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More Information on North Carolina Group Health Insurance

Small Groups

Small groups are those employers with one to 50 employees, including self-employed individuals.

Large Groups

In North Carolina, large employer groups are those with more than 50 eligible employees. When an employer applies for health insurance, the insurance company may fully "underwrite" that group by requesting health information and deciding whether or not to offer coverage. The group of employees must either be accepted or declined as a whole - no one employee can be singled out. Once coverage is issued, large employer groups have guaranteed renewal rights. In addition, large group premium rates usually are developed using each group's past claims history.

Multiple Employer Welfare Arrangements (MEWAs)

MEWAs provide coverage to employees of multiple employers in the same line of business. Rather than purchasing coverage from an insurance company, a group of similar employers may jointly establish a self-insured (self-funded) health benefit plan by pooling funds, and then using the pooled funds to pay members' health care expenses. The North Carolina Department of Insurance licenses and regulates these "Multiple Employer Welfare Arrangements" as it does insurance companies. However, the North Carolina Life and Health Insurance Guaranty Association does not cover MEWA insolvencies; if a self-insured MEWA runs out of money to pay claims, its participating employers may be held responsible for those unpaid claims.

Small Employer Group Health Coverage Reform Act

North Carolina's Small Employer Group Health Coverage Reform Act was enacted in 1992. The purpose of the Act is to promote the availability of accident and health insurance to small employers, eliminate abusive rating and underwriting practices, and improve fairness in the health insurance marketplace. All insurance companies who market or offer small group health insurance in North Carolina must offer all their plans to small employers who have one to 50 employees, provided that the employees reside within the insurance company's service area. Self-employed individuals (as defined by the IRS) do not have guaranteed access to all plans, but they must be offered two standardized plans established by state law (known as the Standard and Basic health plans) regardless of their health status. North Carolina General Statutes define a "small employer" as any individual actively engaged in business that, on at least 50 percent of its working days during the preceding calendar year 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.

Insurance companies have the right to verify whether small employers and self-employed individuals applying for coverage meet the above stated definitions. Insurance companies will most likely request tax and business documents during the application process and may refuse to issue coverage if proper proof is not provided. Additionally, those documents may be requested periodically after coverage is issued to verify ongoing eligibility. No company may single out a small group for termination or non-renewal if it will continue to serve other small groups in the same geographic area. The Small Employer Group Health Coverage Reform Act also establishes limits on how much insurance companies can vary premiums from one small employer to another.