Health plans - North Carolina

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. North Carolina law includes the following provisions:

• Plan coverage must not discriminate against procedures involving bones or joints of the jaw, face, or head. (§58-3-121)
• The plan must cover anesthesia and hospital or facility charges for services performed in a hospital or ambulatory surgical facility in connection with dental procedures for children below the age of nine years, persons with serious mental or physical conditions, and persons with significant behavioral problems, where the provider treating the patient involved certifies that, because of the patient's age or condition or problem, hospitalization or general anesthesia is required in order to safely and effectively perform the procedures. The same deductibles, coinsurance, network requirements, medical necessity provisions, and other limitations as apply to physical illness benefits under the plan must apply to coverage for anesthesia and hospital or facility charges. (§58-3-122)
• The plan must cover qualified individuals for scientifically proven and approved bone mass measurement for the diagnosis and evaluation of osteoporosis or low bone mass. (§58-3-174)
• If the plan covers prescription drugs or devices and issues a prescription drug card, it must issue to its insureds a uniform prescription drug identification card. (§58-3-177)
• If the plan covers prescription drugs or devices, it must cover prescription contraceptive drugs or devices; however, religious employers may request an insurer providing a health benefit plan to provide to the religious employer a health benefit plan that excludes coverage for prescription contraceptive drugs or devices that are contrary to the employer's religious tenets. (§58-3-178)
• Plans must cover colorectal cancer examinations and laboratory tests for cancer for nonsymptomatic covered individuals who are at least 50 years of age, or less than 50 years of age and at high risk for colorectal cancer. (§58-3-179)
• The insurer must cover emergency services to the extent necessary to screen and to stabilize the person covered under the plan and must not require prior authorization of the services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. (§58-3-190)
• No insurer shall raise the premium or contribution rates paid by a group for a group health benefit plan on the basis of genetic information obtained about an individual member of the group; refuse to issue or deliver a health benefit plan because of genetic information obtained about any person to be insured by the health benefit plan; or charge a higher premium rate or charge for a health benefit plan because of genetic information obtained about any person to be insured by the health benefit plan. (§58-3-215)
• The plan must cover specific nonformulary drugs or devices determined to be medically necessary and appropriate by the enrollee's participating physician without prior approval from the insurer. (§58-3-221)
• The plan must allow the insured to receive an extended or standing referral to an in plan specialist. (§58-3-223)
• An insured diagnosed with a serious or chronic degenerative, disabling, or life-threatening disease or condition, either of which requires specialized medical care may select as his or her primary care physician a specialist with expertise in treating the disease or condition who must be responsible for and capable of providing and coordinating the insured's primary and specialty care. (§58-3-235)
• Each insurer offering a health benefit plan that uses a network of contracting health care providers shall allow an insured to choose a contracting pediatrician in the network as the primary care provider for the insured's children under the age of 18 and covered under the policy. (§58-3-240)
• Plans must cover participation in phase II, phase III, and phase IV covered clinical trials by their insureds or enrollees who meet protocol requirements of the trials and provide informed consent. (§58-3-255)
• Plans must cover newborn hearing screening ordered by the attending physician. The same deductibles, coinsurance, reimbursement methodologies, and other limitations and administrative procedures as apply to similar services covered under the health benefit plan must apply to coverage for newborn hearing screening. (§58-3-260)
• If a service is provided, for which payment or reimbursement is required to be made under the plan, the service cannot be denied such payment or reimbursement because such services were rendered through a registered nurse. (§58-50-25)
• If a service is provided, for which payment or reimbursement is required to be made under the plan, the service cannot be denied such payment or reimbursement because such services were rendered through a physician assistant. (§58-50-26)
• IF the plan provides for coverage for, payment of, or reimbursement for any service rendered in connection with a condition or complaint that is within the scope of practice of a duly licensed optometrist, a duly licensed podiatrist, a duly licensed dentist, a duly licensed chiropractor, a duly licensed clinical social worker, a duly certified substance abuse professional, a duly licensed professional counselor, a duly licensed psychologist, a duly licensed pharmacist, a duly certified fee-based practicing pastoral counselor, a duly licensed physician assistant, a duly licensed marriage and family therapist, or an advanced practice registered nurse; the insured or other persons entitled to benefits under the policy must be entitled to coverage of, payment of, or reimbursement for the services, whether the services be performed by a duly licensed physician, or a provider listed in this subsection, notwithstanding any provision contained in the plan or policy limiting access to the providers. (§58-50-30)
• No insurance fiduciary shall: (1) Cause the cancellation or nonrenewal of group health or group life insurance and the consequential loss of the coverages of the persons insured by willfully failing to pay such premiums in accordance with the terms of a group health or group life insurance contract; or, in the case of a group health plan to which there are no premiums contributed, terminate the plan by willfully failing to fund the plan; and (2) Willfully fail to deliver, at least 45 days before the termination of the group health or group life insurance or group health plan, to all persons covered by the group policy or group health plan a written notice of the insurance fiduciary's intention to stop payment of premiums for the group life or health insurance or the insurance fiduciary's intention to cease funding of a group health plan. Violations are considered felonies. (§58-50-40)
• Insurers may enter into preferred provider contracts or enter into other cost containment arrangements to reduce the costs of providing health care services. A person enrolled in a preferred provider benefit plan may obtain covered health care services from a provider who does not participate in the plan. Preferred provider benefit plans may limit coverage for health care services obtained from a nonparticipating provider. (§58-50-56)
• If the plan covers dependent children and indicates that coverage will terminate upon attainment of the limiting age, it must also provide that attainment of such limiting age will not terminate the coverage of dependent children while the children are and continue to be incapable of self-sustaining employment by reason of mental retardation or physical handicap; and chiefly dependent upon the policyholder or subscriber for support and maintenance. (§58-51-25)
• If the plan covers sickness, illness, or disability of any minor child, or covers medical treatment or service furnished by a health care provider or institution to any minor child, it must cover those occurrences beginning with the moment of the child's birth if the birth occurs while the plan is in force. Foster children and adopted children shall be treated the same as newborn infants and eligible for coverage on the same basis upon placement in the foster home or placement for adoption. (§58-51-30)
• The plan must not discriminate on the basis of physical handicap or mental retardation of any minor children of the applicant; nor can the plan carry a higher premium rate or charge or restrict or exclude coverage or benefits by reason of mental retardation or physical handicap. (§58-51-35)
• The plan cannot prohibit or limit participants or beneficiaries from selecting a pharmacy of their choice when the pharmacy has agreed to participate in the health benefit plan according to the terms offered by the insurer. (§58-51-37)
• The plan must not refuse coverage to participants because they possess sickle cell trait or hemoglobin C trait, nor can the plan carry a higher premium rate or charge because participants possess such traits. (§58-51-45)
• The plan must offer optional benefits for the necessary care and treatment of chemical dependency that are not less favorable than benefits for physical illness generally. (§58-51-50)
• The plan must not discriminate against applicants or participants who have or had a mental illness or chemical dependency. This includes issuing, coverage, and rates/charges. (§58-51-55)
• The plan must cover prostate-specific antigen (PSA) tests or equivalent tests for the presence of prostate cancer. The same deductibles, coinsurance, and other limitations as apply to similar services covered under the policy, contract, or plan must apply to coverage for prostate specific antigen (PSA) or equivalent tests. (§58-51-58)
• If the plan covers prescription drugs approved by the federal Food and Drug Administration (FDA) for the treatment of certain types of cancer, it must also cover prescription drugs for the treatment of a type of cancer for which the drug has not been approved by the FDA. (§58-51-59)
• Plans must cover medically appropriate and necessary services, including diabetes outpatient self-management training and educational services, and equipment, supplies, medications, and laboratory procedures used to treat diabetes. (§58-51-61)
• Plans must not limit or exclude coverage or payment for any health care for an individual because the individual is covered under Medicaid, as long as the individual would otherwise be covered or entitled to benefits or services under the employee benefit plan. (§58-51-116)
• The plan cannot deny enrollment of a child under the health benefit plan of the child's parent because the child was born out of wedlock, is not claimed as a dependent on the parent's federal income tax return, or does not reside with the parent or in the insurer's service area. (§58-51-120)
• If the plan covers dependent children, it must provide benefits to dependent children placed with covered persons for adoption under the same terms and conditions that apply to the natural, dependent children of covered persons, irrespective of whether the adoption has become final. (§58-51-125)
• The plan cannot establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the health insurer's plan based on health status-related factors in relation to the individual or a dependent of the individual. (§58-68-35)
• Plans may establish association health plans that meet certain criteria, including membership, plan, solvency, nondiscrimination, and licensure requirements. (§58-50A)

