§ 58-50-110. Definitions. - North Carolina Statutes

§ 58‑50‑110. Definitions.

As used in this Act:

(1)        Repealed by SessionLaws 2001‑334, s. 12.1, effective August 3, 2001.

(1a)      "Actuarialcertification" means a written statement by a member of the AmericanAcademy of Actuaries or other individual acceptable to the Commissioner that asmall employer carrier is in compliance with the provisions of G.S. 58‑50‑130,and to the extent applicable, the provisions of Article 68 of this Chapter,based upon the person's examination, including a review of the appropriaterecords and of the actuarial assumptions and methods used by the small employercarrier in establishing premium rates for applicable health benefit plans.

(1b)      "Adjustedcommunity rating" means a method used to develop carrier premiums whichspreads financial risk across a large population and allows adjustments for thefollowing demographic factors: age, gender, family composition, and geographicareas, as determined pursuant to G.S. 58‑50‑130(b).

(2)        Repealed by SessionLaws 1993, c. 529, s. 3.3.

(3)        "Basic healthcare plan" means a health care plan for small employers that is lower incost than a standard health care plan and is required to be offered by allsmall employer carriers pursuant to G.S. 58‑50‑125 and approved bythe Commissioner in accordance with G.S. 58‑50‑125.

(4)        "Board"means the board of directors of the Pool.

(5)        "Carrier"means any person that provides one or more health benefit plans in this State,including a licensed insurance company, a prepaid hospital or medical serviceplan, a health maintenance organization (HMO), and a multiple employer welfarearrangement.

(5a)      "Casecharacteristics" means the demographic factors age, gender, family size,geographic location, and industry.

(6),       (7)  Repealed bySession Laws 1993, c. 529, s. 3.3.

(8)        "Committee"means the Small Employer Carrier Committee as created by G.S. 58‑50‑120.

(9)        "Dependent"means the spouse or child of an eligible employee, subject to applicable termsof the health care plan covering the employee.

(10)      "Eligible employee"means an employee who works for a small employer on a full‑time basis,with a normal work week of 30 or more hours, including a sole proprietor, apartner or a partnership, or an independent contractor, if included as anemployee under a health care plan of a small employer; but does not includeemployees who work on a part‑time, temporary, or substitute basis.

(11)      "Health benefitplan" means any accident and health insurance policy or certificate;nonprofit hospital or medical service corporation contract; health, hospital,or medical service corporation plan contract; HMO subscriber contract; planprovided by a MEWA or plan provided by another benefit arrangement, to theextent permitted by ERISA, subject to G.S. 58‑50‑115. Healthbenefit plan does not include benefits described in G.S. 58‑68‑25(b).

(12)      "Impairedinsurer" has the same meaning as prescribed in G.S. 58‑62‑20(6)or G.S. 58‑62‑16(8).

(12a)    "Industry"means a demographic factor used to reflect the financial risk associated with aspecific industry.

(13)      Repealed by SessionLaws 1993, c. 529, s. 3.3.

(14)      "Lateenrollee" has the same meaning as defined in G.S. 58‑68‑30(b)(2);provided that the initial enrollment period shall be a period of at least 30consecutive calendar days. In addition to the special enrollment provisions inG.S. 58‑68‑30(f), an eligible employee or dependent shall not beconsidered a late enrollee under a small employer health benefit plan if:

a.         Repealed by SessionLaws 1998‑211, s. 9, effective November 1, 1998.

1,         2. Repealed bySession Laws 1998‑211, s. 9, effective November 1, 1998.

3,         4. Repealed bySession Laws 1993, c. 529, s. 3.3.

b.         The individualelects a different health benefit plan offered by the small employer during anopen enrollment period;

c.         Repealed by SessionLaws 1998‑211, s. 9, effective November 1, 1998.

d.         A court has orderedcoverage be provided for a spouse or minor child under a covered employee'shealth benefit plan and the request for enrollment for a spouse is made within30 days after issuance of the court order. A minor child shall be enrolled inaccordance with the requirements of G.S. 58‑51‑120; or

e.         Repealed by SessionLaws 1998‑211, s. 9, effective November 1, 1998.

(15)      Repealed by SessionLaws 1993, c. 529, s. 3.3.

(16)      "Pool" meansthe North Carolina Small Employer Health Reinsurance Pool created in G.S. 58‑50‑150.

(17)      "Preexisting‑conditionsprovision" means a preexisting‑condition provision as defined inG.S. 58‑68‑30.

(18)      "Premium"includes insurance premiums or other fees charged for a health benefit plan,including the costs of benefits paid or reimbursements made to or on behalf ofpersons covered by the plan.

(19)      "Ratingperiod" means the calendar period for which premium rates established by asmall employer carrier are assumed to be in effect, as determined by the smallemployer carrier.

(20)      "Risk‑assumingcarrier" means a small employer carrier electing to comply with therequirements set forth in G.S. 58‑50‑140.

(21)      "Reinsuringcarrier" means a small employer carrier electing to comply with therequirements set forth in G.S. 58‑50‑145.

(21a)    "Self‑employedindividual" means an individual or sole proprietor who derives a majorityof his or her income from a trade or business carried on by the individual orsole proprietor which results in taxable income as indicated on IRS form 1040,Schedule C or F and which generated taxable income in one of the two previousyears.

(22)      "Smallemployer" means any individual actively engaged in business that, on atleast fifty percent (50%) of its working days during the preceding calendarquarter, employed no more than 50 eligible employees, the majority of whom areemployed within this State, and is not formed primarily for purposes of buyinghealth insurance and in which a bona fide employer‑employee relationshipexists. In determining the number of eligible employees, companies that areaffiliated companies, or that are eligible to file a combined tax return forpurposes of taxation by this State, shall be considered one employer. Subsequentto the issuance of a health benefit plan to a small employer and for thepurpose of determining eligibility, the size of a small employer shall bedetermined annually. Except as otherwise specifically provided, the provisionsof this Act that apply to a small employer shall continue to apply until theplan anniversary following the date the small employer no longer meets therequirements of this definition. For purposes of this Act, the term smallemployer includes self‑employed individuals.

(23)      "Small employercarrier" means any carrier that offers health benefit plans coveringeligible employees of one or more small employers.

(24)      "Standard healthcare plan" means a health care plan for small employers required to beoffered by all small employer carriers under G.S. 58‑50‑125 andapproved by the Commissioner in accordance with G.S. 58‑50‑125. (1991, c. 630, s. 1; 1993, c.408, ss. 1, 2; c. 529, s. 3.3; 1993 (Reg. Sess., 1994), c. 569, s. 6; 1997‑259,s. 2; 1998‑211, s. 9; 2001‑334, ss. 12.1, 12.2; 2006‑154, ss.5, 6.)