North Carolina § 135-48 - 1. General definitions.

§ 135-48. 1. General definitions.

As used in this Article unless the context clearly requires otherwise, the following definitions apply: Authorized representatives who are assisting the State Health Plan Division staff. - Staff of the Department of the State Treasurer, staff of the Department of Justice, or persons providing internal auditing assistance required under G.S. 143-746(b). Benefit period. - The period of time during which charges for covered services provided to a Plan member must be incurred in order to be eligible for payment by the Plan. Chemical dependency. - The pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. Claims Data Feed. - An electronic file provided by a Claims Processor that contains all claims processing data elements for every claim processed by the Claims Processor for the Plan, including Claim Payment Data for each claim. Claim Payment Data. - Data fields within a Claims Data Feed that reflect the provider and the amount the provider billed for services provided to a Plan member, the allowed amount applied to the claim by the Claims Processor, and the amount paid by the Plan on the claim. The term "Claim Payment Data" includes any document, material, or other work, whether tangible or electronic, that is derived from, is based on, or reflects any of the foregoing data fields or information contained therein. If the Claims Processor designates Claim Payment Data as a trade secret, the Claim Payment Data shall be treated as a trade secret as defined in G.S. 66-152(3). Claims Processor. - One or more administrators, third-party administrators, or other parties contracting with the Plan to administer Plan benefits. Comprehensive group health benefit plan. - A comprehensive health benefit plan offered to an individual because of an employment, organizational, or other group affiliation. Comprehensive health benefit plan. - Health care coverage that consists of inpatient and outpatient hospital and medical benefits, as well as other outpatient medical services, prescription drugs, medical supplies, and equipment that are generally available in the health insurance market. Covered service; benefit; allowable expense. - Any medically necessary, reasonable, and customary items of service, including prescription drugs, and medical supplies included in the Plan. Deductible. - The dollar amount that must be incurred for certain covered services in a benefit period before benefits are payable by the Plan. Dependent. - An eligible Plan member other than the subscriber. Dependent child. - Subject to the eligibility requirements of subsections (a) and (b) of G.S. 135-48.41, any of the following up to the first month following the dependent child's 26th birthday: A natural or legally adopted child or children of the employee, whether or not the child is living with the employee. A foster child or children of the employee, whether or not the child is living with the employee. A child for which an employee is a court-appointed guardian. A stepchild of a member who is married to the stepchild's natural parent. Repealed by Session Laws 2011-96, s. 3(a), effective July 1, 2011. Employee or State employee. - Any permanent full-time or permanent part-time regular employee (designated as half-time or more) of an employing unit. Employing Unit. - A North Carolina School System; Community College; State Department, Agency, or Institution; Administrative Office of the Courts; or Association or Examining Board whose employees are eligible for membership in a State-Supported Retirement System. An employing unit also shall mean (i) a charter school in accordance with Article 14A of Chapter 115C of the General Statutes whose board of directors elects to become a participating employer in the Plan under G.S. 135-48.54 or (ii) a local government unit that participates in the Plan under G.S. 135-48.47 or under any other law. Bona fide fire departments, rescue or emergency medical service squads, and National Guard units are deemed to be employing units for the purpose of providing benefits under this Article. Firefighter. - A member of the group "eligible firefighter" as defined in G.S. 58-86-2. Health Benefits Representative or HBR. - The employee designated by the employing unit to administer the Plan for the unit and its employees. The HBR is responsible for enrolling new employees and