reglab/statecodes huggingface dataset:
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 16 - ACTUARIAL SERVICES DIVISION › Section .0700 - HEALTH MAINTENANCE ORGANIZATION CLAIM RESERVE DATA REQUIREMENTS › Section 16 .0704 - CLAIM RESERVE DATA AND FORMAT REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
				data requirements in Paragraph (b) of this Rule shall be recorded for the
				following types of claims:
(1) inpatient
				Claims;
(2) physician
				Claims;
(3) referral Claims;
				and
(4) other.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 16 - ACTUARIAL SERVICES DIVISION › Section .0700 - HEALTH MAINTENANCE ORGANIZATION CLAIM RESERVE DATA REQUIREMENTS › Section 16 .0705 - CLAIM RESERVE METHODOLOGY AND ACTUARIAL CERTIFICATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A
				written description of the claim reserve methodology and a numerical
				verification of the claim reserves submitted in
				11 NCAC
				16 .0704(d) shall be
				included with each annual filing.
(b) Each annual filing shall contain an
				actuarial certification signed by an actuary stating that the actuary has
				examined the claim reserves listed in Schedule - H, Section II, and affirms
				that these claim reserves are calculated in accordance with generally accepted
				actuarial principles and practices and in the actuary's opinion are
				adequate.
Authority
				  G.S.
				  58-2-40;
				  58-67-135(b);
Eff. February 1, 1995;
Readopted Eff. October 1,
				  2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 16 - ACTUARIAL SERVICES DIVISION › Section .0800 - SMALL EMPLOYER GROUP HEALTH INSURANCE ACTUARIAL CERTIFICATION › Section 16 .0801 - SMALL EMPLOYER GROUP HEALTH INSURANCE ACTUARIAL CERTIFICATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each small employer group carrier, as
				defined in
				G.S.
				58-50-110(23), shall use the
				following language in its actuarial certification:
(1) The opening paragraph shall state either
				of the following, as applicable:
(A) For a
				carrier actuary, the opening paragraph shall state:
"I, (name and title of actuary), am an (officer, employee)
				  of (name of carrier) and am a member of the American Academy of Actuaries. I am
				  familiar with
				  G.S.
				  58-50-130."
(B) For a consulting actuary, the opening
				paragraph shall state:
"I, (name and title of consulting actuary), am associated
				  with (name of actuarial consulting firm) and am a member of the American
				  Academy of Actuaries. I have been involved in the preparation of the small
				  employer group health insurance premium rates for the (name of carrier) and am
				  familiar with
				  G.S.
				  58-50-130."
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0101 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
As used in this Chapter:
(1) "Counselor" means a private citizen who
			 has been trained by SHIIP employees and is certified by SHIIP to voluntarily
			 provide counseling in accordance with this Chapter.
(2) "Department" means the Department of
			 Insurance of the State of North Carolina.
(3) "SHIIP" means the Seniors' Health
			 Insurance Information Program.
(4)
			 "SHIIP employee" means an employee of the Department of Insurance who is acting
			 on behalf of SHIIP.
Authority
				G.S.
				58-2-25;
				58-2-40(1);
				58-54-25;
				58-55-30;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. March 24,
				2019.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0102 - PURPOSE AND DUTIES OF SHIIP

