered through Blue Cross Blue Shield of North Carolina. BCBS has voluntarily offered to provide some of their health plans on a guaranteed issue basis to any resident of North Carolina. However, they are permitted to place elimination riders on these plans that exclude paying benefits on pre-existing medical conditions, if the applicant is not HIPAA eligible. The rates for these guaranteed plans may also be substantially higher, since there are no rate caps on the individual health insurance market in North Carolina. Individual medical plans, as well as the majority of plans offered by Blue Cross Blue Shield, may base the approval of your application on your health status or past health history or risk factors. They may decline your application or may choose to offer you coverage with an elimination rider that excludes benefits for specified pre-existing medical conditions. Even if an elimination rider is not placed on your policy, the insurance company may still exclude paying benefits of a pre-existing medical condition for up to 12 months. Prior creditable coverage must be applied to this exclusionary period and the insurance company may not look back at your medical history further than 12 months prior to your application date. Individual health insurance in North Carolina is guaranteed renewable, which means that the insurance company may not cancel your coverage is your health status worsens.

North Carolina (NC)
Small Group Health Insurance Regulations

Any company with 1-50 employees may qualify for small group health insurance in North Carolina. For groups of 2-50, coverage is guaranteed issue and the group may not be turned down due to health status when applying for new coverage. Self-employed persons that qualify as a group of 1 may be turned down on all plans except for the 2 standardized plans that must be offered by every health insurance company offering small group health insurance. These standardized plans are state mandated and they all have the same level of benefits, regardless of the insurance company. All group health plans in North Carolina are non-discrimination, so an individual employee may not be denied coverage under the group plan because of health status.

Insurance companies may medically underwrite small group applications, but only for the purpose of determining the premium to charge. Rates can be modified based on health status and demographics, but are limited to a 1.20 rate adjustment factor. Groups in the highest risk level may not be charged more than 20% of the standard rate. To qualify for a small group health plan, a self-employed group of one may be required to provide proof of business ownership.

North Carolina COBRA and Continuation Coverage

Federal COBRA regulations apply to all groups with more than 19 employees. For groups of 19 or less, North Carolina has a mini-COBRA law which is similar to federal COBRA. Continuation of coverage under the group plan must be available for 18 months. Some qualified dependents are able to remain on COBRA for up to 36 months. Under mini-COBRA law, an employee must have been insured on the group plan for at least 3 months and must accept their COBRA coverage within 31 days of the termination date of employment. Any person accepting COBRA coverage is fully responsible for payment of premium and there will be a 2% administration fee in addition to the monthly premium. For persons that have exhausted their COBRA coverage, or are unable to obtain individual health insurance, Blue Cross Blue Shield of North Carolina offers some of their health plans on a guaranteed issue basis. For those that have exhausted their COBRA, and apply for this coverage within 63 days, there are no pre-existing condition exclusionary periods or elimination riders.

Additional North Carolina Resources

• North Carolina Health Choice (NCHC)
  Provides health insurance coverage to children in the state of North Carolina that are under the age of 21 and whose family income is below 200% of the federal poverty level.
• North Carolina Medicaid
  The North Carolina Medicaid program is overseen by the same agency that manages NC Health Choice for Children, the Division of Medical assistance.
• Seniors' Health Insurance Information Program
  Assisting seniors in North Carolina in knowing their Medicare and insurance rights and options.

NC Medical Insurance Statistics

Total Population: 8,561,000
With Health Insurance: 7,190,000 / 84.0%
Without Health Insurance: 1,371,000 / 16.0%
*According to 2005 CPS Reports / U.S. Census Bureau

Note: The percentage of North Carolina residents without health insurance has decreased by .3% since 2004.

North Carolina Department of Insurance
Phone: 800-546-5664
Determines which insurance companies may sell insurance in North Carolina and oversees the regulations of the state that are designed to protect consumers.

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