§ 58-89A-106. Health insurance plan requirements. - North Carolina Statutes

§ 58‑89A‑106. Health insurance plan requirements.

(a)        In order for alicensee to sponsor and maintain a health benefit plan that is not fullyinsured by one or more of the entities specified in subsection (a) of G.S. 58‑89A‑109[58‑89A‑105] on and after October 1, 2009, as authorized bysubsection (e) of that section, the licensee shall meet all of the requirementslisted in this subsection. A health benefit plan developed under this sectionis not required to provide coverage that meets the requirements of otherprovisions of this Chapter that mandate either coverage or the offer ofcoverage by the type or level of health care services or health care provider.The licensee shall:

(1)        Use a third‑partyadministrator licensed or registered under Article 56 of this Chapter.

(2)        Hold all healthinsurance plan assets, including participant contributions, in a separate trustaccount for use only with the health benefit plan.

(3)        Provide soundreserves for the health benefit plan that are determined on an annual basis byan actuary who is a member in good standing of the American Academy ofActuaries. The Commissioner may establish, by rule, a process for approvingplan reserves.

(4)        Maintain the healthbenefit plan for only employees of the licensee or employees of the clientcompany and neither offer nor advertise the health insurance benefit plan tothe public generally.

(5)        Issue to eachcovered employee a policy, contract, certificate, summary plan description, orother evidence of the benefits and coverages provided. The evidence of benefitsand coverages provided shall contain, in boldface print in a conspicuouslocation, the following statement: "THE BENEFITS UNDER THIS PLAN MAY NOTBE EQUAL TO THE MANDATED BENEFITS REQUIRED OF FULLY INSURED PLANS. THE BENEFITSAND COVERAGES DESCRIBED HEREIN ARE PROVIDED THROUGH A SELF‑FUNDED HEALTHBENEFIT PLAN ESTABLISHED BY [name of PEO]. EXCESS INSURANCE IS PROVIDED BY ANAUTHORIZED INSURANCE COMPANY TO COVER HIGH AMOUNT MEDICAL CLAIMS. THE HEALTHBENEFIT PLAN IS NOT PROTECTED BY ANY INSURANCE GUARANTY ASSOCIATION. OTHERRELATED FINANCIAL INFORMATION IS AVAILABLE FROM YOUR EMPLOYER OR FROM THE [nameof PEO]." Any statement required by this subsection is not required onidentification cards issued to covered employees or other insureds.

(6)        File all contractswith third‑party administrators with the Commissioner and report anychanges to those contracts to the Commissioner before their implementation.

(7)        Obtain and maintainstop‑loss insurance from an insurer authorized to write insurance in thisState and that meets the following requirements:

a.         If individual stop‑lossinsurance, it is actuarially appropriate for the size of the group, surplus,and the expected losses, as determined by a qualified actuary and approved bythe Commissioner.

b.         If aggregate stop‑lossinsurance, it is actuarially appropriate for the size of the group, surplus,and the expected losses as determined by a qualified actuary and approved bythe Commissioner. If the licensee is unable to obtain aggregate stop‑lossinsurance that is actuarially appropriate, the licensee shall maintain at leasta thirty percent (30%) lag reserve above expected losses, as determined by aqualified actuary.

c.         If prescribed by theCommissioner, by rule, it satisfies net retention levels in accordance with aPEO's surplus and expected claims.

(8)        File with theCommissioner for information the summary plan description and the evidence ofthe benefits and coverages provided under the health benefit plan that isissued to the person covered by the health benefit plan.

(9)        Establish andmaintain a written plan of operation for the health benefit plan.

(10)      File with theCommissioner the plan of operation for the health benefit plan and any updatesto the plan of operation within 30 days of implementation.

(11)      Upon request of theCommissioner, provide information that summarizes paid and incurred expensesand contributions or premiums received and any additional evidence that thePEO's health benefit plan is actuarially sound.

(b)        NotwithstandingChapter 132 of the General Statutes, all documents filed by a licensee underthis section are confidential, are not open for public inspection, and are notdiscoverable or admissible in evidence in a civil action brought by a partyother than the Department against a person regulated by the Department, itsdirectors, officers, or employees, unless the court finds that the interests ofjustice require that the documents be discoverable or admissible in evidence.The Commissioner, however, may use the contracts filed under this subsection inthe furtherance of any regulatory or legal action brought as part of theCommissioner's official duties.  (2009‑552, s. 3.)