Current through Register Vol. 39, No. 2, July 15, 2024
(a) SHIIP is
			 established within the Department as a statewide health benefits counseling
			 program to provide Medicare beneficiaries with counseling in Medicare, private
			 health insurance, and related health care coverage plans.
(b) In carrying out its duties under this
			 Chapter, SHIIP:
(1) Acts as a clearinghouse
			 for information and materials relating to Medicare and health
			 insurance.
(2) Develops additional
			 information and materials relating to Medicare and health insurance, as
			 necessary.
(3) Provides minimum
			 standards and materials for training and certifying counselors.
(4) Provides information for health insurance
			 educational activities that are conducted by employers, senior organizations,
			 and other interested groups.
(5)
			 Supports, to the extent possible, additional emphasis on expansion of community
			 educational activities that would provide for announcements on television and
			 in other media that briefly describe the nature of Medicare, Medicare
			 supplement insurance, and long-term care insurance, and the availability of
			 consumer information and materials under this Chapter.
(6) Provides community education on Medicare,
			 Medicare supplement insurance, and long-term care insurance.
(7) Recruits, trains, and coordinates
			 counselors.
(8) Assists individuals
			 and provides informal advocacy with respect to Medicare and health insurance
			 benefits claims.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0103 - LOCATION, MAILING ADDRESS, AND TELEPHONE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
			 primary location of Seniors' Health Insurance Information Program or SHIIP is
			 325 North Salisbury Street, Albemarle Building, Raleigh, NC 27603.
(b) The mailing address of SHIIP is 1201 Mail
			 Service Center, Raleigh, North Carolina, 27699-1201.
(c) The telephone numbers for SHIIP are
			 toll-free 1-855-408-1212 and 1-919-807-6900.
Authority
				G.S.
				58-2-5;
				58-2-25;
				58-2-40(1);
				58-54-25;
				58-55-30;
Eff. July 1,
				1992;
Amended Eff. January 1, 2018; November 1, 2011; September 1,
				2002;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. March 24,
				2019.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0104 - COUNSELORS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Counselors
			 shall not engage in the solicitation of insurance sales. Licensed insurance
			 agents and employees of insurance companies are not eligible for training and
			 certification as counselors by SHIIP.
(b) No counselor shall provide counseling
			 services under this Chapter unless he or she has been trained and certified by
			 SHIIP.
(c) Before providing any
			 counseling services, counselors shall disclose, in writing, to recipients of
			 counseling services pursuant to this Chapter that the counselors are acting in
			 good faith to provide information about the Medicare program and about health
			 insurance policies and benefits on a volunteer basis, but that the information
			 shall not be construed to be legal advice.
(d) Counselors shall not endorse any
			 particular insurance company or insurance agency, agent, broker, brokerage
			 firm, or other private provider of health insurance.
(e) Counselors shall keep all consultations
			 with recipients of counseling services confidential, except for filing of
			 reports with SHIIP employees.
Authority
				G.S.
				58-2-40(1);
				58-54-25;
				58-55-30;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. March 24,
				2019.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0105 - MEDICARE SUPPLEMENT POLICIES

Current through Register Vol. 39, No. 2, July 15, 2024
All Medicare supplement insurance policy forms that have been
				approved by the Life and Health Division of the Department are on file in the
				offices of SHIIP. Copies of these policy forms are available as soon as
				practicable after request therefor and payment of the copying fee specified in
				G.S.
				58-6-5(3).
Authority
				G.S.
				58-2-40(1);
				58-6-5(3);
				58-54-25;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. March 24,
				2019.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM › Section 17 .0106 - BUYER'S GUIDES

Current through Register Vol. 39, No. 2, July 15, 2024
The Guide to Health Insurance for People with Medicare, as
				published by the National Association of Insurance Commissioners, or any
				successor publications, are available from SHIIP to consumers, free of charge.
				Licensed insurance agents and employees of insurance companies shall obtain
				these publications from the insurance companies by which they are appointed or
				employed.
Authority
				G.S.
				58-2-40(1);
				58-54-25;
				58-55-30;
Eff. July 1,
				1992;
Amended Eff. February 1, 1996;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. March 24,
				2019.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0101 - PURPOSE AND SCOPE

Current through Register Vol. 39, No. 2, July 15, 2024
The purpose of this Section is to implement the provisions of
				Article 49 of General Statute Chapter 58 and to regulate the issuance of a
				license and the operation of a MEWA as provided in that Article. The definition
				of "multiple employer welfare arrangement" or "MEWA" contained in
				G.S.
				58-49-30(a) is incorporated
				herein by reference, including any subsequent amendments or
				editions.
Authority
				G.S.
				58-2-40(1);
				58-49-30;
				58-49-35;
				58-49-40;
				58-49-50;
				58-49-55;
58-49-60;
				58-49-65;
Eff. July 1, 1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0102 - GENERAL ELIGIBILITY

