§ 58-68-25. Definitions; excepted benefits; employer size rule. - North Carolina Statutes

Part A. Group Market Reforms.

Subpart 1.  Portability,Access, and Renewability Requirements.

§ 58‑68‑25. Definitions; excepted benefits; employer size rule.

(a)        Definitions. – Inaddition to other definitions throughout this Article, the following definitionsand their cognates apply in this Article:

(1)        "Bona fideassociation". – With respect to health insurance coverage offered in thisState, an association that:

a.         Has been actively inexistence for at least five years.

b.         Has been formed andmaintained in good faith for purposes other than obtaining insurance.

c.         Does not conditionmembership in the association on any health status‑related factorrelating to an individual (including an employee of an employer or a dependentof an employee).

d.         Makes healthinsurance coverage offered through the association available to all membersregardless of any health status‑related factor relating to the members(or individuals eligible for coverage through a member).

e.         Does not make healthinsurance coverage offered through the association available other than inconnection with a member of the association.

f.          Meets theadditional requirements as may be imposed under State law.

(2)        "COBRAcontinuation provision". – Any of the following:

a.         Section 4980B of theInternal Revenue Code of 1986, other than subdivision (f)(1) of the sectioninsofar as it relates to pediatric vaccines.

b.         Part 6 of subtitle Bof title I of the Employee Retirement Income Security Act of 1974, other thansection 609 of the Act.

c.         Title XXII of thePublic Health Service Act (42 U.S.C.S. § 300bb, et seq.,) as requirements forcertain group health plans for certain State and local employees.

d.         Article 53 of thisChapter or the health insurance continuation law of another state.

(3)        "Employee".– The meaning given the term under section 3(6) of the Employee RetirementIncome Security Act of 1974.

(4)        "Employer".– The meaning given the term under section 3(5) of the Employee RetirementIncome Security Act of 1974, except that the term shall include only employersof two or more employees.

(4a)      "Group healthinsurance coverage". –  Health insurance coverage offered in connectionwith a group health plan.

(4b)      "Group healthplan". – The meaning given the term under 45 C.F.R. § 146.145(a).

(4c)      "Groupmarket." – The market for health insurance coverage offered in connectionwith a group health plan.

(5)        "Healthinsurance coverage" or "coverage" or "health insuranceplan" or "plan". – Benefits consisting of medical care, provideddirectly through insurance or otherwise and including items and services paidfor as medical care, under any accident and health insurance policy orcertificate, hospital or medical service plan contract, or health maintenanceorganization contract, written by a health insurer. Health insurance coverageincludes group health insurance coverage and individual health insurancecoverage.

(6)        "Healthinsurer". – An insurance company subject to this Chapter, a hospital ormedical service corporation subject to Article 65 of this Chapter, a healthmaintenance organization subject to Article 67 of this Chapter, or a multipleemployer welfare arrangement subject to Article 49 of this Chapter, that offersand issues health insurance coverage.

(7)        "Health status‑relatedfactor". – Any of the factors described in G.S. 58‑68‑35(a)(1).

(8)        "Individualhealth insurance coverage". – Health insurance coverage offered toindividuals in the individual market, but not short‑term limited durationinsurance.

(9)        "Individualmarket". – The market for health insurance coverage offered toindividuals.

(10)      "Largeemployer". – An employer who employed an average of at least 51 employeeson business days during the preceding calendar year and who employs at leasttwo employees on the first day of the health insurance plan year.

(11)      "Large groupmarket". – The health insurance market under which individuals obtainhealth insurance coverage, directly or through any arrangement, on behalf ofthemselves and their dependents through a group health insurance planmaintained by a large employer.

(12)      "Medicalcare". – Amounts paid for:

a.         The diagnosis, cure,mitigation, treatment, or prevention of disease, or amounts paid for thepurpose of affecting any structure or function of the body.

b.         Amounts paid for transportationprimarily for and essential to medical care referred to in sub‑subdivisiona. of this subdivision.

c.         Amounts paid forinsurance covering medical care referred to in sub‑subdivisions a. and b.of this subdivision.

(13)      "Networkplan". – Health insurance coverage of a health insurer under which thefinancing and delivery of medical care (including items and services paid foras medical care) are provided, in whole or in part, through a defined set ofhealth care providers under contract with the health insurer.

(14)      "Participant".– The meaning given the term under section 3(7) of the Employee RetirementIncome Security Act of 1974.

(15)      "Placed foradoption". – The assumption and retention by a person of a legalobligation for total or partial support of a child in anticipation of adoptionof the child. The child's placement with the person terminates upon thetermination of the legal obligation.

(16)      "Smallemployer". – The meaning given to the term in G.S. 58‑50‑110(22).

(17)      "Small groupmarket". – The health insurance market under which individuals obtainhealth insurance coverage, directly or through any arrangement, on behalf ofthemselves and their dependents through a group health insurance planmaintained by a small employer.

(b)        Excepted Benefits.– For the purposes of this Article, "excepted benefits" meansbenefits under one or more or any combination of the following:

(1)        Benefits not subjectto requirements. –

a.         Coverage only foraccident or disability income insurance or any combination of these.

b.         Coverage issued as asupplement to liability insurance.

c.         Liability insurance,including general liability insurance and automobile liability insurance.

d.         Workers'compensation or similar insurance.

e.         Automobile medicalpayment insurance.

f.          Credit‑onlyinsurance.

g.         Coverage for on‑sitemedical clinics.

h.         Other similarinsurance coverage, specified in federal regulations, under which benefits formedical care are secondary or incidental to other insurance benefits.

i.          Short‑termlimited‑duration health insurance policies as defined in Part 144 ofTitle 45 of the Code of Federal Regulations.

(2)        Benefits not subjectto requirements if offered separately. –

a.         Limited scope dentalor vision benefits.

b.         Benefits for long‑termcare, nursing care, home health care, community‑based care, or anycombination of these.

c.         The other similar,limited benefits as are specified in federal regulations.

(3)        Benefits not subjectto requirements if offered as independent, noncoordinated benefits. –

a.         Coverage only for aspecified disease or illness.

b.         Hospital indemnityor other fixed indemnity insurance.

(4)        Benefits not subjectto requirements if offered as separate insurance policy. – Medicaresupplemental health insurance (as defined under section 1882(g)(1) of theSocial Security Act), coverage supplemental to the coverage provided underchapter 55 of title 10, United States Code, and similar supplemental coverageprovided to coverage under a group health insurance plan.

(c)        Application ofcertain rules in determination of employer size. – For the purposes of thisArticle:

(1)        Application ofaggregation rule for employers. – All persons treated as a single employerunder subsection (b), (c), (m), or (o) of section 414 of the Internal RevenueCode of 1986 shall be treated as one employer.

(2)        Employers not inexistence in preceding year. – In the case of an employer that was not inexistence throughout the preceding calendar year, the determination of whetherthe employer is a small or large employer shall be based on the average numberof employees that it is reasonably expected the employer will employ onbusiness days in the current calendar year.

(3)        Predecessors. – Anyreference in this subsection to an employer shall include a reference to any predecessorof the employer.  (1997‑259,s. 1(c); 2002‑187, s. 5.1; 2009‑382, ss. 2, 3.)