reglab/statecodes huggingface dataset:
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1200 - ACCELERATED BENEFITS › Section 12 .1211 - ACTUARIAL DISCLOSURE AND RESERVES

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				Actuarial Memorandum. A qualified actuary shall describe the accelerated
				benefits, the risks, the expected costs and the calculation of statutory
				reserves in an actuarial memorandum accompanying each filing with the
				Commissioner. The insurer shall maintain in its files descriptions of the bases
				and procedures used to calculate benefits payable under these provisions. These
				descriptions shall be made available for examination by the Commissioner or a
				designee upon request.
(b)
				Reserves:
(1) When benefits are provided
				through the acceleration of benefits under group or individual life policies or
				riders to such policies, policy reserves shall be determined in accordance with
				G.S.
				58-58-50. All valuation assumptions used in
				constructing the reserves shall be determined as appropriate for statutory
				valuation purposes by a member in good standing of the American Academy of
				Actuaries. Mortality tables and interest rates currently recognized for life
				insurance reserves by the NAIC may be used as well as appropriate assumptions
				for the other provisions incorporated in the policy form. The actuary must
				follow both actuarial standards and certification for good and sufficient
				reserves. Reserves in the aggregate should be sufficient to cover:
(A) Policies upon which no claim has yet
				arisen.
(B) Policies upon which an
				accelerated claim has arisen.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1200 - ACCELERATED BENEFITS › Section 12 .1212 - LONG-TERM CARE BENEFITS ACCELERATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) An
				insurer that issues life insurance policies that accelerate benefits for
				long-term care shall comply with
				11 NCAC
				12 .1010 if the policy being replaced is a
				long-term care insurance policy. If the policy being replaced is a life
				insurance policy, the insurer shall comply with
				11 NCAC
				12 .0611. If a life insurance policy that
				accelerates benefits for long-term care is replaced by another life insurance
				policy that accelerates benefits for long-term care, the replacing insurer
				shall comply with
				11 NCAC
				12 .1010 AND
				11 NCAC
				12 .0611
(b)
									11 NCAC
				12 .1013 does not apply to life insurance
				policies that accelerate benefits for long-term care. A life insurance policy
				that funds long-term care benefits entirely by accelerating the death benefit
				is considered to provide reasonable benefits in relation to premiums paid, if
				the policy complies with all of the following provisions:
(1) The interest credited internally to
				determine cash value accumulations, including long-term care, in any, are
				guaranteed interest rate for cash value accumulations without long-term care
				set forth in the policy.
(2) The
				portion of the policy that provides life insurance benefits meets the
				nonforfeiture requirements of
				G.S.
				58-58-30.
(3) The policy meets the disclosure
				requirements of
				G.S.
				58-55-30.
(4) Any policy illustration that meets the
				applicable requirements of
				11 NCAC
				04. 0501
(5) An actuarial memorandum is filed with the
				Division that includes:
(A) A description of
				the basis on which the long-term care rates were determined.
(B) A description of the basis for the
				reserves.
(C) A summary of the type
				of policy, benefits, renewability, general marketing method, and limits on ages
				of issuance.
(D) A description and
				a table of each actuarial assumption used. For expenses, an insurer must
				include percent of premium dollars per policy and dollars per unit of benefits,
				if any.
(E) A description and a
				table of the anticipated policy reserves and additional reserves held in each
				future year for active lives.
(F)
				The estimated average annual premium per policy and the average issue
				age.
(G) A statement as to whether
				underwriting is performed at the time of application. The statement shall
				indicate whether underwriting is used and, if used, the statement shall include
				a description of the type or assessment underwriting. For a group policy, the
				statement shall indicate whether the enrollee or any dependent will be
				underwritten and when that underwriting occurs.
(H) A description of the effect of the
				long-term care policy provision on the required premiums, nonforfeiture values,
				and reserves on the underlying life insurance policy, both for the active lives
				and those in long-term care claim status.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1301 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As used in this
				Section, unless the context clearly indicates otherwise:
(1) "Act" means the North Carolina Small
				Employer Group Health Coverage Reform Act described in
				G.S.
				58-50-100.
(2) "Carrier" means a small employer
				carrier.
(3) "Extra eligible" means
				an individual who is not an eligible employee or a dependent of an eligible
				employee who is insured under the health benefit plan of a small
				employer.
(4) "New entrant" means
				an eligible employee, or the dependent of an eligible employee, who becomes
				part of an employer group after the initial period for enrollment in a health
				benefit plan.
(5) "Nonstatutory
				plan" means any health benefit plan subject to the Act other than the statutory
				plans.
(6) "Policy anniversary" or
				"plan anniversary" means the annual anniversary of the issuance of a health
				benefit plan. If a plan is issued through a multiple employer trust, "policy
				anniversary" or "plan anniversary" means the annual anniversary of the issuance
				of the health benefit plan to the small employer.
(7) "Previously declined group" means a group
				whose application for coverage was declined for any reason by a carrier after
				January 1, 1992, and before August 14, 1992.
(8) "Previously declined individual" means an
				individual whose application for coverage for a health benefit plan was
				declined by a carrier before August 14, 1992.
(9) "Producer" means an insurance agent or
				insurance broker licensed under Article 33 of G.S. Chapter 58.
(10) "Statutory plan" means the basic or
				standard health care plan.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1302 - SCOPE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Any health benefit plan is subject to the
				Act if it is a health benefit plan under
				G.S.
				58-50-115(a)(1) or (2) and
				is not excluded from the Act by
				G.S.
				58-50-110(11).
(b) This Section does not apply to individual
				health insurance policies that are not subject to
				G.S.
				58-50-115.
(c) The Act and this Section apply to a
				health benefit plan provided to a small employer or to the employees of a small
				employer without regard to whether the health benefit plan is offered under or
				provided through a group policy or trust arrangement.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-110(5);
				  58-50-113(a)(3);
				  58-50-115;
Temporary
				  Adoption Eff. December 21, 1992 for a period of 180 days or until the permanent
				  rule becomes effective, whichever is sooner;
Eff. April 1,
				  1993;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1303 - POLICY FORMS AND APPROVALS