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each MEWA shall
			 provide to the Commissioner adequate documentation that the exemption under
			 Section 501(c) of the Internal Revenue Code has been granted, or that the MEWA
			 will operate solely for the benefit of the members of the MEWA. Any profits
			 from the operation of the MEWA shall be invested in securities as allowed by
			 G.S.
			 58-7-160 through
			 G.S.
			 58-7-200, and the interest or other profits
			 accrued or received thereon shall be used to provide rate stability or provide
			 other such benefits for the members to which the trustees and the Commissioner
			 agree; and the trust agreement shall so state.
(b) Each MEWA shall be established by a trade
			 association, industry association, or professional association.
(c) As used in this Rule:
(1) "Industry association" means member
			 employers who are in the same major group code, as defined by the Standard
			 Industrial Classification Manual issued by the Executive Office of the
			 President, Office of Management and Budget; unless restricted by Subparagraph
			 (c)(2) or (3) of this Rule.
(2)
			 "Professional association" means member employers who are of the same type of
			 profession, such as physicians, dentists, accountants, lawyers, or architects;
			 but is not limited to those professions. However, the profession must be one
			 that is recognized by the required licensing agency.
(3) "Trade association" means member
			 employers who are in the same type of trade, such as plumbers or electricians;
			 and any others that are trade designations as recognized by the required
			 licensing agency.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0103 - FILING REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All
			 communications and filings shall be made to the Deputy Commissioner, Life and
			 Health Division, North Carolina Department of Insurance, 1201 Mail Service
			 Center, Raleigh, North Carolina 27699-1201.
(b) To apply for licensure, an applicant
			 shall submit the following information required by
			 G.S.
			 58-49-50:
(1) A Form MEWA-1 entitled "Application for
			 License for Multiple Employer Welfare Arrangement (MEWA)";
(2) A Form MEWA-3A entitled "Biographical
			 Affidavit," for all officers, directors, and trustees of the MEWA that shall
			 contain information to enable the Commissioner to determine if such persons are
			 disqualified pursuant to
			 G.S.
			 58-49-40(e);
(3) A list of all names, addresses, and
			 telephone numbers of participating employers and the number of employees
			 covered by the MEWA;
(4) A
			 statement of the reasons for applying for a North Carolina MEWA
			 license;
(5) A description of how
			 the MEWA proposes to develop and supervise its operations in North
			 Carolina;
(6) The name, title, and
			 qualifications of the person who will be responsible for the MEWA's operation
			 in North Carolina (the managing general agent if the MEWA is domiciled outside
			 of North Carolina); and
(7) The
			 location of and a description of the office facilities that will be provided by
			 the MEWA in North Carolina.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0104 - FINANCIAL

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A MEWA may
			 participate in a cash management program as long as the MEWA has direct access
			 to its funds at all times and the depository or custodian maintains a separate
			 accounting for each account. The depository or custodian must be a national or
			 state bank, savings and loan association, or trust company.
(b) No surplus note(s) or the interest
			 thereon shall be paid or repaid without the specific written approval of the
			 Department. If there is more than one surplus note, each note shall have its
			 own unique identification number in the upper left hand corner of each page of
			 the document.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-60;
Eff. August
				3, 1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0105 - ADMINISTRATIVE, PROVIDER, AND MANAGEMENT CONTRACTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As used in this Rule, "fees" means any
			 compensation, including but not limited to, cash or other assets of a MEWA that
			 is transferred for either contracted or noncontracted services that are
			 rendered to the sponsoring association or the MEWA.
(b) A MEWA is prohibited from paying any
			 fees, other than for reimbursement of specific expenses, to its sponsoring
			 association unless the services rendered to the MEWA are available to the MEWA
			 from persons other than the sponsoring association.
(c) The fees for such services shall not be
			 in excess of what would be charged in an arms length transaction. Reasonable
			 fees may also be determined by comparing those charged to other MEWAs in North
			 Carolina.
(d) A MEWA shall give the
			 Commissioner written notification of any proposed change to a management or
			 administrative contract at least 45 days before the effective date of such
			 change.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0106 - ANNUAL REPORT

Current through Register Vol. 39, No. 2, July 15, 2024
A request for an extension of time to file an annual report
				must be made in writing and filed with the Department no later than 15 days
				before the due date of the annual report. Any request for extension received
				less than 15 days before the due date of the annual report shall be denied
				except in instances of death or disability of key personnel or destruction of
				records by fire or by another event clearly out of the MEWA's
				control.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-60;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0107 - EXAMINATION BY THE DEPARTMENT

Current through Register Vol. 39, No. 2, July 15, 2024
If the Department determines that the records of a MEWA are not
				adequate to make a determination of solvency or insolvency, the Department may
				take any action, administrative or otherwise, available to the Department as if
				the MEWA were insolvent.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-55;
				58-49-65;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0108 - POWER OF ATTORNEY