dependents in accordance with the eligibility requirements under this Article, reporting changes, explaining benefits, reconciling group statements, and remitting group fees. The State Retirement System is the Health Benefits Representative for retired State employees. Plan or State Health Plan. - The North Carolina State Health Plan for Teachers and State Employees. Depending on the context, the term may refer to the entity created in G.S. 153-48.2 [135-48.2] or to the health benefit plans offered by the entity, in which case "Plan" includes all comprehensive health benefit plans offered under the Plan. Plan member. - A subscriber or dependent who is eligible and currently enrolled in the Plan and for whom a premium is paid. Predecessor plan. - The Hospital and Medical Benefits for the Teachers' and State Employees' Retirement System of the State of North Carolina and the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan. Rescue squad worker. - An "eligible rescue squad worker" as defined in G.S. 58-86-30. Retired employee (retiree). - Retired teachers, State employees, and members of the General Assembly who (i) are receiving monthly retirement benefits from the Teachers' and State Employees' Retirement System, the Consolidated Judicial Retirement System, the Legislative Retirement System, or the Optional Retirement Programs established under G.S. 135-5.1 and G.S. 135-5.4 and (ii) earned contributory retirement service in one of these retirement systems prior to January 1, 2021, and did not withdraw that service, so long as the retiree is enrolled. Subscriber. - A Plan member who is not a dependent. History (2008-168, s. 3(e); 2009-16, s. 3(a); 2009-281, s. 1; 2010-120, s. 1; 2011-85, ss. 1.7(a), 1.10(c), 2.6(b), 2.10; 2011-96, s. 3(a); 2011-183, s. 102; 2011-326, s. 19.3; 2012-173, s. 1; 2014-75, s. 1; 2014-97, s. 5(a); 2014-101, s. 7; 2016-104, s. 1; 2017-57, s. 35.21(c); 2017-135, s. 5.) 2009 Health Benefit Changes. - Session Laws 2009-16, s. 2(a), provides: "Eliminate PPO Plus Option. - Effective July 1, 2009, the PPO Plus option (90/10 in-network coverage) under the State Health Plan for Teachers and State Employees ('Plan') is eliminated. The Executive Administrator shall provide notice to all members of the Plan that this option will no longer be available as of July 1, 2009. Employees enrolled in the Plan's Plus option shall have the choice of enrolling in the Basic or Standard Plan options for the 2009-2010 benefit year." Session Laws 2009-16, s. 2(h), provides: "Pharmacy Benefit Savings. - The Plan shall direct its pharmacy benefit manager (PBM), within the terms of the Plan's PBM contract, to achieve the sum of eighteen million dollars ($18,000,000) in savings in pharmacy benefit costs in the 2009-2010 fiscal year, and the sum of twenty million dollars ($20,000,000) in savings in pharmacy benefit costs in the 2010-2011 fiscal year through reduced reimbursements paid to pharmacies for prescription drugs. If the savings achieved in each six-month period of the fiscal year do not exceed one hundred five percent (105%) of the savings amount specified in this section for that fiscal year, there shall be no further adjustment to reimbursements paid to pharmacies for that six-month period. If the total savings achieved, by fiscal year, exceeds one hundred five percent (105%) of the specified savings amount in each six-month period of the fiscal year, the Plan shall adjust pharmacy reimbursement reductions accordingly. The Plan shall review savings achieved twice annually to ensure compliance with this section. The Plan shall calculate the savings to be achieved based on Plan enrollment and estimated cost and utilization trends incorporated in the Plan's Financial Projections as of March 20, 2009. The total savings by fiscal year achieved in this section may be increased or decreased without adjustment based on a change in total enrollment provided that the rate of savings achieved on a per-member per-month basis remains constant. Not later than 60 days immediately following each six-month period, the Plan shall report the amount of savings achieved and any adjustments made for that period to the Committee on Employee Hospital and Medical Benefits." Editor's Note. - Session Laws 2011-85, s. 2.6(b), effective January 1, 2012, recodified former G.S. 135-45.1 as G.S. 135-48.1 . Former G.S. 135-45.1 itself was formerly codified as G.S. 