Paul Sanchez
As a resident of North Carolina, you are not required by law to have medical insurance, but if you do not have a health insurance plan, you will have to pay a penalty fee that will appear as an additional tax or a reduction in your federal income tax return. The state offers a range of health insurance plans provided by private insurance companies, and you can also purchase individual and family coverage from private insurers through HealthCare.gov. If you are self-employed, you can also use the federal exchange to purchase coverage.
| Characteristics | Values |
|---|---|
| Is health insurance mandatory in NC? | No, but there is a penalty fee for not having insurance. |
| What are the options for health insurance in NC? | Private insurance companies, Medicaid, Medicare, COBRA, Children's Health Insurance Program (CHIP), HealthCare.gov |
| What are the benefits of health insurance in NC? | Coordination of benefits, Explanation of Benefits, Health Maintenance Organization (HMO), Health Savings Account (HSA), In-Network Provider, Out-of-Network Provider, Out-of-Pocket Maximum |
| Are there any additional benefits that NC requires insurance companies to provide? | Yes, access to non-formulary drugs, hearing aids coverage, and reconstructive breast surgery following mastectomy. |
| Are employers in NC required to offer health insurance to their employees? | No, but large businesses may have to make a tax payment called the Employer Shared Responsibility Payment (ESRP). |
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What You'll Learn
Private health insurance plans
Blue Cross NC, for example, offers plans like Blue Advantage and Blue Care, which provide access to a broad choice of in-network providers, doctors, specialists, and hospitals within North Carolina and nationwide. They also have plans like Blue Local and Blue Home, which are collaborations with specific healthcare providers to offer exclusive benefits.
UnitedHealthcare, on the other hand, provides a range of ACA plans, including short-term health insurance, hospital insurance, and dental insurance. They also offer supplemental plans, such as accident insurance and Health ProtectorGuard fixed indemnity insurance, to cover services that may not be included in your primary medical plan.
When considering private health insurance plans, it's important to understand the different types of coverage and networks available. Private insurers often offer exclusive benefits and additional benefits beyond the standardized essential benefits required by law. These essential benefits include preventive care, pediatric services, and chronic disease management.
Additionally, North Carolina has specific mandates for private insurance providers, requiring them to offer benefits such as access to non-formulary drugs, hearing aid coverage, and reconstructive breast surgery following a mastectomy.
It's worth noting that North Carolina residents have the flexibility to choose from various private insurance companies and plans, allowing them to find the coverage that best suits their needs.
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Medicaid and Medicare
In North Carolina, residents can choose from health insurance plans offered to individuals and groups by private insurance companies. They may also be entitled to certain state and federal programs such as Medicaid and Medicare.
Medicaid is a joint federal and state program that helps cover medical costs for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities. The eligibility requirements for Medicaid vary from state to state. Generally, you must meet your state’s rules for income and resources, as well as being a resident of the state. Some states allow you to “spend down" your income to qualify for Medicaid. This is done by paying non-covered medical expenses and cost-sharing until your income is lowered to a level that qualifies you for Medicaid. If you are enrolled in NC Medicaid coverage, you are not eligible for financial help with the cost of your Marketplace plan.
Medicare is a health insurance program that provides benefits to Americans aged 65 and older. This program has two parts: Part A, which covers hospital services, and Part B, which covers doctor services. If you have both Medicare and full Medicaid coverage, you are considered "dually eligible". Medicare pays first when you are dually eligible and you get Medicare-covered services. Medicaid may also pay for other drugs and services that Medicare does not cover.
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Penalties for no insurance
While it is not illegal to live without a health insurance policy in North Carolina, the Affordable Care Act (also known as Obamacare) requires most Americans to maintain a comprehensive plan that meets ten essential healthcare benefits. If you do not have a health insurance plan, you must pay a penalty fee that is added to your taxes or reduces your federal income tax return.
However, driving without insurance in North Carolina is illegal and is considered a Class 1 misdemeanour. If you are caught driving without insurance, you could face several penalties, including fines, license suspension, and even jail time. The severity of the punishment increases with each offence. The minimum amount of car insurance required in North Carolina is $30,000 per person for bodily injury liability, $60,000 per accident, and $25,000 in property damage per accident.
If you are caught driving without insurance, a police officer will likely give you a ticket, and your car may be towed and impounded. You will have to pay towing and impound fees, in addition to a civil penalty fee ranging from $50 to $150, depending on the number of lapses on record. If you have two offences within three years, the civil penalty increases to $100, and your registration and license plates will be taken away for 30 days until you buy insurance. For a third offence within three years, the civil penalty fine increases to $150, and you will again lose your registration and license plates for 30 days.
