North Carolina § 58-50-110 - Definitions.

§ 58-50-110. Definitions.

As used in this Act: Repealed by Session Laws 2001-334, s. 12.1, effective August 3, 2001. "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the Commissioner that a small employer carrier is in compliance with the provisions of G.S. 58-50-130, and to the extent applicable, the provisions of Article 68 of this Chapter, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefit plans. "Adjusted community rating" means a method used to develop carrier premiums which spreads financial risk across a large population and allows adjustments for the following demographic factors: age, gender, family composition, and geographic areas, as determined pursuant to G.S. 58-50-130(b). Repealed by Session Laws 1993, c. 529, s. 3.3. "Basic health care plan" means a health care plan for small employers that is lower in cost than a standard health care plan and is required to be offered by all small employer carriers pursuant to G.S. 58-50-125 and approved by the Commissioner in accordance with G.S. 58-50-125. "Board" means the board of directors of the Pool. "Carrier" means any person that provides one or more health benefit plans in this State, including a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization (HMO), and a multiple employer welfare arrangement. "Case characteristics" means the demographic factors age, gender, family size, geographic location, and industry. , (7) Repealed by Session Laws 1993, c. 529, s. 3.3. "Grandfathered health plan" means a health benefit plan providing coverage considered grandfathered health coverage described in 45 C.F.R. § 147.140(a). "Industry" means a demographic factor used to reflect the financial risk associated with a specific industry. Repealed by Session Laws 1998-211, s. 9, effective November 1, 1998. The individual elects a different health benefit plan offered by the small employer during an open enrollment period; Repealed by Session Laws 1998-211, s. 9, effective November 1, 1998. A court has ordered coverage be provided for a spouse or minor child under a covered employee's health benefit plan and the request for enrollment for a spouse is made within 30 days after issuance of the court order. A minor child shall be enrolled in accordance with the requirements of G.S. 58-51-120; or Repealed by Session Laws 1998-211, s. 9, effective November 1, 1998. "Self-employed individual" means an individual or sole proprietor who derives a majority of his or her income from a trade or business carried on by the individual or sole proprietor which results in taxable income as indicated on IRS form 1040, Schedule C or F and which generated taxable income in one of the two previous years. Repealed by Session Laws 2013-357, s. 4(a), effective January 1, 2016. "Small employer" means, in connection with a nongrandfathered nontransitional group health plan with respect to a calendar year and a plan year, an employer who meets the definition of small employer under 42 U.S.C. § 18024(b). The number of employees shall be determined using the method set forth in section 4980H(c)(2) of the Internal Revenue Code. (8) "Committee" means the Small Employer Carrier Committee as created by G.S. 58-50-120 . (9) "Dependent" means the spouse or child of an eligible employee, subject to applicable terms of the health care plan covering the employee. (10) "Eligible employee" means an employee who works for a small employer on a full-time basis, with a normal work week of 30 or more hours, including a sole proprietor, a partner or a partnership, or an independent contractor, if included as an employee under a health care plan of a small employer; but does not include employees who work on a part-time, temporary, or substitute basis. (11) "Health benefit plan" means any accident and health insurance policy or certificate; nonprofit hospital or medical service corporation contract; health, hospital, or medical service corporation plan contract; HMO subscriber contract; plan provided by a MEWA or plan provided by another benefit arrangement, to the extent permitted by ERISA, subject to G.S. 58-50-115 . Health benefit plan does not include benefits described in G.S. 58-68-25(b) . (12) "Impaired insurer" has the same meaning as prescribed in G.S. 58-62-20(6) or G.S. 58-62-16(8) . (13) Repealed by Session Laws 1993, c. 529, s. 3.3. (14) "Late enrollee" has the same meaning as defined in G.S. 58-68-30(b)(2) ; provided that the initial enrollment period shall be a period of at least 30 consecutive calendar days. In addition to the special enrollment provisions in G.S. 58-68-30(f) , an eligible employee or dependent shall not be considered a late enrollee under a small employer health benefit plan if: 1, 2. Repealed by Session Laws 1998-211, s. 9, effective November 1, 1998. 