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?
What does guaranteed issue mean for North Carolina individual health insurance?
How long is the free look period for individual health insurance in North Carolina?