Current through Register Vol. 39, No. 2, July 15, 2024
A power of attorney appointing an individual to receive service
				of legal process must be submitted by every MEWA on Form MEWA-4 entitled "Power
				of Attorney". Such individual shall be a resident of North Carolina and either
				a corporate official of the MEWA or the MEWA's managing general agent for the
				State, and must be readily accessible and available for service. Both the
				residential and business addresses of such individual must be provided. Any
				change in the power of attorney after issuance of the MEWA's license must be
				reported to the Commissioner within two business days after the effective date
				of the change.
Authority
				G.S.
				58-2-40(1);
				58-16-30;
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0109 - FIDELITY BOND

Current through Register Vol. 39, No. 2, July 15, 2024
The fidelity bond required by
				G.S.
				58-49-50(5) shall be issued
				only by a surety company licensed to transact insurance in North Carolina. The
				bond shall be in an amount equal to no less than 10 percent of the funds or
				assets of the MEWA that are managed or handled annually, subject to the minimum
				and maximum amounts stated in
				G.S.
				58-49-50(5). The MEWA shall
				notify the Commissioner of any change to the bond, including termination,
				change in bond amount, or change in bonded MEWA employee, within two business
				days after the effective date of the change.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0110 - SALES AND MARKETING

Current through Register Vol. 39, No. 2, July 15, 2024
Any person who solicits memberships for a MEWA shall solicit
				only eligible member employers of the sponsoring association, and only if that
				person is appointed to solicit by the Board of Trustees of the MEWA. The
				sponsoring association shall provide the representative with a list of eligible
				member employers that are not in the MEWA.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0111 - DISCLOSURE

Current through Register Vol. 39, No. 2, July 15, 2024
Any person who advertises or solicits coverage on behalf of a
				MEWA or who in any manner secures, helps, or aids in the planning or
				administration of coverage with any MEWA shall:
(1) Prominently disclose in writing to every
			 employer being solicited for participation the information specified in
			 G.S.
			 58-49-25 and
			 58-49-40(b);
			 and
(2) Provide such employer with
			 a statement, if applicable, as to which provisions of North Carolina insurance
			 statutes and rules, such as mandated benefits, freedom of choice of providers,
			 continuation or conversion privileges, pre-existing conditions limitations, or
			 premium rate revision guarantees, are not afforded by the MEWA.
Authority
				G.S.
				58-2-40(1);
				58-49-25;
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0112 - CLAIMS PAYMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
In order to assure that all valid claims for payments for
				benefits provided are paid within a reasonable time, the following standards
				apply:
(1) Each MEWA shall pay within
			 30 days of receipt by the MEWA or its administrator, if applicable, all valid
			 claims for benefits.
(2) If the
			 MEWA requires additional information, the MEWA shall request such additional
			 information in writing within the 30-day period; and upon receipt of the
			 additional information, the claim shall be paid within 30 days of receipt of
			 the additional information.
(3) If
			 the claim is denied, the MEWA shall provide the reason or reasons for the
			 denial in writing to the claimant and the claimant's health care
			 provider.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0113 - DISSOLUTION

