§ 135-45. Undertaking. - North Carolina Statutes

Part 3. State Health Plan forTeachers and State Employees.

§ 135‑45.  Undertaking.

(a)        The State of NorthCarolina undertakes to make available a State Health Plan (hereinafter calledthe "Plan") exclusively for the benefit of eligible employees,eligible retired employees, and certain of their eligible dependents, whichwill pay benefits in accordance with the terms of this Article. The Plan shallhave all the powers and privileges of a corporation and shall be known as theState Health Plan for Teachers and State Employees. The Executive Administratorand Board of Trustees shall carry out their duties and responsibilities asfiduciaries for the Plan. The Plan shall administer one or more group healthplans that are comprehensive in coverage and shall provide eligible employeesand retired employees coverage on a noncontributory basis under at least one ofthe group plans with benefits equal to that specified in subsection (g) of thissection. The Executive Administrator and Board of Trustees may operate groupplans as a preferred provider option, or health maintenance, point‑of‑service,or other organizational arrangement and may offer the plans to employees andretirees on a noncontributory or partially contributory basis. Plans offered ona partially contributory basis must provide benefits that are additional tothat specified in subsection (g) of this section and may not be offered unlessapproved in an act of the General Assembly.

(b)        Individualseligible for coverage under G.S. 135‑45.2 on a fully or partiallycontributory basis are eligible to participate in any plan authorized underthis section.

(c)        The State of NorthCarolina deems it to be in the public interest for North Carolina firefighters,rescue squad workers, and members of the National Guard, and certain of theirdependents, who are not eligible for any other type of comprehensive grouphealth insurance or other comprehensive group health benefits, and who havebeen without any form of group health insurance or other comprehensive group healthbenefit coverage for at least six consecutive months, to be given theopportunity to participate in the benefits provided by the State Health Planfor Teachers and State Employees. Coverage under the Plan shall be voluntaryfor eligible firefighters, rescue squad workers, and members of the NationalGuard who elect participation in the Plan for themselves and their eligibledependents.

(d)        The Plan benefitsshall be provided under contracts between the Plan and the claims processorsselected by the Plan. The Executive Administrator may contract with a pharmacybenefits manager to administer pharmacy benefits under the Plan. Such contractsshall include the applicable provisions of G.S. 135‑45.1 through G.S. 135‑45.15and the description of the Plan in the request for proposal, and shall beadministered by the respective claims processor or Pharmacy Benefits Manager,which will determine benefits and other questions arising thereunder. Thecontracts necessarily will conform to applicable State law. If any of theprovisions of G.S. 135‑45.1 through G.S. 135‑45.15 and the requestfor proposals must be modified for inclusion in the contract because of Statelaw, such modification shall be made. The Executive Administrator shall ensurethat the terms of the contract between the Plan and the Plan's ClaimsProcessing Contractor, the Pharmacy Benefit Manager, and the Disease ManagementContractor require the contractor to provide the following:

(1)        Detailed billing byeach entity showing itemized cost information, including individualadministrative services provided;

(2)        Transactional data;and

(3)        The cost to the Planfor each administrative function performed by the contractor.

(e)        Payroll deductionshall be available for coverage under this Part for subscribers able to meetthe Plan's requirements for payroll deduction.

(f)         Notwithstandingany other provisions of the Plan, the Executive Administrator and Board ofTrustees are specifically authorized to use all appropriate means to secure taxqualification of the Plan under any applicable provisions of the InternalRevenue Code of 1954 as amended. The Executive Administrator and Board ofTrustees shall furthermore comply with all applicable provisions of theInternal Revenue Code as amended, to the extent that this compliance is notprohibited by this Article.

(g)        The ExecutiveAdministrator and Board of Trustees shall not change the Plan's comprehensivehealth benefit coverage, co‑payments, deductibles, out‑of‑pocketexpenditures, and lifetime maximums in effect on July 1, 2009, that wouldresult in a net increased cost to the Plan or in a reduction in benefits toPlan members unless and until the proposed changes are directed to be made inan act of the General Assembly.

(h)        The Plan shallprovide coverage under its Basic and Standard PPO options for the diagnosis andtreatment of lymphedema. The coverage shall be the equivalent of coverage underG.S. 58‑3‑280.  (2008‑168, s. 3(c); 2009‑16, ss. 2(f),5(h); 2009‑281, s. 1; 2009‑313, s. 2.)