North Carolina Administrative Code

11 NCAC 16 .0705 CLAIM RESERVE METHODOLOGY AND ACTUARIAL CERTIFICATION (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 …

SECTION .0800 - SMALL EMPLOYER GROUP HEALTH INSURANCE ACTUARIAL CERTIFICATION 11 NCAC 16 .0801 SMALL EMPLOYER GROUP HEALTH INSURANCE ACTUARIAL CERTIFICATION (a) Each small employer group carrier, as defined in G.S. 58-50-110(23), shall use the following language in its actuarial …

CHAPTER 17 - SENIORS' HEALTH INSURANCE INFORMATION PROGRAM 11 NCAC 17 .0101 DEFINITIONS 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 Cha…

11 NCAC 17 .0102 PURPOSE AND DUTIES OF SHIIP (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 ca…

11 NCAC 17 .0103 LOCATION, MAILING ADDRESS, AND TELEPHONE (a) The primary location of Seniors' Health Insurance Information Program or SHIIP is 3200 Beechleaf Court, Raleigh, NC 27604. (b) The mailing address of SHIIP is 1201 Mail Service Center, Raleigh, North Carolina, 27699-12…

11 NCAC 17 .0104 COUNSELORS (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 ser…

11 NCAC 17 .0105 MEDICARE SUPPLEMENT POLICIES 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 requ…

11 NCAC 17 .0106 BUYER'S GUIDES 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 employe…

CHAPTER 18 - MULTIPLE EMPLOYER WELFARE ARRANGEMENTS 11 NCAC 18 .0101 PURPOSE AND SCOPE 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 …

11 NCAC 18 .0102 GENERAL ELIGIBILITY (a) Each MEWA shall provide to the Commissioner documentation from the Internal Revenue Service confirming that the exemption under Section 501(c) of the Internal Revenue Code has been granted, or that the MEWA will operate solely for the bene…

11 NCAC 18 .0103 FILING REQUIREMENTS (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 applica…

11 NCAC 18 .0104 FINANCIAL (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 s…

11 NCAC 18 .0105 ADMINISTRATIVE, PROVIDER, AND MANAGEMENT CONTRACTS (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 s…

11 NCAC 18 .0106 ANNUAL REPORT 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 dat…

11 NCAC 18 .0107 EXAMINATION BY THE DEPARTMENT 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 w…

11 NCAC 18 .0108 POWER OF ATTORNEY 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 o…

11 NCAC 18 .0109 FIDELITY BOND 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 man…

11 NCAC 18 .0110 SALES AND MARKETING 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 p…

11 NCAC 18 .0111 DISCLOSURE 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…

11 NCAC 18 .0112 CLAIMS PAYMENTS 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 va…

11 NCAC 18 .0113 DISSOLUTION 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. Suc…

11 NCAC 18 .0114 DEFINITIONS 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 l…

11 NCAC 18 .0115 MINIMUM RESERVE STANDARDS (a) The following two categories of reserves shall be established by every MEWA: (1) Claim reserves; and (2) Premium reserves. (b) The adequacy of a MEWA's health insurance reserves shall be determined on the basis of the two categories …

11 NCAC 18 .0116 CLAIM RESERVES (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 determi…

11 NCAC 18 .0117 PREMIUM RESERVES (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…

11 NCAC 18 .0118 MAXIMUM NET RETENTION STANDARD (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…

11 NCAC 18 .0119 "QUALIFIED ACTUARY"; MAXIMUM NET RETENTION FILING (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 o…

11 NCAC 18 .0120 CERTIFICATION OF RESERVES FILING 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 rev…

11 NCAC 18 .0121 DEFINITIONS AND CERTIFICATION OF RATES FILING (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…

CHAPTER 19 - MARKET REGULATION DIVISION SECTION .0100 - GENERAL PROVISIONS 11 NCAC 19 .0101 REPORT AND COLLECTION PROCEDURES History Note: 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); 58-2…