Current through Register Vol. 39, No. 2, July 15, 2024
Any application to dissolve a MEWA must be made on Form MEWA-5
				entitled "Application for Dissolution". An application for dissolution will not
				be considered to have been received by the Commissioner until it has been
				completed to his satisfaction. Such application shall be filed with the
				Commissioner at the same time the MEWA files articles of dissolution with the
				Secretary of State of North Carolina, a copy of which articles shall accompany
				the application.
Authority
				G.S.
				58-2-40(1);
				58-49-40;
				58-49-50;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0114 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
As used in this Rule and in
				11 NCAC
				18 .0115,
				11 NCAC
				18 .0116, and
				11 NCAC
				18 .0117, the following terms have the
				meanings ascribed to them:
(1) "Claims
			 accrued" means that portion of claims incurred on or prior to the valuation
			 date that result in liability of the MEWA for the payment of benefits for
			 medical services that have been rendered on or prior to the valuation date, and
			 for the payment of benefits for days of hospitalization and days of disability
			 that have occurred on or prior to the valuation date, that the MEWA has not
			 paid as of the valuation date, but for which it is liable, and will have to pay
			 after the valuation date. This liability is sometimes referred to as a
			 liability for accrued benefits.
(2)
			 "Claims reported" means when a MEWA has been informed that a claim has been
			 incurred, if the date reported is on or prior to the valuation date, the claim
			 is considered as a reported claim for annual statement purposes.
(3) "Claims unaccrued" means that portion of
			 claims incurred on or before the valuation date that result in liability of the
			 MEWA for the payment of benefits for medical services expected to be rendered
			 after the valuation date, and for benefits expected to be payable for days of
			 hospitalization and days of disability occurring after the valuation date. This
			 liability is sometimes referred to as a liability for unaccrued
			 benefits.
(4) "Claims unreported"
			 means when a MEWA has not been informed, on or before the valuation date,
			 concerning a claim that has been incurred on or prior to the valuation date,
			 the claim is considered as an unreported claim for annual statement
			 purposes.
(5) "Claim reserves" mean
			 reserves or liabilities held for claims incurred on or before the valuation
			 date, but unpaid as of the valuation date. Claim reserves include both reported
			 and unreported claims. Claim reserves are established for both accrued and
			 unaccrued benefits.
(6) "Incurred
			 date" means the date that a claim is determined to be a liability of the MEWA.
			 For example, the charges for inpatient hospital and physician visits in
			 hospitals would be assigned an incurred date equal to the date of admission;
			 outpatient hospital charges would be assigned an incurred date equal to the
			 date of service; surgical expenses would be assigned an incurred date equal to
			 the date of the surgery.
(7)
			 "Unearned premium reserves" mean reserves established for premiums received
			 that produce insuring periods extending beyond the valuation date.
Authority
				G.S.
				58-2-40;
				58-49-40;
				58-49-60;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0115 - MINIMUM RESERVE STANDARDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
			 following two categories of reserves shall be established by every MEWA:
(1) Claim reserves; and
(2) Premium reserves.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0116 - CLAIM RESERVES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Minimum claim
			 reserves are required for all incurred but unpaid claims, which include claims
			 accrued and claims unaccrued.
(b)
			 For the current year exposures, where historical claim information is either
			 not available or not credible as determined by an actuary, the minimum claim
			 reserve shall be calculated in the following manner:
(1) Calculate the total earned premium as of
			 the end of a valuation period for each policy form, group of policy forms,
			 master contract, or group of master contracts.
(2) Multiply the total earned premium by the
			 expected incurred loss ratio for each policy form, group of policy forms,
			 master contract, or group of master contracts. The sum of the results of these
			 multiplications is referred to as the "total incurred claims".
(3) Subtract from the total incurred claims
			 the total amount of claims paid as of the end of a valuation period. The result
			 of this subtraction is the total "minimum" amount that shall be added to the
			 claim reserves established at the beginning of the valuation period.
(4) The calculations in Subparagraphs (b)(1)
			 and (2) of this Rule may give recognition to duration.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0117 - PREMIUM RESERVES

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Unearned
			 premium reserves are required for all MEWAs with respect to the period of
			 coverage for which premiums, other than premiums paid in advance, have been
			 paid beyond the date of valuation.
(b) If premiums due and unpaid are carried as
			 an asset, such premiums must be treated as premiums in force, subject to
			 unearned premium reserve determination. The value of the unpaid commissions and
			 the cost of collection associated with due and unpaid premiums must be carried
			 as an offsetting liability.
(c) The
			 minimum unearned premium reserve with respect to any contract is the pro rata
			 gross unearned modal premium that applies to the premium period beyond the
			 valuation date.
(d) MEWAs may
			 employ suitable approximations or estimates, including groupings, averages, and
			 aggregate estimation, in computing premium reserves. Such approximations or
			 estimates shall be tested periodically to determine their continuing adequacy
			 and reliability.
Authority
				G.S.
				58-2-40;
				58-49-40;
				58-49-60;
Eff. July 1,
				1992;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0118 - MAXIMUM NET RETENTION STANDARD