To avoid penalties, it is important to maintain active insurance coverage and understand the state's insurance laws.
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COBRA and State Continuation
The Consolidated Omnibus Budget Reconciliation Act, or COBRA, is a federal law that allows employees and their families to continue their employer-provided health insurance for a limited period after leaving a job or experiencing certain life events that would otherwise end their coverage. COBRA outlines how employees and family members may elect to continue their coverage.
COBRA applies to businesses with 20 or more employees in the prior year, requiring them to offer employees and their families the opportunity for a temporary extension of health coverage. This includes the employee's spouse, former spouse, or children, who are eligible for COBRA coverage even if the employee does not sign up. Qualifying events include the death of the covered employee, divorce or legal separation, the covered employee becoming entitled to Medicare, or a dependent child ceasing to be a dependent under the plan.
The length of COBRA coverage depends on the type of qualifying event, generally lasting between 18 and 36 months. Individuals continuing their group plan are responsible for the full premiums and any administrative fees, which can amount to up to 102% of the cost to the plan. COBRA coverage can be terminated early if premiums and other costs are not paid on time, or if the individual accepts a new job with health insurance before COBRA coverage ends.
State continuation is similar to COBRA but applies to group health insurance policies of employers with fewer than 20 employees. In some states, state continuation coverage rules also apply to larger group insurance policies, enhancing COBRA protections. For example, in certain states, individuals must be allowed to continue their coverage until they reach the age of Medicare eligibility if they are leaving a job-based plan.
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Explanation of Benefits
As a North Carolina resident, you have several options for health insurance. You can choose from health insurance plans offered to individuals and groups by private insurance companies. You may also purchase individual and family coverage from participating private insurers through HealthCare.gov, the federal exchange. If you are self-employed with no employees, you can also use the federal exchange to purchase coverage. You may also be entitled to certain state and federal programs such as Medicaid, Medicare, and COBRA.
Regardless of which health insurance option you choose, you will receive an Explanation of Benefits (EOB) each time you receive medical care. An EOB is a written explanation from your health insurance company that explains how a medical claim was paid, including what the company paid and the costs you are responsible for. It will also show you which doctor or healthcare provider sent the bill, so you can make sure it matches up with the care you received.
Your EOB will also detail any copayments, deductibles, or coinsurance you may owe. A copayment is a flat fee you pay each time you receive medical care, and the insurance company pays the rest. A deductible is the amount you must pay out-of-pocket before your insurance company begins to pay for your care. Coinsurance is the percentage of the total cost of care that you are responsible for after you have met your deductible.
If you have a group health insurance plan, your EOB may also include information about coordination of benefits. This is when the benefits payable under more than one group health insurance plan are coordinated so that the insurance benefits provided by multiple group plans do not exceed allowable medical expenses or eliminate patient incentives to contain costs. This only applies to group plans issued in North Carolina, but self-funded plans and plans issued out of other states may also include Coordination of Benefits clauses.
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Frequently asked questions
While it is not illegal to live without a health insurance policy, the Affordable Care Act (ACA) mandates that most Americans must maintain a comprehensive plan or pay a penalty fee. As of 2018, however, this fee no longer exists.
North Carolina residents can choose from health insurance plans offered to individuals and groups by private insurance companies. You may also purchase individual and family coverage from participating private insurers through HealthCare.gov, the federal exchange.
North Carolina mandates that the following benefits, which exceed ACA requirements, must be provided or offered by private providers:
- Access to non-formulary drugs
- Hearing aids coverage
- Reconstructive breast surgery following mastectomy
- Congenital anomaly including cleft lip/palate coverage
- Diabetes care management
- Off-label prescription drug coverage for certain drug use in cancer treatment
- TMJ disorder treatment
The Affordable Care Act, also known as Obamacare, is a federal law that was passed in 2010. It requires that insurance companies offering major medical/comprehensive policies set a base rate for everyone and then adjust that rate based on certain factors. The ACA also offers subsidies to help reduce the cost of health insurance, depending on income.
The monthly bill from your insurance company is called a premium. In addition to the premium, there are also out-of-pocket costs like copays/copayments, deductibles, coinsurance, and out-of-pocket limits. Generally, a higher premium corresponds to lower out-of-pocket costs when you receive care.