Current through Register Vol. 39, No. 2, July 15, 2024
All carriers must file all health benefit plan policy forms
				  with the Department for approval before they may be used. The following
				  procedures apply to filing those policy forms:
(1) The filing cover letter shall include a
				certification by the carrier that specifies that the health benefit plan will
				be marketed to small employers. Each health benefit plan that will be marketed
				with payroll deduction shall include this certification.
(2) Carriers are not required to file new
				health benefit plan policy forms. Existing policy forms may be brought into
				compliance with the Act by means of amendments or variable language.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-125(b);
				  58-51-1;
Temporary
				  Adoption Eff. December 21, 1992 for a period of 180 days or until the permanent
				  rule becomes effective, whichever is sooner;
Eff. April 1,
				  1993;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1304 - COMPLIANCE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each carrier
				and third party administrator shall file a report on North Carolina small
				employer group insurance activity annually on or before March 15, which report
				shall describe case characteristics and numbers of health benefit plans in
				various categories marketed or issued to small employers. The report shall be
				in a format prescribed by the Commissioner.
(b) Each carrier shall provide the same
				health benefit plan to eligible employees and dependents; provided, however,
				under G.S. 58-67-35(a)(5) and
				(a)(6)b. and c., an HMO may offer its
				approved small employer health benefit plan in conjunction with an approved
				indemnity benefit plan to eligible employees and dependents, and the two plans
				must be of similar value in that the deductibles, copayments, and covered
				benefits must be comparable.
(c) A
				carrier shall not set contribution and participation requirements for the
				statutory plans that are more restrictive than those for the carrier's
				nonstatutory plans.
(d) If any
				eligible employee or dependent has qualifying existing coverage, as defined in
				G.S.
				58-50-130(a)(5), and
				therefore does not participate in the employer's health benefit plan, a carrier
				is not required to issue or renew the employer's plan unless either:
(1) at least two eligible employees in a
				group of seven or less elect to participate; or
(2) at least 25 percent of eligible employees
				in a group of more than seven elect to participate.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1305 - PROHIBITED ACTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A carrier shall
				not unilaterally change a small employer group from one health benefit plan to
				another. A carrier shall not require an in-force health benefit plan risk to
				replace existing coverage with the basic or standard health care
				plans.
(b) No carrier, its agents
				or field representatives, a broker, nor a small employer shall discourage any
				employee or dependent from applying for coverage so that the small employer can
				be issued a more favorable premium rate or benefit package.
(c) No carrier shall set classes of employees
				in such a way as to exclude any employees who are eligible for insurance by
				definition. This Paragraph does not prevent a carrier from classifying
				ineligible employees or "extra-eligibles".
Authority
				  G.S.
				  58-2-40(1);
				  58-50-125(d);
				  58-50-130(a)(3);
Temporary Adoption Eff. December 21, 1992 for a period of 180 days or until the
				  permanent rule becomes effective, whichever is sooner;
Eff. April
				  1, 1993;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1306 - REPEALED - REINSURANCE POOL