Information on women’s health issues can be found under the topic Women’s Health Rights.

State

Contact

North Carolina Department of Insurance

Regulations

North Carolina General Statutes

§58-3-121 Discrimination against coverage of certain bones and joints prohibited

§58-3-122 Anesthesia and hospital charges necessary for safe and effective administration of dental procedures for young children, persons with serious mental or physical conditions, and persons with significant behavioral problems; coverage in health benefit plans

§58-3-174 Coverage for bone mass measurement for diagnosis and evaluation of osteoporosis or low bone mass

§58-3-177 Uniform prescription drug identification cards

§58-3-178 Coverage for prescription contraceptive drugs or devices and for outpatient contraceptive services; exemption for religious employers

§58-3-179 Coverage for colorectal cancer screening

§58-3-190 Coverage required for emergency care

§58-3-215 Genetic information in health insurance

§58-3-221 Access to non-formulary drugs and devices

§58-3-223 Managed care access to specialist care.

§58-3-235 Selection of specialist as primary care provider

§58-3-240Direct access to pediatrician for minors

§58-3-255 Coverage of clinical trials

§58-3-260 Insurance coverage for newborn hearing screening mandated

§58-50-25 Nurses' services

§58-50-26 Physician services provided by physician assistants

§58-50-30 Right to choose services of optometrist, podiatrist, licensed clinical social worker, certified substance abuse professional, licensed professional counselor, dentist, chiropractor, psychologist, pharmacist, certified fee-based practicing pastoral counselor, advanced practice nurse, licensed marriage and family therapist, or physician assistant

§58-50-40 Willful failure to pay group insurance premiums; willful termination of a group health plan; notice to persons insured; penalty; restitution; examination of  insurance transactions

§58-50-56 Insurers, preferred provider organizations, and preferred provider benefit plans

§58-50A Association Health Plans and Multiple Employer Welfare Arrangements

§58-51-25 Policy coverage to continue as to mentally retarded or physically handicapped children

§58-51-30 Policies to cover newborn infants, foster children, and adopted children

§58-51-35 Insurers and others to afford coverage to mentally retarded and physically handicapped children

§58-51-37 Pharmacy of choice

§58-51-45 Policies to be issued to any person possessing the sickle cell trait or hemoglobin C trait

§58-51-50 Coverage for chemical dependency treatment

§58-51-55 No discrimination against the mentally ill and chemically dependent

§58-51-58 Coverage for prostate-specific antigen (PSA) tests

§58-51-59 Coverage of certain prescribed drugs for cancer treatment

§58-51-61 Coverage for certain treatment for diabetes

§58-51-116 ERISA plans may not require Medicaid to pay first

§58-51-120 Coverage of children

§58-51-125 Adopted child coverage

§58-68-35 Prohibiting discrimination against individual participants and beneficiaries based on health status

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)