North Carolina Small Business
Health Insurance Plans 2023

The average price of a standard North Carolina small business health insurance policy ranges from around $583 to over $1706 per employee per month based on; single or family, location, coverages offered, deductibles and more.

When it comes to health insurance regulations, North Carolina has fewer than most states. Nevertheless, it is important that you're aware of these regulations so that you can make the right choice for you and your employees.

In North Carolina, some of the most important health insurance laws specifically relate to the policies. Of the provisions, the guaranteed renewability provision is one of the most universal.

In the State of North Carolina, this clause states that policyholders have the right to renew existing health insurance plans, so long as their existing contract was not violated. The guaranteed renewability provision is required, and it is in place to protect insurance policyholders.

Another essential provision that relates to health insurance policies in North Carolina that is permitted, but not necessary, is the "pre-existing condition exclusion period" clause. As per this clause, certain types of pre-existing conditions, which are clearly specified by the clause, will not be covered for a specific period of time.

This is known as the "exclusion period", and it can last for as long as 12 months, but usually, it's in place between 3 and 6 months. Health conditions are deemed "pre-existing" if they were diagnosed or treated within the exclusion period before the North Carolina small business health insurance plans begin.

Additionally, if insured individuals would like to change their health insurance from one policy to another, or one company to another, it's important to ensure that you have continuous coverage; meaning no lapses in your coverage. So long as you do so, your previous coverage can be used to credit the pre-existing condition clause on your new health insurance policy.

To clarify, if you have satisfied the exclusion period for a pre-existing condition with your previous policy, if there was no lapse in your coverage between policies, there will be no exclusions on your new policy.

Similarly, if an insurance policy was active for 4 months, the maximum length of time for the exclusion period under your new health insurance plan would be 6 months, not 12 months.

Lastly, as per North Carolina health insurance laws, newborn babies and adopted children are automatically covered by their parents' health insurance policy if their policy offered coverage for dependents.

The coverage for the newborn or adopted child will end 31 days after the baby is born or the child is adopted, and thereafter, the policy will have to be amended so that the dependents are included.

According to NC Department of Insurance, as an "Effective Rate Review State" under federal health care reform, the North Carolina Department of Insurance must make public the information contained in Parts I, II and III of the federal Rate Filing Justification for comprehensive health insurance rate filings with significant rate increases. The threshold for this requirement is 15%.

In 2010, the Affordable Care Act (ACA or "ObamaCare") was passed by the United States Congress and was signed into law by Obama. Following its passage, provisions of the law have continued to be phased in, and as of January 1, 2014, the majority of American citizens and legal residents of the United States are required, by law, to have qualifying health care coverage.

If they fail to have coverage, they are responsible for paying an annual tax penalty for each month they aren't insured, which is known as the "individual mandate".

The cost of the penalty for failure to have qualifying coverage is $95 per adult and $47.50 per child, or 1% of your total taxable income; whichever amount is higher - as much as $285 per family. In 2017, the penalty increased, and has continued to increase thereafter.

Qualifying Exemptions For The Individual Mandate

Individuals who meet one of the following are exempt from the individual mandate and the associated tax penalties in NC:

• Illegal aliens
• Jailed individuals
• Religious objections
• The cost of health insurance coverage is higher than 8% of your household income
• Those who aren't covered for less than three months during the calendar year
• Those who have hardship waivers
• Your income level is blow the 100% poverty level

If you're a small business owner in North Carolina, you must provide your employees with insurance. This is a requirement that was put into place by the Affordable Care Act.

Referred to as the Employer Shared Responsibility provision, all employers must offer their employees at least one of the ACA-compliant North Carolina small business health insurance plans, otherwise then can face fines of up to $2,000 per employee.

North Carolina small business owners can purchase coverage for their employees through the state's Small Health Option Program (SHOP) exchange, or from a private insurance agent or broker.

Affordable Care Act Standardized Essential Health Benefits

As per the ACA, all qualifying health insurance plans must offer 10 standardized essential benefits.

