reglab/housing_qa huggingface dataset:
NC Gen Stat § 58-67-79 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-79 - Coverage for reconstructive breast surgery following mastectomy.

 58-67-79. Coverage for reconstructive breast surgery following mastectomy.(a) Every health care plan written by a health maintenance organization that is subject to this Article and that provides coverage for mastectomy shall provide coverage for reconstructive breast surgery following a mastectomy. The coverage shall include coverage for all stages and revisions of reconstructive breast surgery performed on a nondiseased breast to establish symmetry if reconstructive surgery on a diseased breast is performed, as well as coverage for prostheses and physical complications in all stages of mastectomy, including lymphademas. The same deductibles, coinsurance, and other limitations as apply to similar services covered under the policy, contract, or plan shall apply to coverage for reconstructive breast surgery. Reconstruction of the nipple/areolar complex following a mastectomy is covered without regard to the lapse of time between the mastectomy and the reconstruction, subject to the approval of the treating physician.(b) As used in this section, the following terms have the meanings indicated:(1) "Mastectomy" means the surgical removal of all or part of a breast as a result of breast cancer or breast disease.(2) "Reconstructive breast surgery" means surgery performed as a result of a mastectomy to reestablish symmetry between the two breasts, and includes reconstruction of the mastectomy site, creation of a new breast mound, and creation of a new nipple/areolar complex. "Reconstructive breast surgery" also includes augmentation mammoplasty, reduction mammoplasty, and mastopexy of the nondiseased breast.(c) A policy, contract, or plan subject to this section shall not:(1) Deny coverage described in subsection (a) of this section on the basis that the coverage is for cosmetic surgery;(2) Deny to a woman eligibility or continued eligibility to enroll or to renew coverage under the terms of the contract, policy, or plan, solely for the purpose of avoiding the requirements of this section;(3) Provide monetary payments or rebates to a woman to encourage her to accept less than the minimum protections available under this section;(4) Penalize or otherwise reduce or limit the reimbursement of an attending provider because the provider provided care to an individual participant or beneficiary in accordance with this section; or(5) Provide incentives, monetary or otherwise, to an attending provider to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.(d) Written notice of the availability of the coverage provided by this section shall be delivered to every subscriber under the plan upon enrollment and annually thereafter. The notice required by this subsection may be included as a part of any yearly informational packet sent to the subscriber. (1997-312, s. 3; 1999-351, s. 3.3; 2001-334, s. 13.3.)
NC Gen Stat § 58-67-80 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-80 - Meaning of terms "accident", "accidental injury", and "accidental means".

 58-67-80. Meaning of terms "accident", "accidental injury", and "accidental means".(a) Effective October 1, 1989, this section applies to all health maintenance organization plans under this Article.(b) "Accident", "accidental injury", and "accidental means" shall be defined to imply "result" language and shall not include words that establish an accidental means test. (1989, c. 485, s. 12.)
NC Gen Stat § 58-67-90 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-90 - Licensing and regulation of agents.

 58-67-90. Licensing and regulation of agents.Every agent of any HMO authorized to do business in this State under this Article is subject to the licensing provisions of Article 33 of this Chapter and all other provisions in this Chapter applicable to life and health insurance agents. (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1985 (Reg. Sess., 1986), c. 928, s. 5; 1987, c. 629, s. 3; 1999-244, s. 8.)
NC Gen Stat § 58-67-95 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-95 - Powers of insurers, hospitals, prepaid health plans, and medical service corporations.

 58-67-95. Powers of insurers, hospitals, prepaid health plans, and medical service corporations.(a) Upon demonstration to the Commissioner of compliance with this Article, an insurance company licensed in this State, a prepaid health plan licensed to do business in this State, or a hospital or medical service corporation authorized to do business in this State, may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this Article. Notwithstanding any other law which may be inconsistent herewith, any two or more such insurance companies, hospital or medical service corporations, prepaid health plans, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the arranging of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.(b) Notwithstanding any provision of the insurance and hospital or medical service corporation laws contained in Articles 1 through 66 of this Chapter, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under such contracts, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers pursuant to the health care plan.  (1977, c. 580, s. 1; 1979, c. 876, s. 1; 2018-49, s. 2(d).)
NC Gen Stat § 58-67-100 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-100 - Examinations.

 58-67-100. Examinations.(a) The Commissioner may make an examination of the affairs of any health maintenance organization and the contracts, agreements or other arrangements pursuant to its health care plan as often as the Commissioner deems it necessary for the protection of the interests of the people of this State but not less frequently than once every five years. Examinations shall otherwise be conducted under G.S. 58-2-131 through G.S. 58-2-134.(b) Repealed by Session Laws 1997-519, s. 1, effective January 1, 1998.(c) Repealed by Session Laws 1995, c. 360, s. 2(m).(d) Instead of conducting an examination, the Commissioner may accept the report of an examination made by the HMO regulator of another state. (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1995, c. 360, s. 2(m); 1997-519, s. 1.4; 1999-132, s. 11.10; 2007-127, s. 16.)
NC Gen Stat § 58-67-105 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-105 - Hazardous financial condition.