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The
			 specific maximum net retention limit for any MEWA, associated with the period
			 of time that the excess insurance coverage is in force, shall be calculated in
			 the following manner:
(1) Determine the total
			 expected dollar value of claims;
(2) Determine the total surplus at the
			 beginning of the period of time that the excess insurance coverage is scheduled
			 to be in force;
(3) Multiply
			 Subparagraph (a)(1) of this Rule by one percent and add that product to
			 Subparagraph (a)(2) of this Rule;
(4) Multiply the result of the calculation in
			 Subparagraph (a)(3) of this Rule times itself;
(5) Multiply Subparagraph (a)(1) of this Rule
			 by the number 3.4; and
(6) Divide
			 the product of the calculation in Subparagraph (a)(4) of this Rule by the
			 product of the calculation in Subparagraph (a)(5) of this Rule.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0119 - "QUALIFIED ACTUARY"; MAXIMUM NET RETENTION FILING

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As
			 used in this Rule and in
			 11 NCAC
			 18 .0120 and
			 11 NCAC
			 18 .0121, "qualified actuary" means an
			 individual who is either an Associate or Fellow of the Society of Actuaries or
			 a Member of the American Academy of Actuaries and who has at least five years
			 of actuarial experience with MEWAs.
(b) Every year each MEWA shall calculate its
			 maximum net retention limit in accordance with
			 11 NCAC
			 18 .0118. This calculation must be performed
			 before the anniversary date of the MEWA's stop-loss insurance contract and
			 shall be filed, no later than 30 days before the anniversary date of the
			 stop-loss insurance contract, with the Actuarial Services Division of the
			 Department. This calculation shall include the numerical results of all steps
			 in 11
			 NCAC 18 .0118 and shall be performed by a
			 qualified actuary.
Authority
				G.S.
				58-2-40;
				58-49-40(c);
				58-49-50;
Eff. July 1,
				1994;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0120 - CERTIFICATION OF RESERVES FILING

Current through Register Vol. 39, No. 2, July 15, 2024
Every year each MEWA shall file the following actuarial
				certifications executed by a qualified actuary in the following manner:
"I (Name of Qualified Actuary) am a qualified actuary as
				defined by
				11 NCAC
				18 .0119(a) and I have
				reviewed:"
(1)
								11 NCAC
			 18 .0115 titled, "Minimum Reserve Standards,"
			 and I certify that if the adequacy of the MEWA's reserves requires reserves in
			 excess of the minimum standards described in
			 11 NCAC
			 18 .0116 and
			 11 NCAC
			 18 .0117, then such increased reserves will
			 be held and considered the minimum reserves for (Name of MEWA).
(2)
								11 NCAC
			 18 .0116 titled, "Claim Reserves," and I
			 certify that the MEWA's claim reserves are being calculated in an actuarially
			 sound manner that produces reserves at least as great as those prescribed in
			 11 NCAC
			 18 .0116.
(3)
								11 NCAC
			 18 .0117 titled, "Premium Reserves," and I
			 certify that the MEWA's premium reserves are being calculated in an actuarially
			 sound manner that produces reserves at least as great as those prescribed in
			 11 NCAC
			 18 .0117.
(4)
								11 NCAC
			 18 .0118 titled, "Maximum Net Retention
			 Standard," and I certify that the MEWA's maximum net retention limits are being
			 calculated in an actuarially sound manner that produces maximum net retention
			 limits no greater than those prescribed in
			 11 NCAC
			 18 .0118, unless the Commissioner of
			 Insurance has approved such higher limits as described in
			 11 NCAC
			 18 .0118(d).
Authority
				G.S.
				58-2-40;
				58-49-40(c);
Eff. July 1, 1994;
Pursuant to
				G.S.
				150B-21.3A, rule is necessary without
				substantive public interest Eff. December 16,
				2014.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 18 - MUTIPLE EMPLOYER WELFARE ARRANGEMENTS › Section 18 .0121 - DEFINITIONS AND CERTIFICATION OF RATES FILING

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As used in
			 this Rule, the following terms have the meanings ascribed to them:
(1) "Rates are adequate" for a given block of
			 policies or certificates means that the total payments collected now and in the
			 future by the MEWA plus the investment earnings attributable to any net
			 retained funds should be at least sufficient to fund the current and future
			 benefits promised plus cover related expenses.
(2) "Block of policies" means all policies or
			 certificates issued by the MEWA under the same schedule of rates and on the
			 same policy form or under the same group master contract.
(3) "Rates are not excessive" for a given
			 block of policies or certificates means that the most recent calendar year
			 incurred loss ratio is greater than or equal to one minus the expense ratio for
			 that given block of policies or certificates.
(4) "Expense ratio" means the ratio of the
			 MEWA's operating expenses for a block of policies or certificates to its earned
			 premium for that block of policies or certificates.
(5) "Operating expense" means any combination
			 of the following expenses:
(A)
			 Commissions;
(B) Other
			 acquisition;
(C) General
			 administration;
(D) Taxes,
			 licenses, and fees; and
(E) Profit
			 and contingency margin.
(6) Rates are not "unfairly discriminatory"
			 if they reflect equitably differences in expected risk.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0101 - EXPIRED - REPORT AND COLLECTION PROCEDURES