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40(1);
				  58-50-130(b)(4);
				  58-50-150(a);
				  58-50-150(f)(5);
				  58-50-150(g);
Filed as a Temporary Adoption Eff. December 21, 1992 for a period of 180 days
				  or until the permanent rule becomes effective, whichever is sooner;
Eff. April 1, 1993;
Filed as a Temporary Amendment Eff. October 11,
				  1993 for a period of 180 days or until the permanent rule becomes effective,
				  whichever is sooner;
Amended Eff. February 1, 1994;
Repealed Eff. July 1, 2012.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1307 - GUARANTEED ISSUE AND RENEWAL

Current through Register Vol. 39, No. 2, July 15, 2024
(a) No carrier
				shall decline an application for coverage under the statutory plans. A carrier
				may continue to issue health benefit plans other than the statutory
				plans.
(b) If an eligible employee
				commits fraud or makes material misrepresentation to a carrier, the carrier may
				rescind coverage for that employee. If the small employer commits fraud or
				makes a material misrepresentation to a carrier, the carrier may rescind
				coverage for that entire small employer group.
(c) The late enrollee provision in
				G.S.
				58-50-130(a)(4) applies to
				all health benefit plans subject to the Act.
(d) Any health benefit plan covering an
				employer that by definition becomes a small employer is not subject to the Act
				until the next anniversary date of that plan.
(e) Any health benefit plan covering a small
				employer that by definition loses its status as a small employer is subject to
				the Act until the next anniversary date of that plan. At that time, the carrier
				shall determine if the employer is by definition a small employer. If the
				employer is not a small employer, the carrier may terminate the plan. If the
				carrier does not terminate the plan, the carrier shall amend the plan with
				riders or endorsements to comply with requirements of statutes and rules that
				were not reflected in the plan before the anniversary date.
(f) Before a plan anniversary date, a small
				employer may request that coverage be changed from one statutory plan to
				another statutory plan.
(g)
				Previously declined individuals are not late enrollees unless they fail to
				enroll during their initial enrollment periods.
(h) On the next health benefit plan
				anniversary date that falls on or after August 14, 1992, a carrier shall remove
				all exclusionary riders or conditional modifications on any health benefit plan
				that is subject to the Act.
(i) A
				carrier may base termination on nonpayment of premium; and shall apply
				termination decisions uniformly to all of the carrier's small employer group
				business.
(j) A carrier is not
				required to issue a statutory plan to a small employer if within the prior 12
				months the carrier terminated a health benefit plan of the small employer
				because the employer:
(1) failed to pay the
				premium;
(2) committed fraud or
				materially misrepresented information necessary to determine the group size,
				group participation rate, or the group premium rate; or
(3) failed to materially comply with a health
				benefit plan provision, including carrier requirements for employee group
				premium contributions.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1308 - ELECTIONS BY CARRIERS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) If an election
				to be a risk assuming carrier is disapproved by the Commissioner, the carrier
				shall be considered a reinsuring carrier as of the date of the disapproval,
				unless the carrier is already so considered.
(b) An insurer that has previously notified
				the Commissioner that it is not a small employer carrier may enter the small
				employer group health insurance market upon notification to the Commissioner
				and the Commissioner's approval of the carrier's statutory health benefit
				plans; and that carrier shall be a reinsuring carrier.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-135(a);
				  58-50-135(c);
				  58-50-150(a);
Temporary Adoption Eff. December 21, 1992 for a period of 180 days or until the
				  permanent rule becomes effective, whichever is sooner;
Eff. April
				  1, 1993;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1300 - SMALL EMPLOYER GROUP HEALTH COVERAGE › Section 12 .1309 - FAIR MARKETING STANDARDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A
				carrier may select those agents with whom it chooses to contract. If a carrier
				chooses to contract with an agent, the carrier may not terminate or refuse to
				renew the agency contract for any reason related to the health status, claims
				experience, occupation, or geographic location of the small employer groups
				placed by the agent with the carrier. If the agent is directing statutory plan
				business to the carrier, the carrier may terminate the agency
				contract.
(b) No carrier shall,
				directly or indirectly, enter into any contract, agreement, or arrangement with
				an agent that provides for or results in any consideration provided to an agent
				for the issuance or renewal of a health benefit plan to vary on account of the
				health status, claims experience, industry, occupation, or geographic location
				of a small employer group covered by the plan.
(c) Each carrier shall provide all small
				employers in the same class of business an equal opportunity to obtain coverage
				under the statutory plans.
(d) No
				carrier shall apply more stringent application or informational requirements
				for enrollment for the statutory plans than are applied for other health
				benefit plans offered by the carrier.
(e) No carrier shall limit or discourage any
				producer marketing the statutory plans.
(f) A carrier shall provide a price quote to
				a small employer, directly or through an authorized producer, within seven
				business days after receiving a request for a quote and such information
				necessary to provide that quote. If additional information is necessary for the
				quote, a carrier shall notify a small employer, directly or through an
				authorized producer, within five business days after receiving the additional
				information.
Authority
				  G.S.
				  58-2-40(1);
				  58-50-120(c)(7);
				  58-50-125(f);
Temporary Adoption Eff. December 21, 1992 for a period of 180 days or until the
				  permanent rule becomes effective, whichever is sooner;
Eff. April
				  1, 1993;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1400 - HMO: POINT-OF-SERVICE › Section 12 .1401 - APPLICABILITY AND SCOPE