 58-67-105. Hazardous financial condition.(a) Whenever the financial condition of any health maintenance organization indicates a condition such that the continued operation of the health maintenance organization might be hazardous to its enrollees, creditors, or the general public, then the Commissioner may order the health maintenance organization to take such action as may be reasonably necessary to rectify the existing condition, including but not limited to one or more of the following steps:(1) To reduce the total amount of present and potential liability for benefits by reinsurance;(2) To reduce the volume of new business being accepted;(3) To reduce the expenses by specified methods;(4) To suspend or limit the writing of new business for a period of time; or(5) To require an increase to the health maintenance organization's net worth by contribution.(b) The Commissioner may adopt rules to set uniform standards and criteria for the early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public, and to set standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purposes expressed in subsection (a) of this section. (1987, c. 631, s. 5.)
NC Gen Stat § 58-67-110 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-110 - Protection against insolvency.

 58-67-110. Protection against insolvency.(a) The Commissioner shall require deposits in accordance with the provisions of G.S. 58-67-25.(b) Each full service health maintenance organization shall maintain a minimum net worth equal to the greater of one million dollars ($1,000,000) or the amount required pursuant to the risk-based capital provisions of Article 12 of this Chapter. Each single service health maintenance organization shall maintain a minimum net worth equal to the greater of fifty thousand dollars ($50,000) or that amount required pursuant to the risk-based capital provisions of Article 12 of this Chapter.(c), (d) Repealed by Session Laws 2003-212, s. 21, effective October 1, 2003.(e) Every full service medical health maintenance organization shall have and maintain at all times an adequate plan for protection against insolvency acceptable to the Commissioner. In determining the adequacy of such a plan, the Commissioner may consider:(1) A reinsurance agreement preapproved by the Commissioner covering excess loss, stop loss, or catastrophes. The agreement must provide that the Commissioner will be notified no less than 60 days prior to cancellation or reduction of coverage.(2) A conversion policy or policies that will be offered by an insurer to the enrollees in the event of the health maintenance organization's insolvency.(3) Any other arrangements offering protection against insolvency that the Commissioner may require. (1987, c. 631, s. 5; 1989, c. 776, ss. 11, 12; 2003-212, s. 21.)
NC Gen Stat § 58-67-120 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-120 - Continuation of benefits.

 58-67-120. Continuation of benefits.(a) The Commissioner shall require that each HMO have a plan for handling insolvency, which plan allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to enrollees who are confined in an inpatient facility until their discharge or expiration of benefits. In considering such a plan, the Commissioner may require:(1) Insurance to cover the expenses to be paid for benefits after an insolvency;(2) Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the HMO's insolvency for which premium payment has been made and until the enrollees' discharge from inpatient facilities;(3) Insolvency reserves such as the Commissioner may require;(4) Letters of credit acceptable to the Commissioner;(5) Any other arrangements to assure that benefits are continued as specified above. (1989, c. 776, s. 13.)
NC Gen Stat § 58-67-125 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-125 - Enrollment period.

 58-67-125. Enrollment period.(a) In the event of an insolvency of an HMO upon order of the Commissioner, all other carriers that participated in the enrollment process with the insolvent HMO at a group's last regular enrollment period shall offer such group's enrollees of the insolvent HMO a 30-day enrollment period commencing upon the date of insolvency. Each carrier shall offer such enrollees of the insolvent HMO the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period.(b) If no other carrier had been offered to some groups enrolled in the insolvent HMO, or if the Commissioner determines that the other health benefit plan or plans lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group enrollees of the insolvent HMO, then the Commissioner shall allocate the insolvent HMO's group contracts for such groups among all other HMOs that operate within a portion of the insolvent HMO's service area, taking into consideration the health care delivery resources of each HMO. Each HMO to which a group or groups are so allocated shall offer such group or groups that HMO's existing coverage that is most similar to each group's coverage with the insolvent HMO at rates determined in accordance with the successor HMO's existing rating methodology.(c) The Commissioner shall also allocate the insolvent HMO's nongroup enrollees who are unable to obtain other coverage among all HMOs that operate within a portion of the insolvent HMO's service area, taking into consideration the health care delivery resources of each such HMO. Each HMO to which nongroup enrollees are allocated shall offer such nongroup enrollees that HMO's existing coverage for individual or conversion coverage as determined by his type of coverage in the insolvent HMO at rates determined in accordance with the successor HMO's existing rating methodology. Successor HMOs that do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes. (1989, c. 776, s. 13.)
NC Gen Stat § 58-67-130 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-130 - Replacement coverage.

