11 N.C. Admin. Code 12.0328

Current through Register Vol. 39, No. 9, November 1, 2024

Section 12 .0328 - ELIGIBLE INDIVIDUAL COVERAGE

(a) As used in this Rule, "designated health plan" means a guaranteed available plan an insurer must issue to an eligible individual under G.S. 58-68-60.

(b) As used in this Rule, "eligible individual" has the same meaning as in G.S. 58-68-60(b).

(c) As used in this Rule, "insurer" means an entity licensed under G.S. Chapter 58 that offers health insurance coverage in the individual market in this State.

(d) An insurer shall market each of its designated health plan(s) to eligible individuals.

(e) In marketing the designated health plan(s) to eligible individuals, an insurer shall use at least the same sources and methods of distribution that it uses to market other health benefit plans to individuals. An agent authorized by an insurer to market health benefit plans to individuals in this State shall also be authorized to market to eligible individuals.

(f) An insurer shall offer at least the designated health plan(s) to any eligible individual who applies for or makes an inquiry regarding health insurance coverage from the insurer. The offer may be provided directly to the eligible individual or delivered through an agent. The offer shall be in writing and shall include at least the following information:

(1) A general description of the benefits contained in the designated health plan(s) and any other health benefit plan being offered to the eligible individual; and

(2) Information describing how the eligible individual may enroll in the plans.

(g) An insurer shall provide a price quote to an eligible individual (directly or through an authorized agent) within 10 working days of receiving a request for a quote and information necessary to provide the quote. An insurer shall notify an eligible individual within five working days of receiving a request for a quote of any additional information needed by the insurer to provide the quote.

(h) An insurer shall not apply more stringent or detailed requirements related to the application process for an eligible individual than are applied for other individual applicants for other health benefit plans offered by the insurer.

(i) If an insurer denies coverage under a health benefit plan to an eligible individual, the denial shall be in writing and shall state with specificity the reasons for the denial, subject to any restrictions related to confidentiality of medical information. The written denial shall be accompanied by a written explanation of the guaranteed availability of coverage under the designated health plan(s) from the insurer. The explanation shall include at least the following:

(1) A general description of the benefit contained in each designated health plan;

(2) A price quote for each designated health plan; and

(3) Information describing how the eligible individual may enroll in a designated health plan.

(j) The written information described in Paragraph (i) of this Rule shall be provided within the time periods provided in Paragraph (g) of this Rule and may be provided directly to the eligible individual or delivered through an authorized agent.

(k) An insurer shall maintain a toll-free telephone service that answers its telephone calls in a timely manner to provide information to eligible individuals about the availability of the designated health plan(s) in this State. The service shall provide information to callers on how to apply for designated health plan coverage from the insurer. The information may include the names and telephone numbers of agents located near to the caller or other information designed to assist the caller to locate an authorized agent or to otherwise apply for coverage.

(l) An insurer shall not require, as a condition to the offer or sale of a designated health plan to an eligible individual, that the eligible individual purchase or qualify for any other insurance product or service.

(m) An insurer shall not create financial incentives or disincentives for agents to sell or to not sell any of its individual heath benefit plans, including designated health plans.

11 N.C. Admin. Code 12 .0328

Authority G.S. 58-2-40(1); 58-68-60;
Eff. April 1, 2003;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.

Authority G.S. 58-2-40(1); 58-68-60;
Eff. April 1, 2003.