Current through Register Vol. 39, No. 2, July 15, 2024
This Section applies to any HMO that, under
				  G.S.
				  58-67-35(a)(6)d, offers
				  coverage to its enrollees for health care services that are received, other
				  than in an emergency, from:
(1)
				Providers who are not employed by, under contract with, or otherwise affiliated
				with the HMO; or
(2) Providers who
				are employed by, under contract with, or otherwise affiliated with the HMO in
				instances when such services are not received in compliance with the HMO's
				health care plan requirements.
Authority
				  G.S.
				  58-2-40;
				  58-67-35;
				  58-67-150;
Eff.
				  January 1, 1994;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1400 - HMO: POINT-OF-SERVICE › Section 12 .1402 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
In this Section, unless the context clearly indicates
				  otherwise:
(1) "Coinsurance" means the
				percentage of an allowed charge or expense for a covered health care service
				that an enrollee must pay.
(2)
				"Copayment" means a fixed dollar amount that an enrollee must pay each time a
				covered health care service is provided.
(3) "Deductible" means a specified amount of
				covered health care services, expressed in dollars, that must be incurred by an
				enrollee before the HMO will assume any financial liability for all or part of
				covered health care services.
(4)
				"In-plan covered services" means covered health care services that are received
				according to the rules of the health care plan from providers employed by,
				under contract with, or approved in advance by the HMO; and means emergency
				health care services.
(5)
				"Out-of-plan covered services" means non-emergency, medically necessary covered
				health care services that are not received according to the rules of the health
				care plan, including services from affiliated providers that are received
				without the approval of the HMO.
(6) "Out-of-pocket expense" means a specified
				dollar amount of coinsurance incurred and payable by an enrollee for covered
				health care services in a specified period; but does not include deductible
				amounts, copayment amounts, charges in excess of the amount allowed by the HMO,
				amounts exceeding the maximum benefits, nor any disallowed or noncovered
				expenses under the rules of the health care plan.
(7) "Point-of-service product" means a
				feature in a health care plan that provides benefits for both in-plan covered
				services and out-of-plan covered services.
(8) The definitions contained in
				G.S.
				58-67-5 are incorporated into this Section by
				reference.
Authority
				  G.S.
				  58-2-40;
				  58-67-35;
				  58-67-150;
Eff.
				  January 1, 1994;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1400 - HMO: POINT-OF-SERVICE › Section 12 .1403 - GENERAL REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
No HMO shall provide any point-of-service product unless it
				  complies with the following requirements and with
				  G.S.
				  58-67-10(d)(1):
(1) Where the covered benefits of a
				point-of-service product include coinsurance, the difference in coinsurance
				rates between in-plan covered services and out-of-plan covered services shall
				not exceed 30 percentage points.
(2) If the schedule of benefits for a
				point-of-service product imposes a deductible for in-plan covered services, the
				amount of any annual deductible per enrollee or per family for out-of-plan
				covered services may not exceed five times the amount of the corresponding
				annual deductible applied to in-plan covered services.
(3) If the schedule of benefits for a
				point-of-service product does not include an annual deductible for in-plan
				covered services, the annual deductibles for out-of-plan covered services shall
				not exceed two thousand dollars ($2000) per enrollee and the family deductible
				may not exceed three times the amount of the corresponding annual deductible
				for the enrollee.
(4) The portion
				of any charge for out-of-plan covered services to be applied to an annual
				deductible may be based on the amount the HMO would have recognized as an
				allowable charge had the service been rendered as an in-plan covered