 58-67-130. Replacement coverage.(a) Any carrier providing replacement coverage with respect to group hospital, medical, or surgical expense or service benefits, within a period of 60 days from the date of discontinuance of a prior HMO contract or policy providing such hospital, medical or surgical expense or service benefits, shall immediately cover all enrollees who were validly covered under the previous HMO contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy.(b) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract of replacement coverage that would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preceded the effective date of the succeeding carrier's contract shall be applied with respect to those enrollees validly covered under the prior carrier's contract or policy on the date of discontinuance. (1989, c. 776. s. 13.)
NC Gen Stat § 58-67-135 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-135 - Incurred but not reported claims.

 58-67-135. Incurred but not reported claims.(a) Every HMO shall, when determining liability, include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures that have been incurred, whether reported or unreported, that are unpaid and for which such HMO is or may be liable; and to provide for the expense of adjustment or settlement of such claims.(b) Such liabilities shall be computed in accordance with rules adopted by the Commissioner upon reasonable consideration of the ascertained experience and character of the HMO. (1989, c. 776, s. 13.)
NC Gen Stat § 58-67-140 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-140 - Suspension or revocation of license.

 58-67-140. Suspension or revocation of license.(a) The Commissioner may suspend or revoke an HMO license if the Commissioner finds that the HMO:(1) Is operating significantly in contravention of its basic organizational document, or in a manner contrary to that described in and reasonably inferred from any other information submitted under G.S. 58-67-10, unless amendments to such submissions have been filed with and approved by the Commissioner.(2) Issues evidences of coverage or uses a schedule of premiums for health care services that do not comply with G.S. 58-67-50.(3) Is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees.(4) Has itself or through any person on its behalf advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner.(5) Is operating in a manner that would be hazardous to its enrollees.(6) Knowingly or repeatedly fails or refuses to comply with any law or rule applicable to the HMO or with any order issued by the Commissioner after notice and opportunity for a hearing.(7) Repealed by Session Laws 2015-92, s. 7, effective June 19, 2015.(b) A license shall be suspended or revoked only after compliance with G.S. 58-67-155.(c) When an HMO license is suspended, the HMO shall not, during the suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation.(d) When an HMO license is revoked, the HMO shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the HMO. The HMO shall engage in no advertising or solicitation. The Commissioner may, by written order, permit such further operation of the HMO as the Commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.  (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1997-519, s. 1.5; 2003-212, ss. 22, 23, 26(l); 2015-92, s. 7.)
NC Gen Stat § 58-67-145 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-145 - Rehabilitation, liquidation, or conservation of health maintenance organization.

 58-67-145. Rehabilitation, liquidation, or conservation of health maintenance organization.Any rehabilitation, liquidation or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the Commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies, except that the provisions of Article 48 of this Chapter shall not apply to health maintenance organizations. The Commissioner may apply for an order directing him to rehabilitate, liquidate, or conserve a health maintenance organization upon one or more grounds set out in Article 30 of this Chapter or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this State.  (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1989, c. 452, s. 2; c. 776, s. 14; 1998-211, s. 5; 2018-120, s. 1.2(a).)
NC Gen Stat § 58-67-150 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-150 - Regulations.

 58-67-150. Regulations.The Commissioner may, after notice and hearing, promulgate reasonable rules and regulations as are necessary or proper to carry out the provisions of this Article. Such rules and regulations shall be subject to review in accordance with G.S. 58-67-155. (1977, c. 580, s. 1; 1979, c. 876, s. 1.)
NC Gen Stat § 58-67-155 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-155 - Administrative procedures.

 58-67-155. Administrative procedures.(a) When the Commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health maintenance organization in writing specifically stating the grounds for denial, suspension, or revocation and fixing a time of at least 30 days thereafter for a hearing on the matter.(b) After such hearing, or upon the failure of the health maintenance organization to appear at such hearing, the Commissioner shall take action as is deemed advisable or written findings which shall be mailed to the health maintenance organization. The action of the Commissioner shall be subject to review by the Superior Court of Wake County. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the Commissioner in whole or in part.(c) The provisions of Chapter 150B of the General Statutes of this State shall apply to proceedings under this section to the extent that they are not in conflict with subsections (a) and (b). (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1987, c. 827, s. 1.)
NC Gen Stat § 58-67-160 (2021)
2021 North Carolina General Statutes|Chapter 58 - Insurance|Article 67 - Health Maintenance Organization Act.|§ 58-67-160 - Fees.

 58-67-160. Fees.Every health maintenance organization subject to this Article shall pay to the Commissioner a fee of five hundred dollars ($500.00) for filing an application for a license and an annual license continuation fee of two thousand dollars ($2,000) for each license. The license shall continue in full force and effect, subject to timely payment of the annual license continuation fee in accordance with G.S. 58-6-7 and subject to any other applicable provisions of the insurance laws of this State.  (1977, c. 580, s. 1; 1979, c. 876, s. 1; 1989 (Reg. Sess., 1990), c. 1069, s. 6; 1995, c. 507, s. 11A(c); 1999-435, s. 6; 2003-212, s. 26(m); 2005-424, s. 1.6; 2009-451, s. 21.10(a).)