NON-DISCRIMINATION

Health Status
Health plans have certain rules that prevent them from discriminating against people because of their health status. There are different rules for people enrolled in group plans, (typically employer-sponsored plans), and those who are seeking coverage in the individual market (non-group plans).

• Group plans: Health plans may not exclude individuals from coverage or refuse to renew coverage because of their health status, medical condition, claims experience, genetic information, disability or use of health care services. In addition, the health plan may not charge any individual covered under a group plan a higher premium on the basis of that person’s health. However, health plans may charge the group (as a whole) higher premiums based on that group’s use of health services (NCGS 58-68-35).
  
  
• Non-group plans: Health plans cannot refuse to enroll eligible individuals in the non-group market because of their health status. Eligible individuals are people who:
  
  
  • Had 18 or more months of prior health insurance coverage;
  • Do not have access to another group or government-sponsored health plan;
  • Did not lose prior health insurance coverage because of nonpayment of premiums or fraud; and
  • Elected continuation coverage if it was offered, and if so, continued the coverage until the guaranteed time period ran out.
    

Insurers are not required to offer individuals coverage under all the health insurance policies they sell in the non-group market. At a minimum, plans must offer the two most popular non-group plans, such as the policies with the largest premium volume. While plans have to offer coverage to certain individuals in the non-group market, there is no limit on the premiums that can be charged (NCGS 58-68-60 et. seq.).

Race, Color or National Origin
Health plans are prohibited under state law from limiting coverage, refusing to insure, refusing to continue coverage or for charging different premium rates because of a person’s race, color or national or ethnic origin (NCGS 58-67-65(e)(f), 58-3-25(c), 58-65-85).

Gender or Marital Status
No health plan can limit the coverage, refuse to issue or refuse to continue coverage because of a person’s sex or marital status. However, the plan may charge different premiums and may take marital status into account when determining a person’s eligibility for dependent coverage. For example, a plan could not deny health insurance coverage to women working part-time if men working similar part-time jobs could obtain coverage. A plan also may not deny dependent coverage to husbands of female employees when dependent coverage is available to the wives of male employees. Similarly, plans may not restrict, reduce or modify benefits payable for disorders of the genital organs of only one sex (NCGS 58-67-65(b); 58-63-1, 11 NCAC 4.0317).

Newborns, Adoptive Children and Foster Care Children
Health plans must provide coverage for newborn infants and foster children from the moment of the child’s birth or on the day that the foster child is placed in a foster home. The plan shall provide the same coverage for congenital defects or anomalies that are provided for most sicknesses or illnesses (NCGS 58-51-30). The plan must also cover adopted children upon placement with a person who has insurance coverage, and may not impose preexisting-condition exclusions (NCGS 58-51-125).

Coverage of Children
No children may be denied coverage because the child was born out of wedlock, was not claimed as a dependent on the parent’s federal income tax return, or does not reside with the parent or in the health plan’s service area. In addition, the plan must allow a parent to enroll a child when required to do so by court or administrative order. This is true even if it is outside the normal enrollment period (NCGS 58-51-120).

Children with Developmental Disabilities or Other Disabilities
Health plans cannot refuse to enroll a child in an insurance plan that covers physical illness or injury because of that child’s physical disability or mental retardation (NCGS 58-51-35). Insurance companies must continue coverage for dependent children who are mentally retarded or have physical disabilities after the child reaches the age that coverage would normally terminate. This applies if the child is incapable of self-supporting employment and is chiefly dependent upon the policyholder for support and maintenance (NCGS 58-67-65(e), 58-51-25, 58-65-2, 58-67-171).

Sickle Cell Trait or Hemoglobin C Trait
Health plans cannot refuse to enroll an individual in an insurance plan that covers physical illness or injury because of that person’s sickle cell or hemoglobin C trait (NCGS 58-67-65(e), 58-51-45, 58-65-70, 58-67-171). In addition, insurers are prohibited from charging higher premiums because of these health conditions.

Blindness or Deafness
Health plans cannot refuse to enroll an individual, limit coverage or charge higher premiums because the member is fully or partially blind or deaf (NCGS 58-67-65(e), 58-3-25).

People with Mental Illness or Chemical Dependency
Individuals with mental illness or chemical dependence enrolled in group contracts covering 20 or more employees are given limited protections. Health plans may not refuse to enroll an individual in a health plan that covers physical illness or injury because the person has a mental illness or chemical dependence. Similarly, health plans may not charge these individuals a higher premium or reduce the coverage for physical illness or injury (NCGS 58-67-75, 58-51-55; 58-65-90).

Additional protections are available to individuals enrolled in group contracts covering 50 or more employees. Large group plans that cover both physical illness/injury and mental illness cannot impose a lesser lifetime or annual dollar limit on mental health benefits than for the physical illness/injury benefits.¹ However, health plans may still charge higher copayments or have lower limits on provider visits or days of coverage for mental health benefits. Health plans and insurance companies need not offer any coverage for mental illness (NCGS 58-67-75(b1)).

Acquired Immune Deficiency Syndrome & Human Immunodeficiency Virus
Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Virus (AIDS) must be covered as any other illness or sickness in health insurance policies. Health plans may not write plans excluding coverage of AIDS or HIV (11 NCAC 12.0324).

Medicaid Coverage
Health plans are also prohibited from taking into account the fact that an individual is receiving Medicaid coverage in insuring the person or making payments under the health benefit plan (NCGS 58-51-115). In other words, health plans may not exclude individuals or services because they are already covered by Medicaid.

Genetic Information
Recent laws prohibit health plans from discriminating against members on the basis of genetic information (NCGS 58-3-215(c)). Specifically, health plans may not raise either the group premium rates or the premium rates for any specific individual in the group, and may not refuse to issue a policy because of genetic information obtained about one of the prospective members.

¹ Employers that can demonstrate that the cost of providing the same annual and lifetime limits would exceed 1% of the cost of the plan can obtain an exemption from this requirement (NCGS 58-67-75(b1)(6)).

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