135-39.13 under Part 3A of Article 3A of Chapter 135 by Session Laws 2008-168, s. 3(e), effective July 1, 2008, but was renumbered as G.S. 135-45.1 at the direction of the Revisor of Statutes. Session Laws 2010-3, s. 2, provides: "The Executive Administrator of the State Health Plan for Teachers and State Employees shall consult with the Committee on Employee and Hospital Medical Benefits prior to implementing any program to verify tobacco usage by members of the Plan." Session Laws 2011-85, s. 2.2, provides: "The North Carolina State Health Plan for Teachers and State Employees is transferred to the Department of State Treasurer. This transfer shall have all the elements of a Type II transfer, as defined by G.S. 143A-6 ." Session Laws 2011-85, ss. 2.3 through 2.8, effective January 1, 2011, recodified former Article 3A ( §§ 135-43 through 135-47.3) of Chapter 135 as Article 3B of Chapter 135 containing §§ 135-48.1 through 135-48.62. Where appropriate, the historical citations to former sections have been added to corresponding new sections. At the end of Article 3A are tables showing comparable sections of Article 3A and their disposition in Article 3B. Session Laws 2011-85, s. 2.12, provides: "In repealing a specific, detailed provision of Article 3A of Chapter 135 of the General Statutes and not placing that detailed provision into Article 3B of Chapter 135 of the General Statutes, it is not necessarily the intent of the General Assembly to prohibit the State Treasurer or the State Health Plan from having that authority." Session Laws 2011-85, s. 2.13(a), provides: "Rules and policies adopted by the Executive Administrator and the Board of Trustees prior to the effective date of this section shall continue to be in effect unless the rule or policy directly conflicts with a provision of Article 3B of Chapter 135 of the General Statutes or until the State Treasurer changes the rule or policy." Session Laws 2011-85, s. 3.1(a), provides: "The State Treasurer and the Board of Trustees of the State Health Plan for Teachers and State Employees shall do the following: "(1) Examine the issue of moving to a calendar year, including the costs and mechanics of doing so. "(2) Find savings through wellness programs, Medicare Advantage plans, alternative plan designs, or other resources and use those savings to offer a premium-free plan option no later than July 1, 2013. "(3) Strive to keep all premiums low by finding savings through wellness programs, Medicare Advantage plans, alternative plan designs, or other resources." Session Laws 2011-85, s. 3.1(b), provides: "The State Health Plan for Teachers and State Employees shall issue a Request for Proposals for a Medicare Advantage Plan no later than June 30, 2012." Session Laws 2011-96, s. 3(a), which amended this section, was contingent on Senate Bill 323, 2011 Regular Session becoming law. Senate Bill 323, 2011 Regular Session, was enacted as Session Laws 2011-85. Former G.S. 135-45.1 was amended by Session Laws 2011-183, s. 102, effective June 20, 2011, by deleting "Army and Air" and three times inserting "North Carolina" before "National Guard." Pursuant to Session Laws 2011-326, s. 19.3, the amendment to this section by Session Laws 2011-183, s. 102 was repealed effective June 27, 2011. In this section as amended by Session Laws 2011-85, s. 2.10, the reference in subdivision (14) to "153-48.2" should probably be to "135-48.2." The bracketed reference was added at the direction of the Revisor of Statutes. Also, subdivisions (4) and (5) were renumbered as subdivisions (5) and (4), respectively, at the direction of the Revisor of Statutes to maintain alphabetical order. Session Laws 2012-173, s. 3(a), effective January 1, 2013, rewrote the Article heading, which formerly read: "State Health Plan for Teachers and State Employees; Long-Term Care Benefits." Session Laws 2013-382, s. 10.2, provides: "The State Health Plan for Teachers and State Employees shall establish a workgroup to examine the best way to provide teachers and State employees greater transparency in the costs of health services provided under the State Health Plan. The State Health Plan for Teachers and State Employees shall report the findings and recommendations of the workgroup to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Committee on Governmental Operations on or before December 31, 2013, and annually thereafter through