More Benefits Covered by North Carolina Health Insurance Laws

Newborn Hearing Screening

All health insurance companies are required to cover hearing screenings for newborn children, subject to the deductibles, copayments and coinsurance that generally apply to other services covered by the plan.

Clinical Trials

All health insurance companies are required to cover medically necessary expenses for phase II, III and IV clinical trials that are not directly related to conducting the trial itself, not provided by the parties conducting the trial, and that would be covered if provided outside of a clinical trial. To be covered, the trials must meet certain minimum medical and scientific requirements.

Adding Newborn Infants and Adopted or Foster Children

Newborn children, newly adopted children and newly placed foster children who are covered as dependents are considered to be covered from the moment of birth or moment of placement in a home, as long as the policy was in effect at that time. When coverage becomes effective in this manner, exclusions and waiting periods for pre-existing conditions may not be applied. If your existing policy automatically covers your new child with no additional premium, then the policy is considered to be in place at the moment of birth or placement, regardless of whether you provided your insurance company with advance notification of your new child. However, notifying the insurance company prior to or soon after birth or placement is a good idea in order to avoid delays in claim processing.

If your policy will require additional premium, however, you must notify your plan prior to birth or placement or within 30 days of birth or placement, in order for the coverage to be in effect from the moment of birth or placement. Otherwise your plan may exclude or place a waiting period on coverage for pre-existing conditions, including birth defects.

Mentally Retarded or Physically Handicapped Children

The age limitation for dependent children will not apply for a child who is, and continues to be:

• Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and
• Chiefly dependent on the policyholder for support and maintenance.

Policy guidelines must be followed to properly notify the insurance company of any request to continue coverage for qualified children.

Network Adequacy

Managed care (HMO and PPO) plans must maintain adequate provider networks that provide access to covered services within a reasonable distance, and without unreasonable delay. If a managed care plan's network does not offer reasonable access to an appropriate provider, then the plan must allow its member to receive needed care from out-of-network providers, without holding the member responsible for any more than the standard in-network copayment, coinsurance or deductible. Managed care plans are required to establish their own standards for network accessibility.