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;
				  58-2-133;
				  58-2-134;
				  58-2-155;
				  58-6-5;
				  58-20-30;
				  58-21-40;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-36-85(1);
				  58-39-70;
				  58-47-100;
				  58-48-65;
				  58-49-55;
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-100;
Eff. March
				  1, 1993;
Expired Eff. January 1, 2016 pursuant to
				  G.S.
				  150B-21.3A.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0102 - MAINTENANCE OF RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Every insurer
				licensed to do business in this State shall maintain for at least five years
				all records, books, documents, and other business records that are required by
				this Section and by Chapter 58 of the North Carolina General
				Statutes.
(b) Every agency, agent,
				broker, or producer of record shall maintain a file for each policy sold. The
				file shall contain all work papers and written communications in his or her
				possession pertaining to that policy. These records shall be retained for at
				least five years after the final disposition or, for domestic companies, until
				the Commissioner has adopted a final report of a general examination that
				contains a review of these records for that calendar year, whichever is
				later.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;
				  58-2-133;
				  58-2-134;
				  58-2-185;
				  58-2-190;
				  58-2-195;
				  58-2-200;
				  58-7-50;
				  58-20-30;
				  58-21-40;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-36-85(1);
				  58-39-70;
				  58-41-15;
				  58-41-20;
				  58-41-25;
				  58-47-100;
				  58-48-65;
				  58-49-55;
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-100;
Eff. March
				  1, 1993;
Amended Eff. January 1, 2009; August 1, 1998;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 20,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0103 - COMPLAINT RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
Each insurer or its agents shall maintain or cause to be
				  maintained an itemization register or log of every written complaint listing
				  the Department's file number, the name of the insured, the nature of the
				  complaint, the insurer's department subject to the complaint, the policy or
				  claim number of the insured, and the final disposition of the complaint. These
				  records shall be retained for at least five years after the final disposition
				  of the complaint or, for domestic companies, until the Commissioner has adopted
				  a final report of a general examination that contains a review of these records
				  for that calendar year, whichever is later.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;58-2-133;
				  58-2-134;
				  58-2-195;
				  58-7-50;
				  58-20-30;
				  58-21-40;
				  58-36-85(1);
				  58-47-100;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-39-70;
				  58-48-65;
				  58-49-55;
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-100;
Eff. March
				  1, 1993;
Amended Eff. January 1, 2009; August 1, 1998;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 20,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0104 - POLICY RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
Each insurer or its agents shall maintain or cause to be
				  maintained a record of each policy that specifies the policy period, basis for
				  rating, and if terminated, documentation supporting policy termination by the
				  insurer or policyholder, and accounting records indicating return premium
				  amounts. These records shall be retained for at least five years after the
				  termination of the policy or, for domestic companies until the Commissioner has
				  adopted a final report of a general examination that contains a review of these
				  records for that calendar year, whichever is later.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;
				  58-2-133;
				  58-2-134;
				  58-2-190;
				  58-2-195;
				  58-7-50;
				  58-20-30;
				  58-21-40;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-36-85(1);
				  58-39-70;
				  58-47-100;
				  58-48-65;
				  58-49-55;
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-100;
Eff. March
				  1, 1993;
Amended Eff. January 1, 2009; August 1, 1998;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 20,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0105 - CLAIM RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
Each insurer or its agents shall maintain or cause to be
				  maintained a record of all claim reports that specifies the inception,
				  handling, and disposition of each claim. These records shall be retained for at
				  least five years after the claim is settled or, for domestic companies, until
				  the Commissioner has adopted a final report of a general examination that
				  contains a review of these records for that calendar year, whichever is
				  later.
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;
				  58-2-133;
				  58-2-134;
				  58-2-190;
				  58-2-195;
				  58-20-30;