				service.
(5) If there is a lifetime
				maximum benefit for in-plan covered services, the amount of any annual and
				lifetime maximum limits for out-of-plan covered services shall not be less than
				one-half of the amount of any annual and lifetime maximum limits for in-plan
				covered services.
(6) If a
				point-of-service product includes copayments for both in-plan covered services
				and out-of-plan covered services, the amount of the copayment for an
				out-of-plan covered service shall not exceed the copayment for an in-plan
				covered service by more than fifty dollars ($50.00) or 100%, whichever is
				greater.
(7) A point-of-service
				product shall make all mandated benefits available in the form of in-plan
				covered services.
(8)
				Point-of-service products shall provide incentives, including financial
				incentives, for enrollees to use in-plan covered services.
(9) Any offered out-of-plan covered service
				must be available on an in-plan covered service basis.
(10) A HMO offering a point-of-service
				product may exclude coverage for preventive health care services provided on an
				out-of-plan basis.
(11)
				Point-of-service products shall give enrollees the option to choose in-plan
				covered services or out-of-plan covered services each time such covered
				services are authorized, obtained, or rendered.
Authority
				  G.S.
				  58-2-40;
				  58-67-35;
				  58-67-150;
Eff.
				  January 1, 1994;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1400 - HMO: POINT-OF-SERVICE › Section 12 .1404 - DISCLOSURE REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Every
				explanation of benefits shall contain an explanation of coverage for
				out-of-plan covered services that allows each enrollee to determine his or her
				obligations with respect to such services.
(b) Marketing materials, evidences of
				coverage, enrollee handbooks, and other materials given to enrollees by an HMO
				that offers a point-of-service product shall contain an explanation of the
				point-of-service product. The explanation shall include:
(1) the method of reimbursement;
(2) applicable copayment and deductible
				amounts;
(3) any other uncovered
				costs or charges;
(4) the covered
				health care services that an enrollee may receive on an out-of-plan basis;
				and
(5) instructions for submittal
				of claims for out-of-plan covered services.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1501 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
In this Section, unless the context indicates
				  otherwise:
(1) "CPT-4 Codes" means the
				Physician Current Procedural Terminology published by the American Medical
				Association.
(2) "Current ADA
				Dental Claim Form" means the most recent health insurance claim form published
				by the American Dental Association.
(3) "Ethnic origin code" is the established
				Ethnic (Race) Code as used by the Economics and Statistics Administration,
				Bureau of Labor Statistics, U.S. Department of Commerce.
(4) "CMS" means Centers for Medicare and
				Medicaid Services of the U.S. Department of Health and Human
				Services.
(5) "CMS Form 1450
				(UB-04)" means the health insurance claim form published by the CMS for use by
				institutional health care providers.
(6) "CMS Form 1500" means the health
				insurance claim form published by the CMS for use by individual health care
				providers.
(7) "HCPCS" means
				Healthcare Common Procedure Coding System, a coding system that describes
				products, supplies, procedures, and health care provider services; and includes
				the CPT-4 Codes, alphanumeric codes, and related modifiers. HCPCS includes:
(a) "HCPCS Level I Codes", which are the
				CPT-4 codes and modifiers for professional services and procedures;
(b) "HCPCS Level II Codes", which are
				national alphanumeric codes and modifiers for health care products and
				suppliers, as well as some codes for professional services not included in the
				CPT-4 Codes;
(c) "HCPCS Level III
				Codes", which are local alphanumeric codes and modifiers for items and services
				not included in HCPCS Level I or HCPCS Level II.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1502 - REQUIREMENTS FOR USE OF CMS FORM 1450 (UB-04)

