§ 58-50-195. Eligibility for Pool coverage. - North Carolina Statutes

§ 58‑50‑195. Eligibility for Pool coverage.

(a)        Any individual whois and continues to be a resident of this State is eligible for Pool coverageif the individual provides evidence of any of the following:

(1)        A notice ofrejection or refusal to issue substantially similar health insurance coveragefor health reasons by an insurer. A rejection or refusal by an insurer offeringonly stop‑loss, excess loss, or reinsurance coverage with respect to theapplicant is not sufficient evidence of eligibility.

(2)        An offer to issuehealth insurance coverage only with a conditional rider that limits coveragefor the individual's high‑risk medical condition.

(3)        A refusal by aninsurer to issue health insurance coverage except at a rate exceeding the Poolrate.

(4)        A diagnosis of theindividual with one of the medical or health conditions listed by the Board inaccordance with this section. An individual diagnosed with one or more of theseconditions is eligible for Pool coverage without applying for other health insurancecoverage.

(5)        Qualification as afederally defined eligible individual, whether or not currently covered by aninsurer under that qualification.

(6)        An individual who islegally domiciled in this State and is eligible for the credit for healthinsurance costs under the Trade Adjustment Assistance Reform Act of 2002,section 35 of the Internal Revenue Code of 1986. Each dependent of anindividual who is eligible for Pool coverage under this subdivision shall alsobe eligible for Pool coverage.

(7)        The individual hascurrent individual health insurance coverage at a rate exceeding the Pool rate.

(b)        The Board, uponrecommendation of the Executive Director, shall adopt a list of medical orhealth conditions for which a person shall be eligible for Pool coverage undersubdivision (a)(4) of this section. The Board may amend the list as the Boardconsiders appropriate.

(c)        An individual isnot eligible for coverage under the Pool if:

(1)        The individual hasor obtains medical care benefits substantially similar to or more comprehensivethan the benefit plan offered by the Pool, or would be eligible to havecoverage if the person elected to obtain it, except that:

a.         An individual maymaintain other coverage for the period of time the individual is satisfying anypreexisting condition waiting period under a Pool policy; and

b.         An individual maymaintain Pool coverage for the period of time the individual is satisfying apreexisting condition waiting period under another health insurance policyintended to replace the Pool policy.

(2)        The individual isdetermined to be eligible for enrollment in the State Medical Assistance Planor in Medicare, unless the Pool offers Medicare supplemental insurancecoverage.

(3)        The individual haspreviously terminated Pool coverage unless 12 months have lapsed since thetermination, except that this subdivision shall not apply with respect to anapplicant who is a federally defined eligible individual or to an applicanteligible for or receiving benefits under the Trade Adjustment AssistanceProgram.

(4)        The individual is aninmate or resident of a public institution, except that this subdivision shallnot apply with respect to an applicant who is a federally defined eligibleindividual.

(5)        The individual'spremiums are paid for or reimbursed under any government‑sponsoredprogram or by any government agency or health care provider, except as anotherwise qualifying full‑time employee, or dependent thereof, of agovernment agency or health care provider. This subdivision shall not apply forindividuals receiving benefits under the Trade Adjustment Assistance Program orto individuals receiving premium subsidies made available by the State based onindividual income levels.

(6)        The individual hasin effect on the date Pool coverage takes effect health insurance coverage froman insurer or insurance arrangement.

(d)        Coverage under thePool shall cease:

(1)        On the date anindividual is no longer a resident of this State.

(2)        On the date anindividual requests coverage to end.

(3)        Upon the death ofthe covered individual.

(4)        On the date Statelaw requires cancellation of the Pool policy.

(5)        At the option of thePool, 30 days after the Pool makes any inquiry concerning the individual'seligibility or residence to which the individual does not reply.

(6)        Because theindividual has failed to make the payments required under this Part.

(7)        Because theindividual has performed an act or practice that constitutes fraud or made anintentional misrepresentation of material fact under the terms of the coverage.

(e)        Except as providedin subsection (d) of this section, an individual who ceases to meet theeligibility requirements of this section may be terminated at the end of thePool policy period for which the necessary premiums have been paid.  (2007‑532, s. 1.1;2008‑124, s. 6.4.)