Medical Insurance Blog

North Carolina Individual Health Insurance Regulations

The state of North Carolina requires all individual and family health insurance policies to go through the medical underwriting process, except for some plans provided by Blue Cross Blue Shield of North Carolina. Blue Cross Blue Shield (BCBS) in this state offers to provide a select number of their medical plans guarantee issue to any North Carolina resident. The insurance company reserves the right to impose elimination riders on plans that do not pay benefits on pre-existing conditions if the individual applying is ineligible for HIPAA.

Premium rates for BCBS guaranteed issue plans will likely be higher due to the fact that there are no caps on rates for the North Carolina individual medical insurance market. Other individual policies, including most of those offered through BCBS, will take into consideration current health and health history as well as other risk factors as they consider an application.

These insurers may decline an application or may decide to offer the applicant coverage with an elimination rider, excluding certain benefits for specific pre-existing health conditions. If the company does not impose an elimination rider, they may still choose to put a hold on paying benefits for a pre-existing condition for up to one year.

The insurer may only look back into one's medical history files as far as 12 months prior to the application date for pre-existing conditions, and prior creditable coverage must be applied to any exclusionary period. The state of North Carolina guarantees the renewal of individual medical insurance plans, meaning an insurer does not have the right to cancel coverage if one's health declines or claims increase.

North Carolina Small Group Health Insurance Regulations

North Carolina companies with one to 50 employees likely qualify for small group health insurance. Groups of two to 50 qualify for guaranteed issue coverage, meaning the group may not be turned down due to health history or current medical issues during the application process. On the flip side, self-employed individuals which are labeled a small group of one may be declined coverage on all insurance policies except for two standardized plans offered by every insurer that provides small group insurance.

These state-mandated plans have the same benefits from insurance company to insurance company. In North Carolina, all small group health policies are equal opportunity, so an individual employee will not be declined coverage under the group plan due to health issues. While insurers may put small group applicants though the medical underwriting process, it is only for the purpose of deciding the premium rate. Providers can adjust rates based on health history, lifestyle habits and demographics. The adjust factor is limited to a 1.2 rate. The highest risk groups may not be charged premiums in excess of 20% of the standard rate.

Understanding North Carolina and Continuation Coverage Issues

Small groups in North Caroline with more than 19 employees fall under federal COBRA regulations in the case of terminated employees. Groups with 19 or less employees fall under the state's mini-COBRA law. Continuation of coverage is available for 18 months from the termination date, with some qualified dependents being able to stay with the COBRA coverage for up to 3 years.

North Carolina's mini-COBRA law states that an employee must have been with the group plan for a minimum of three months. Furthermore, the employee must put the choice to go on COBRA in writing within 31 days of the employment termination.

When a person is using COBRA coverage, he or she is 100% responsible for premium payments as well as a 2% administration fee. If an individual has used all of the available time with COBRA and is unable to gain acceptance through private insurance, they can find guaranteed issue basis coverage through BCBS of North Carolina.

North Carolina Medical Insurance Quotes