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The CMS
				Form 1450 (UB-04) shall be the standard claim form for all manual billing by
				institutional health care providers, and the CMS Form 1450 shall be accepted by
				all payors conducting business in this State.
(b) The cause of injury code shall be located
				in form locator 72. This code shall be required on all CMS Form 1450 (UB-04)
				claims generated by institutional health care providers for claims of
				inpatients and of patients treated in emergency rooms or trauma centers; and
				where the diagnosis includes an injury diagnosis, which means a diagnostic code
				in the range or 800-999 as defined in the ICD-10 coding manual.
(c) Payors may require institutional health
				care providers to use only the following coding systems for the filing of
				claims for health care services:
(1) Codes to
				report all diagnoses, reasons for encounters, and procedures based upon code
				level changes made effective October 1 of each year or other effective date
				designated by the CMS.
(2) HCPCS
				Level I and II Codes based upon code level changes made effective October 1 of
				each year or other effective date designated by the CMS.
(3) CPT-4 Codes based upon code level changes
				made effective January 1 of each year or other effective date designated by the
				CMS.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1503 - REQUIREMENTS FOR USE OF CMS FORM 1500

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The CMS
				Form 1500 shall be the standard claim form for all manual individual health
				care provider billing, and the CMS Form 1500 shall be accepted by all payors
				conducting business in this State.
(b) Payors may require individual health care
				providers to use only the following coding system for the filing of claims for
				health care services:
(1) ICD-9-CM Codes to
				report all diagnoses, reasons for encounters, and procedures based upon code
				level changes made effective October 1 of each year or other effective date
				designated by the CMS.
(2) HCPCS
				Level I and Level II Codes based upon code level changes made effective October
				1 of each year or other effective date designated by the CMS.
(3) CPT-4 Codes based upon code level changes
				made effective January 1 of each year or other effective date designated by the
				CMS.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1504 - REQUIREMENTS FOR USE OF THE CURRENT ADA DENTAL CLAIM FORM

Current through Register Vol. 39, No. 2, July 15, 2024
Dentists shall use the current ADA Dental Claim Form and
				  instructions for all manual claims filing with payors. The ADA Dental Claim
				  Form is hereby incorporated by reference, including subsequent amendments and
				  additions, and is available at no cost at
				  https://www.ada.org/en/publications/cdt/ada-dental-claim-form.
Authority
				  G.S.
				  58-2-40;
				  58-3-171;
Eff. October
				  1, 1994;
Amended Eff. February 1, 1995;
Readopted Eff.
				  May 1, 2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1505 - MANAGED CARE FORMS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As used in this
				Rule, "managed care plan" includes a health maintenance organization or a
				preferred provider organization.
(b) The following managed care forms may be
				used by managed care plans, but shall not be a part of the standard claim form:
(1) An "out-of-network" justification form
				shall be used by patients filing claims with their managed care plans when they
				have to justify the reasons they sought out-of-network health care services.
				This form shall be standardized, and the managed care plan industry shall
				develop and file this form with the Commissioner.
(2) A "patient encounter form and electronic
				format" shall be used by managed care plans to record and report encounter
				information. This form shall provide information similar to the CMS Form 1450
				(UB-04) and CMS Form 1500 and shall include information on patient
				identification, dates of services provided, types of services provided, and
				identities of health care providers. This form and electronic formats shall be
				standardized, and the managed care plan industry shall develop and file these
				with the Commissioner.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1506 - ELECTRONIC FORMAT STANDARDS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As
				used in this Rule, "ASC X12 Standard Format" means the standards for electronic
				data interchange within the health care provider industry developed by the
				Accredited Standards Committee X12 Insurance Subcommittee of the American
				National Standards Institute.
(b)
				Payors and health care providers that receive or generate claims or send
				payments by electronic means shall accept or generate the appropriate ASC X12
				Standard Format for their health care claims submission and remittance
				transactions.
Authority
				  G.S.
				  58-2-40;
				  58-3-171;
Eff. October
				  1, 1994;
Readopted Eff. May 1,
				  2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1507 - ATTACHMENT FORM OR FORMAT

Current through Register Vol. 39, No. 2, July 15, 2024
(a) As used in
				this Rule, "attachment form or format" means a form, document, or communication
				of any kind used by a payor to request additional information, other than that
				contained on the standard claim form, from a health care provider in connection
				with processing a claim for payment.
(b) Payors shall not require the submission
				of information already contained in the standard claim form.
Authority
				  G.S.
				  58-2-40;
				  58-3-171;
Eff. October
				  1, 1994;
Readopted Eff. May 1,
				  2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1508 - MEDICARE SUPPLEMENT PAYORS