11 NCAC 19 .0102 MAINTENANCE OF RECORDS (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 Statu…

11 NCAC 19 .0103 COMPLAINT RECORDS 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 su…

11 NCAC 19 .0104 POLICY RECORDS 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 accou…

11 NCAC 19 .0105 CLAIM RECORDS 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 settl…

11 NCAC 19 .0106 RECORDS REQUIRED FOR EXAMINATION (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 …

11 NCAC 19 .0107 ORIGINAL AND DUPLICATE RECORDS (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 …

11 NCAC 19 .0108 DEFINITIONS 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, serv…

CHAPTER 20 - MANAGED CARE HEALTH BENEFIT PLANS SECTION .0100 - MANAGED CARE DEFINITIONS 11 NCAC 20 .0101 SCOPE AND DEFINITIONS (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 t…

SECTION .0200 - CONTRACTS BETWEEN NETWORK PLAN CARRIERS AND HEALTHCARE PROVIDERS 11 NCAC 20 .0201 WRITTEN CONTRACTS (a) All contracts between network plan carriers and health care providers and between network plan carriers and intermediary organizations offering networks of heal…

11 NCAC 20 .0202 CONTRACT PROVISIONS All contract forms shall contain provisions addressing the following: (1) Whether the contract and any attached or incorporated amendments, exhibits, or appendices constitute the entire contract between the parties. (2) Definitions of technica…

11 NCAC 20 .0203 CHANGES REQUIRING APPROVAL All material changes to an approved contract form shall be filed with the Division for approval before use. For the purpose of this Rule, a "material change" includes a change in: (1) the means of calculating payment to the provider; fo…

11 NCAC 20 .0204 CARRIER AND INTERMEDIARY CONTRACTS (a) If a carrier contracts with an intermediary for the provision of a network to deliver health care services, the carrier shall file with the Division for prior approval its form contract with the intermediary. The filing shal…

11 NCAC 20 .0205 FILING REQUIREMENTS All contract form filings shall be submitted to the Department in the following manner: (1) New managed care contract forms shall be submitted in either paper or an electronic format in accordance with 11 NCAC 12 .0329. (2) Amendments to contr…

SECTION .0300 - PROVIDER ACCESSIBILITY AND AVAILABILITY 11 NCAC 20 .0301 PROVIDER AVAILABILITY STANDARDS Each network plan carrier shall develop a methodology to determine the size and adequacy of the provider network necessary to serve the members. The methodology shall provide …

11 NCAC 20 .0302 PROVIDER ACCESSIBILITY STANDARDS Each carrier shall establish performance targets for member accessibility to primary and specialty care physician services and hospital-based services. Carriers shall also establish similar performance targets for health care serv…

11 NCAC 20 .0303 PROVIDER NETWORK SAFEGUARDS History Note: Authority G.S. 58-2-40(1); 58-50-55(b); 58-65-1; 58-65-25; 58-65-140; 58-67-10; 58-67-20; 58-67-35; 58-67-65; 58-67-140; 58-67-150; Eff. October 1, 1996; Pursuant to G.S. 150B-21.3A, rule Expired January 1, 2015.

11 NCAC 20 .0304 MONITORING ACTIVITIES Each carrier shall, by means of site visits or review of information gathered by the carrier, monitor compliance with this Section and evaluate provider availability and accessibility at least annually to ensure that the needs of its members…

SECTION .0400 - NETWORK PROVIDER CREDENTIALS 11 NCAC 20 .0401 CREDENTIAL VERIFICATION PROGRAM In order to assure accessibility and availability of services, each carrier shall establish a program in accordance with this Section that verifies that its network providers are credent…

11 NCAC 20 .0402 ORGANIZATION STRUCTURE The program established under Rule .0401 of this Section shall provide for an identifiable person or persons to be responsible for all credential verification activities, which person or persons shall be capable of carrying out that respons…

11 NCAC 20 .0403 WRITTEN CREDENTIAL VERIFICATION PLAN Each carrier shall develop and adopt a written credentialing plan that contains policies and procedures to support the credential verification program. The plan shall include: (1) The purpose, goals, and objectives of the cred…