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Benefits Covered by North Carolina Health Insurance

North Carolina law requires insurance carriers to include certain benefits in major medical health insurance policies that are offered in this state. Some of these benefits are:

Emergency Services

Every insurance company must cover emergency services necessary to screen and stabilize the insured person, if those services meet the "prudent layperson" standard (meaning that a layperson would have reasonably believed that an emergency medical condition existed). A managed care plan cannot require prior authorization for emergency services, or require that an in-network hospital's emergency room be used. Copayments and/or deductibles generally apply.

Minimum Hospital Stay Following Childbirth

Health benefit plans that provide maternity and childbirth benefits are required to cover both the mother and her newborn child for a minimum of 48 hours of inpatient care after normal childbirth, or for a minimum of 96 hours of inpatient care following a cesarean section, as long as the physician determines that inpatient care is appropriate. Unless the child is covered as a dependent under a parent's plan, coverage for the newborn's care will end after the first 48 hours (or 96 hours for a cesarean section). State law does not require health insurance plans to offer maternity care.

Mammograms and Pap Smears

Every policy must cover pap smears and low-dose screening mammography.

Bone Mass Measurement

Health benefit plans must cover scientifically proven and approved bone mass measurement for the diagnosis and evaluation of osteoporosis or low bone mass in certain "qualified" individuals. To be a qualified individual, the insured person must meet at least one of the following characteristics:

• estrogen-deficient and at clinical risk of osteoporosis or low bone mass.
• possessing radiographic osteopenia anywhere in the skeleton.
• receiving long-term glucocorticoid (steroid) therapy.
• having primary hyperparathyroidism.
• being monitored to assess the response to or efficacy of commonly accepted osteoporosis drug therapies.
• having a history of low trauma fractures.
• having other conditions or on medical therapies known to cause osteoporosis or low bone mass.

Diabetes Treatment and Services

Policies must cover medically appropriate and necessary diabetes treatment and services. Outpatient self-management training and educational services, equipment, supplies, medications and laboratory procedures used to treat diabetes must also be covered.

Mastectomy Length of Stay and Reconstructive Breast Surgery Following Mastectomy

Insurance companies must allow the patient's physician and the patient to determine how long she will remain in the hospital following a mastectomy. Coverage must be provided for reconstructive breast surgery following a mastectomy performed in the course of treating cancer or breast disease.

Chemical Dependency

All insurance companies offering group policies must offer benefits for the care and treatment of chemical dependency.

Contraceptives

Every insurance company providing a health benefit plan covering prescription drugs or devices must also provide coverage for prescription contraceptive drugs or devices. This includes outpatient contraceptive services if outpatient care is provided. Religion-based employers may request an exemption.