Current through Register Vol. 39, No. 2, July 15, 2024
Medicare supplement insurance payors shall electronically
				  interface claims data with the Medicare Section of CMS.
Authority
				  G.S.
				  58-2-40;
				  58-3-171;
Eff. October
				  1, 1994;
Readopted Eff. May 1,
				  2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1500 - UNIFORM CLAIM FORMS › Section 12 .1509 - PATIENT SUBMITTED CLAIM FORMS

Current through Register Vol. 39, No. 2, July 15, 2024
The health care provider shall provide a patient the CMS-1500
				  and UB-04 (CMS-1450) standard claim forms, if the patient must submit a claim
				  to a payor. The standard claim form shall be provided as the initial bill for
				  payment of services and shall be used by the patient to request reimbursement
				  from a payor. Health care providers shall also continue to provide patients
				  billing statements for subsequent billing of the same services. A payor shall
				  not require any additional documentation from a patient to support a claim for
				  reimbursement payment by a patient if the information required is already
				  contained on the standard claim form. No payor shall require any patient to
				  submit claims or other information in an electronic format.
Authority
				  G.S.
				  58-2-40;
				  58-3-171;
Eff. October
				  1, 1994;
Readopted Eff. May 1,
				  2020.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1600 - RETAINED ASSET ACCOUNTS › Section 12 .1601 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
As used in this Section:
(1) "Policy" means any policy or certificate
				of insurance that provides a death benefit.
(2) "Retained asset account" or "account"
				means any mechanism whereby the settlement of proceeds payable under an
				insurance policy is accomplished through the use of a temporary repository of
				proceeds into a checking or draft account.
Authority
				  G.S.
				  58-2-40;
				  58-3-150;
				  58-7-15;
				  58-58-1;
				  58-58-110;
Eff.
				  February 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1600 - RETAINED ASSET ACCOUNTS › Section 12 .1602 - GENERAL REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
No insurer shall offer retained asset accounts as a mode of
				  settlement of proceeds unless the insurer complies with the following:
(1) The retained asset account shall be
				specifically identified as a settlement option within the terms of the claim
				form in conjunction with any other mode of settlement.
(2) The policy owner shall be provided the
				contractual right of selection from all available optional modes of settlement
				before death or death of the insured if the insured is not the policy
				owner.
(3) The insurer shall
				provide the beneficiary with information that clearly discloses the rights and
				obligations of both the beneficiary and the insurer with respect to the mode of
				settlement.
Authority
				  G.S.
				  58-2-40;
				  58-3-150;
				  58-7-15;
				  58-58-1;
				  58-58-110;
Eff.
				  February 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1600 - RETAINED ASSET ACCOUNTS › Section 12 .1603 - DISCLOSURE REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
In conjunction with the use of a retained asset account as a
				  mode of settlement, the insurer shall disclose the following, in writing, to
				  any beneficiary or, in the case of a group contract, to the policy
				  owner:
(1) Any other settlement
				options available under the policy.
(2) Any interest being paid under other
				options.
(3) Whether the retained
				asset account is the equivalent of a checking or draft account.
(4) An explanation of the account's features,
				including:
(a) What banking services are
				provided to the account holder.
(b)
				Which services are provided at no charge and which services involve a fee and
				the amount of the fee.
(c) The
				nature and frequency of account statements.
(d) A telephone number and address where the
				beneficiary can obtain additional information regarding the account.
(e) Any minimum or maximum benefit payment
				requirements under the account.
(f)
				The number of withdrawals permitted within any time period.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1600 - RETAINED ASSET ACCOUNTS › Section 12 .1604 - ACCOUNTING

Current through Register Vol. 39, No. 2, July 15, 2024
Funds necessary to cover liabilities under retained asset
				  accounts shall be reported on the annual statement.
Authority
				  G.S.
				  58-2-40;
				  58-2-165;
				  58-58-1;
				  58-58-110;
Eff.
				  February 1, 1996;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1700 - VIATICAL SETTLEMENTS › Section 12 .1701-.1709