Depending on the state, additional benefits may also be required. The 10 ACA standardized essential benefits are as follows:

1. Ambulatory patient services (medical care that is offered without being admitted to a hospital)
2. Emergency services
3. Hospitalizations, such as overnight stays and surgical procedures
4. Lab services
5. Mental health and substance abuse disorder services, including behavioral health treatments, such as psychotherapy and counseling
6. Pediatric health care services, including vision and oral care; however, adult vision and dental coverage aren't essential health benefits under ACA
7. Pregnancy, maternity, and newborn care, including before and after birth
8. Prescription pharmaceuticals
9. Preventative and wellness services, as well as management for chronic diseases
10. Rehabilitative and habilitative services and devices, including services and devices for injuries, disabilities, and chronic health conditions

Additional Health Benefits Mandated In North Carolina

Not only do small group health insurance policies in North Carolina have to include the ACA essential standardized health benefits, but they must also include the benefits that have been mandated by the state government. These additional benefits include the following:

• Access to non-formulary drugs
• Congenital anomaly, including cleft lip/palate
• Diabetes care management
• Hearing aid coverage
• Off-label prescription pharmaceutical drugs
• Reconstructive breast surgery following mastectomy
• TMJ disorder treatments

Standardized North Carolina Small Business Health Insurance Plans

In order to make it easier to compare costs and benefits, the Affordable Care Act has designated all qualifying North Carolina small business health insurance plans to be one of four metal colors, including Bronze, Silver, Gold, and Platinum.

Each of these designations is based on the average amount of health care costs that the plan will cover, which is illustrates at percentages of how much the insurance company will cover for health care, as well as the amount the insured will have to pay out-of-pocket.

All insurance companies that are participating in the federal or state health care exchange program must offer at least the Silver and Gold North Carolina small business health insurance plans.

All four of the metal plans have a shared maximum out-of-pocked amount that the insured can be charged during any calendar year. The following table illustrates this information:

Guaranteed Issue

As per the ACA, individuals cannot be denied coverage or charged higher premiums because of their past health history, or their gender.

Additionally, look-back and waiting periods cannot be imposed. Additionally, policies are effective when they are issued and all coverage is renewable if the individual chooses to renew the policy.

However, plans can be canceled if the individual fails to pay their premiums or commits fraud.

A premium is the amount the insured must pay out-of-pocket in order to maintain their health insurance policy. The premiums that are charged for any of the qualifying metal plans can be based on the following:

• Age of the individual
• Whether or not the individual uses tobacco
• Where the individual lives, based on a rating area
• The number of family members who will be enrolling

While there are several types of health insurance plans to choose from, the following plans are the most popular among NC small business owners:

Health Maintenance Organization - Simply known as an "HMO", this type of plan offers a variety of health-related services via a network of health care providers and hospitals that exclusively contract with the HMO, or who agree to offer their services to members of the HMO. Employees who participate in this type of plan usually have to choose a primary care physician (PCP), and receive most of their care from this physician. If a specialist is needed, the PCP will recommend one that is affiliated with the HMO.

Preferred Provider Organization - More commonly referred to simply as "PPO", this type of health insurance plan is the most common among North Carolina small business owners. The insurance company provides a preferred list of health care providers, and employees must receive their medical care from the doctors and hospitals on that list for their claims to be paid at the highest level possible - but they also have the flexibility to see any other provider anywhere in or out of state.

Point-of-Service Plan - Known as a (POS), this type of health insurance plan provides access to health care services at a lower overall cost, but with fewer choices. Members can access care from in-network or out-of-network providers and facilities, but coverage is better when you stay in-network. POS plans may vary, but generally, plans are considered a blend of HMO and PPO plans - offering more flexibility than HMOs, but less than PPOs.

Health Savings Account - A health savings account (HSA) is a special type of bank account that allows participants in the insurance plan to save money that can be used specifically for the medical care they require in the future. HSA-qualified health insurance plans are usually PPO plans that are specifically designed to be used with an HSA.

Indemnity Health Insurance - This type of health insurance plan allows members to control their own health care and to visit any doctor or hospital they choose. The insurance company would then pay a pre-determined percentage of the total charges for the services that were rendered. Employees may have to pay for some types of services up-front and then they can submit a request for reimbursement with the insurance company.