Key Takeaways
- North Carolina group health insurance is regulated under both state and federal law (ERISA, ACA)
- COBRA continuation coverage applies to employers with 20 or more employees
- North Carolina has state continuation coverage for employers with fewer than 20 employees
- Small group defined as 1-50 employees in North Carolina
- Mental health parity requirements apply to group health plans
North Carolina Group Health Insurance
North Carolina group health insurance is heavily regulated at both state and federal levels to protect employees and their dependents.
Regulatory Framework
| Regulation | Applies To |
|---|---|
| ERISA | Most private employer plans |
| ACA | All health plans |
| NC General Statutes Chapter 58 | Insured group plans |
| NC HMO Act | HMO group plans |
Group Size Definitions
North Carolina uses these group size definitions:
| Market Segment | Employee Count |
|---|---|
| Small Group | 1-50 full-time equivalent |
| Large Group | 51 or more full-time equivalent |
Small Group Requirements
North Carolina small group health insurance must provide:
- Guaranteed issue (cannot deny coverage)
- Community rating (limited health-based rates)
- Essential health benefits
- Mental health parity
- No pre-existing condition exclusions
COBRA Continuation Coverage
The federal COBRA law requires continuation coverage:
COBRA Basics
| Aspect | Requirement |
|---|---|
| Applies To | Employers with 20+ employees |
| Duration | 18-36 months depending on event |
| Premium | Up to 102% of group rate |
| Coverage | Same as active employees |
Qualifying Events
| Event | Duration |
|---|---|
| Employment termination | 18 months |
| Reduced hours | 18 months |
| Divorce/legal separation | 36 months |
| Death of employee | 36 months |
| Medicare entitlement | 36 months |
| Dependent child aging out | 36 months |
Exam Tip: COBRA applies to employers with 20 or more employees. For smaller employers, North Carolina provides state continuation coverage.
North Carolina State Continuation Coverage
For employers with fewer than 20 employees, North Carolina provides continuation coverage:
State Continuation Coverage
| Aspect | North Carolina Requirement |
|---|---|
| Applies To | Employers not subject to COBRA |
| Duration | 18 months |
| Premium | At group rate |
| Coverage | Continuation of group benefits |
When State Continuation Applies
- Employee loses coverage due to termination or reduced hours
- Dependent loses coverage due to qualifying event
- Not eligible for COBRA
Mental Health Parity
North Carolina requires mental health parity in group health plans:
Parity Requirements
| Aspect | Must Be Equal |
|---|---|
| Copays | Same as medical/surgical |
| Deductibles | Same as medical/surgical |
| Annual Limits | Same as medical/surgical |
| Lifetime Limits | Same as medical/surgical |
| Treatment Limits | Same as medical/surgical |
Covered Conditions
North Carolina mental health parity applies to:
- All mental health conditions
- Substance use disorders
- Behavioral health conditions
HIPAA Portability
Group health plans must comply with HIPAA portability:
Key HIPAA Provisions
- Cannot deny enrollment based on health status
- Must provide certificate of creditable coverage
- Limits pre-existing condition exclusions
- Protects against discrimination
What is the minimum employer size for federal COBRA to apply?
What does mental health parity require in North Carolina group health plans?
What is the definition of a small group in North Carolina?
How long is the state continuation coverage period in North Carolina?