3, 4. Repealed by Session Laws 1993, c. 529, s. 3.3. (15) Repealed by Session Laws 1993, c. 529, s. 3.3. (16) "Pool" means the North Carolina Small Employer Health Reinsurance Pool created in G.S. 58-50-150 . (17) "Preexisting-conditions provision" means a preexisting-condition provision as defined in G.S. 58-68-30 . (18) "Premium" includes insurance premiums or other fees charged for a health benefit plan, including the costs of benefits paid or reimbursements made to or on behalf of persons covered by the plan. (19) "Rating period" means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier. (20) "Risk-assuming carrier" means a small employer carrier electing to comply with the requirements set forth in G.S. 58-50-140 . (21) "Reinsuring carrier" means a small employer carrier electing to comply with the requirements set forth in G.S. 58-50-145. (22) "Small employer" means any individual actively engaged in business that, on at least fifty percent (50%) of its working days during the preceding calendar quarter, employed no more than 50 eligible employees, the majority of whom are employed within this State, and is not formed primarily for purposes of buying health insurance and in which a bona fide employer-employee relationship exists. In determining the number of eligible employees, companies that are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation by this State, shall be considered one employer. Subsequent to the issuance of a health benefit plan to a small employer and for the purpose of determining eligibility, the size of a small employer shall be determined annually. Except as otherwise specifically provided, the provisions of this Act that apply to a small employer shall continue to apply until the plan anniversary following the date the small employer no longer meets the requirements of this definition. For purposes of this subdivision, the term small employer includes self-employed individuals. Effective January 1, 2014, this definition shall apply only to grandfathered group health plans subject to this Act. (23) "Small employer carrier" means any carrier that offers health benefit plans covering eligible employees of one or more small employers. (24) "Standard health care plan" means a health care plan for small employers required to be offered by all small employer carriers under G.S. 58-50-125 and approved by the Commissioner in accordance with G.S. 58-50-125 . History (1991, c. 630, s. 1; 1993, c. 408, ss. 1, 2; c. 529, s. 3.3; 1993 (Reg. Sess., 1994), c. 569, s. 6; 1997-259, s. 2; 1998-211, s. 9; 2001-334, ss. 12.1, 12.2; 2006-154, ss. 5, 6; 2013-357, ss. 2(b), 4(a), (b); 2015-281, s. 12.) Editor's Note. - G.S. 58-50-120 , referred to in subdivision (8), was repealed by Session Laws 2006-154, s. 9, effective July 23, 2006. G.S. 58-50-140 , referred to in subdivision (20), was repealed by Session Laws 2006-154, s. 9, effective July 23, 2006. G.S. 58-50-145, referred to in subdivision (21), was repealed by Session Laws 2006-154, s. 9, effective July 23, 2006. For meaning of the words "this Act" see G.S. 58-50-100 . Session Laws 2013-357, s. 1, provides: "Corrections to small group act. - No small employer carrier shall be required to issue the basic or standard health benefit plan as described in G.S. 58-50-125(a) . Any basic or standard health benefit plans described in G.S. 58-50-125(a) that are not 'grandfathered health plans,' as that term is used under Section 1251 of the Affordable Care Act, P.L. 11-148, as amended, shall be terminated on the next anniversary date on or after January 1, 2014, and the small employer carrier shall offer the employer replacement coverage from available small group health benefit plans pursuant to and in accordance with all applicable State and federal laws and regulations. The termination shall be preceded by a 90-day notice to the Commissioner, the employer policyholder, the participants, and the beneficiaries. If the plan is issued to a self-employed individual, as defined in G.S. 58-50-110 (21a), then the small employer carrier shall offer (i) replacement coverage from available individual health benefit plans or (ii) if the small employer carrier does not offer individual health benefit plans in this State, then individual conversion coverage pursuant to G.S. 58-53-45 ." Session Laws 2013-357, s. 6, makes the amendments to this section by Session Laws 2013-357, s. 2(b), effective January 1, 2014, and applicable to all insurance contracts and policies issued, renewed, or amended on or after that date. Session Laws 2013-357, s. 6, made the amendment to this section by Session Laws 2013-357, s. 2(b), applicable to all insurance contracts and policies issued, renewed, or amended on or after January 1, 2014. Effect of Amendments. - Session Laws 2006-154, ss. 5 and 6, effective July 23, 2006, in subdivision (5a), substituted "geographic location, and industry" for "and geographic location"; and added subdivision (12a). Session Laws 2013-357, s. 2(b), effective January 1, 2014, added subdivisions (10a) and (22a); and, in subdivision (22), substituted "this subdivision" for "this Act" in the next-to-last sentence, and added the last sentence. For applicability, see editor's note. Session Laws 2013-357, s. 4(a), (b), as amended by Session Laws 2015-281, s. 12, effective January 1, 2016, repealed subdivision (22a); and added subdivision (22b).