Key Takeaways
- North Carolina requires a 10-day free look period for individual health insurance policies
- Pre-existing condition exclusions are prohibited in the individual and small group markets under ACA
- North Carolina requires coverage for mental health parity under federal and state law
- North Carolina uses the federal healthcare marketplace (Healthcare.gov) for ACA plans
- Small group is defined as 1-50 employees in North Carolina
North Carolina Health Insurance Policy Requirements
North Carolina has comprehensive health insurance regulations that work alongside federal requirements. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
North Carolina health coverage is regulated primarily by NCDOI:
| Agency | Regulates |
|---|---|
| NC Department of Insurance | All health insurers in North Carolina |
| Federal CMS | Medicare, Medicaid policy (state administers) |
Free Look Period
North Carolina requires a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Allows review of terms and conditions
Required Coverage
North Carolina follows the ACA essential health benefits:
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Mental Health Parity
North Carolina follows federal Mental Health Parity requirements:
- Mental health benefits equal to medical benefits
- Same copays, deductibles, and limits
- Covers mental illness and substance use
- Applies to group and individual plans
Pre-Existing Condition Protections
North Carolina follows the ACA prohibition on pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Prohibited |
| Medicare Supplement | Special rules apply |
Health Insurance Marketplace
North Carolina uses the federal marketplace (Healthcare.gov):
- Residents enroll through Healthcare.gov
- Federal government administers marketplace
- Premium tax credits available based on income
- Open enrollment and special enrollment periods
Key Features
- Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
- Premium tax credits based on income
- Cost-sharing reductions for Silver plans
- Special enrollment for qualifying life events
Guaranteed Issue and Renewal
North Carolina requires:
Guaranteed Issue
- Insurers must accept all applicants during open enrollment
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with notice)
Small Group Definition
North Carolina defines small group as:
| Group Size | Classification |
|---|---|
| 1-50 employees | Small group |
| 51+ employees | Large group |
Exam Tip: North Carolina follows the standard definition of small group as 1-50 employees.
Which marketplace does North Carolina use for ACA health insurance plans?
How does North Carolina define a small group for health insurance purposes?