				  58-21-40;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-36-85(1);
				  58-39-70;
				  58-48-65;
				  58-47-100;
				  58-49-55;
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-100;
Eff. March
				  1, 1993;
Amended Eff. January 1, 2009;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 20,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0106 - RECORDS REQUIRED FOR EXAMINATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Market
				conduct examinations of property and liability insurers. Insurers being
				examined by the Department shall provide examiners access to information about
				the following areas of operation:
(1) Company
				overview: history and profile, company operations and management, and
				certificates of authority;
(2)
				Policyholder treatment: consumer complaints;
(3) Marketing: policy forms and filings,
				sales and advertising, agency management;
(4) Underwriting and rating practices:
				personal lines and commercial lines; all terminations (cancellations and
				nonrenewals) and declinations or rejections; and
(5) Claims practices: organization and
				procedures, closed with payment, closed without payment, total loss settlements
				(salvage), subrogation, and litigation.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0107 - ORIGINAL AND DUPLICATE RECORDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All records
				that are required to be maintained by this Chapter shall be either original or
				duplicate records, as defined in this Rule.
(b) For the purpose of this Chapter, an
				"original record" is the writing or recording itself or any counterpart
				intended to have the same effect by a person executing or issuing it. An
				"original" of a photograph includes the negative or any print therefrom. If
				data are, in the normal and ordinary course of business, stored in a computer
				or similar device, any printout or other output readable by sight, shown to
				reflect the data accurately, is an "original record".
(c) For the purpose of this Chapter, a
				"duplicate record" is a counterpart produced by the same impression as the
				original record, or from the same matrix, or by mechanical or electronic
				re-recording or by chemical reproduction, or by equivalent techniques, such as
				imaging or image processing, that accurately reproduce the original
				record.
(d) If only duplicate
				records are maintained, the following requirements must be met:
(1) The data must be easily accessible to the
				Department in readable form; and readable, reproduced copies must be
				obtainable;
(2) Before the
				destruction of any original records, the person in possession of the original
				records shall verify that the records stored consist of all information
				contained in the original records and that the original records can be
				constructed therefrom in a form acceptable to the Department; and
(3) Adequate controls must be established
				with respect to the transfer and maintenance of data.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 19 - MARKET REGULATION DIVISION › Section .0100 - GENERAL PROVISIONS › Section 19 .0108 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
As used in this Chapter:
(1) Examination is defined in
				G.S.
				58-2-131(b)(2).
(2) Examiner is defined in
				G.S.
				58-2-131(b)(3).
(3) Health maintenance organization is
				defined in
				G.S.
				58-67-5(f).
(4) Insurer includes a health maintenance
				organization, service corporation, and a multiple employer welfare
				arrangement.
(5) Managed care plan
				is defined in
				G.S.
				58-50-61(a)(11).
(6) Provider is defined in
				G.S.
				58-67-5(h).
Authority
				  G.S.
				  58-2-40(1);
				  58-2-50;
				  58-2-131;
				  58-2-132;
				  58-2-133;
				  58-2-134;
				  58-2-190;
				  58-2-195;
				  58-7-50;
				  58-20-30;
				  58-21-40;
				  58-21-75;
				  58-22-20(6);
				  58-23-25;
				  58-24-135;
				  58-27-10;
				  58-36-85(1);
				  58-39-70;
				  58-47-100;
				  58-48-65;
				  58-49-55;
				  58-50-56,
				  58-50-61,
				  58-50-62,
				  58-56-16;
				  58-62-66;
				  58-63-20;
				  58-64-55;
				  58-65-105;
				  58-67-10;
				  58-67-11;
				  58-67-100;
Eff.
				  January 1, 2009;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. December 20,
				  2015.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0100 - MANAGED CARE DEFINITIONS › Section 20 .0101 - SCOPE AND DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Scope.
(1) Sections .0200, .0300, and .0400 of this
				Chapter shall apply to HMOs, licensed insurers offering PPO benefit plans, and
				any other entity that is a network plan carrier as defined in this
				Rule.
(2) Sections .0500 and .0600
				of this Chapter shall apply only to HMOs.
(3) Nothing in this Chapter shall apply to
				service corporations offering benefit plans pursuant to
				G.S.
				58-65-25 or
				G.S.
				58-65-30 that do not have any differences in
				copayments, coinsurance, or deductibles based on the use of network versus
				non-network providers.