Current through Register Vol. 39, No. 2, July 15, 2024
Authority
				  G.S.
				  58-2-40;
				  58-16-30;
				  58-58-42;
				  58-58-42(e);
				  58-58-42(j);
				  58-63-15;
				  58-63-65;
Eff.
				  February 1, 1996;
Amended Eff. January 1, 1998; May 1,
				  1997;
Temporary Amendment Eff. December 1, 1999;
Amended Eff. July 1, 2000;
Temporary Repeal Eff. April 1,
				  2002;
Repealed Eff. April 1,
				  2003.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1700 - VIATICAL SETTLEMENTS › Section 12 .1710 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) The definitions
				contained in
				G.S.
				58-58-205 apply to this Section.
(b) The following definitions shall apply to
				this Section:
(1) "Division" means the Life
				and Health Division of the Department of Insurance.
(2) "Insured" means the person covered under
				the policy being considered for viatication.
(3) "Life expectancy" means the mean of the
				number of months the individual insured under the life insurance policy to be
				viaticated can be expected to live as determined by the viatical settlement
				provider considering medical records and appropriate experiential
				data.
(4) "Net death benefit" means
				the amount of the life insurance policy or certificate to be viaticated less
				any outstanding debts or liens.
(5)
				"Patient identifying information" includes an insured's name, address,
				telephone number, facsimile number, electronic mail address, photograph or
				likeness, employer, employment status, or social security number.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1700 - VIATICAL SETTLEMENTS › Section 12 .1711 - LICENSE REQUIREMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) In addition to
				the information required by
				G.S.
				58-58-210, applicants for provider licenses
				shall submit the following:
(1) A plan of
				operation, including the manner in which the provider proposes to operate in
				North Carolina and the type or types of insurance policies or contracts it
				intends to viaticate.
(2) The
				provider's plan of operation shall be a narrative overview of the provider's
				business and shall include the following information:
(A) A certified copy of the provider's
				charter and by-laws, if a corporation or limited liability company, and a copy
				of the partnership agreement, if a partnership.
(B) A chart showing the relationship of the
				provider to any parent, affiliated, or subsidiary corporation.
(C) A description of the provider's marketing
				techniques, including a description of training programs for those individuals
				who will have direct contact with viators.
(D) A list of the names of the provider's
				directors and management personnel, including job titles and descriptions of
				the job duties.
(E) A schedule
				listing the names of financial institutions with which the provider has escrow
				trust agreements.
(F) A description
				of what steps through which the viator will have access to funds, including the
				source that will make such funds available.
(G) A financing plan.
(H) A statement disclosing the identities of
				all stockholders holding 10% or more of the provider, and all partners,
				directors, officers and members of the provider, depending on whether the
				provider is a partnership, corporation, or limited liability company.
(I) An antifraud plan, as specified in
				G.S.
				58-58-268(b).
(3) Each provider shall notify the
				Division of any change in the items listed in Paragraph (a)(2) of this Rule
				within 30 business days after the change.
(4) Every nonresident provider shall file a
				power of attorney designating the Commissioner as the provider's agent for
				service of legal process in accordance with
				G.S.
				58-58-210(g).
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1700 - VIATICAL SETTLEMENTS › Section 12 .1712 - VIATICAL SETTLEMENT BROKERS

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				Applications for broker licenses shall be made with the Agent Services Division
				of the Department of Insurance.
(b)
				A broker shall not, without the written agreement of the viator obtained before
				performing any services in connection with a viatical settlement, seek or
				obtain any compensation from the viator.
Authority
				  G.S.
				  58-2-40;
				  58-16-30;
				  58-58-300;
Temporary
				  Adoption Eff. April 1, 2002;
Eff. April 1, 2003;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.
North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 12 - LIFE AND HEALTH DIVISION › Section .1700 - VIATICAL SETTLEMENTS › Section 12 .1713 - STANDARDS FOR EVALUATION OF REASONABLE PAYMENTS

Current through Register Vol. 39, No. 2, July 15, 2024
(a)
				Insureds who are terminally or chronically ill shall receive no less than the
				following payouts for viaticating a policy. The percentage may be reduced by 5%
				for viaticating a policy written by an insurer rated less than the highest four
				categories by A.M. Best, or a comparable rating by another rating agency.
Insured's Life Expectancy
Minimum Percentage of Face Value Less Outstanding
							 Loans Received by Viator
Less than 6 months
[80%]
At least 6 but less than 12 months
[70%]
At least 12 but less than 18 months
[65%]
At least 18 but less than 25 months
[60%]
25 months or more
Viator must receive at least the greater of the cash
							 surrender value or accelerated death benefit for the policy
(b)
				Insureds who are not terminally or chronically ill shall receive at least the
				cash surrender value of the policy.
Authority
				  G.S.
				  58-2-40;
				  58-58-300;
Temporary
				  Adoption Eff. April 1, 2002;
Eff. April 1, 2003;
Pursuant to
				  G.S.
				  150B-21.3A, rule is necessary without
				  substantive public interest Eff. May 1, 2018.