December 31, 2016." For transparency in health care costs generally, see Article 11B of Chapter 131E (G.S. 131E-214.11 through 131E-214.14). Session Laws 2014-101, s. 8, provides, in part: "Except as otherwise provided, this act is effective when it becomes law [August 6, 2014] and applies beginning with the 2014-2015 school year." Session Laws 2016-104, s. 9, made subdivisions (2a) and (2b) of this section, as added by Session Laws 2016-104, s. 1, applicable to contracts entered into on or after July 22, 2016. Session Laws 2016-106, s. 1, effective July 22, 2016, provides: "Notwithstanding the time limitation contained in G.S. 135-48.54 , the Board of Directors of Longleaf School of the Arts, a charter school located in Raleigh, may elect to become a participating employing unit in the State Health Plan for Teachers and State Employees in accordance with Article 3B of Chapter 135 of the General Statutes. The election authorized by this act shall be made no later than 30 days after the effective date of this act and shall be made in accordance with all other requirements of G.S. 135-48.54 ." Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'" Session Laws 2017-57, s. 39.6, is a severability clause. Session Laws 2017-128, s. 7, provides: "The Executive Administrator and the Board of Trustees of the State Health Plan (Plan) shall not approve resolutions electing to cover retirees under the Plan for local government entities that were authorized under S.L. 2004-124, S.L. 2006-7, S.L. 2005-276, and S.L. 2006-249 to participate in the Plan but that did not opt to cover retirees before January 1, 2017." Session Laws 2017-128, s. 9, is a severability clause. Effect of Amendments. - Session Laws 2010-120, s. 1, effective July 1, 2010, added the second sentence in subdivision (10). Session Laws 2011-85, s. 1.7(a), effective July 1, 2011, rewrote subdivision (10) [now (9)]. Session Laws 2011-85, s. 1.10(c), effective July 1, 2011, in subdivision (15), inserted "or HBR" in the first sentence, and inserted "and dependents in accordance with the eligibility requirements under this Article" in the third sentence. Session Laws 2011-96, s. 3(a), effective July 1, 2011, in subdivision (10) [now (9)], inserted "up to the first month following the dependent child's 26th birthday" in the introductory paragraph and deleted the same language following "children of the employee" in subdivision a; deleted "up to the first month following the child's 19th birthday" in subdivision b; substituted "A stepchild of" for "A stepchild who primarily resides with" in d; and deleted e, which read: "Any child under age 19 who has reached his or her 18th birthday, provided the employee was legally responsible for the child's maintenance and support on his or her 18th birthday." Session Laws 2012-173, s. 1, effective July 1, 2012, in subdivision (9), deleted "as long as the employee is legally responsible for the child's maintenance and support" from the end of subdivision b., and deleted "as long as the employee is legally responsible for the child's maintenance and support" from the end of subdivision c. Session Laws 2014-75, s. 1, effective July 22, 2014, in subdivision (11), inserted designation (i) and added "or (ii) a local government unit that participates in the Plan under G.S. 135-48.47 or under any other law" at the end of the second sentence. Session Laws 2014-97, s. 5(a), effective July 1, 2014, substituted "'eligible firefighter' as defined in G.S. 58-86-2 " for "'eligible firemen' as defined in G.S. 58-86-25 " in subdivision (12). Session Laws 2014-101, s. 7, effective August 6, 2014, substituted "Article 14A of Chapter 115C " for "Part 6A of Chapter 115C " in subdivision (11). See Editor's note for applicability. Session Laws 2016-104, s. 1, effective July 22, 2016, inserted subdivisions (2a) and (2b). See editor's note for applicability. Session Laws 2017-57, s. 35.21(c), effective January 1, 2021, rewrote subdivision (18), which read: "Retired employee (retiree). - Retired teachers, State employees, and members of the General Assembly who are receiving monthly retirement benefits from any retirement system supported in whole or in part by contributions of the State of North Carolina, so long as the retiree is enrolled." Session Laws 2017-135, s. 5, effective July 20, 2017, added present subdivision (1) and redesignated former subdivision (1) as subdivision (1a).