Health Insurance Marketplace in North Carolina
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
North Carolina has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under North Carolina’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
Randolph Hospital, Inc., will use Navigator funds to serve a three county area in North Carolina. Randolph Hospital plans on targeting specific geographic regions with high uninsured populations, and working with community organizations in those areas to leverage resources and reach the most people. Additionally, Randolph Hospital will work with hospital financial counselors that already work with uninsured hospital patients to inform those patients of their coverage options.
Mountain Projects, Inc. is a non-profit Community Action Agency serving Haywood and Jackson counties in North Carolina. Mountain Projects plans on providing Navigator services to the seven western-most rural counties of North Carolina, including Haywood, Jackson, Macon, Swain, Graham, Clay, and Cherokee. They will leverage existing relationships in these rural communities with the goal of educating the uninsured and facilitating access to the new insurance options now available.
North Carolina Community Care Networks, Inc. are consortia that total more than 100 organizations who will work to inform consumers statewide, with particular focus in areas where there is a higher concentration of uninsured. These networks will be serving to reach out, inform, educate and help enroll North Carolinians, and include organizations in the legal rights, faith-based, agricultural, and aging communities.
The Alcohol/Drug Council of North Carolina plans on using Navigator grant funds to establish Project Jumpstart, implemented by a consortium formed to provide specialized navigation services to people in recovery from mental illness and/or substance abuse. A majority of people working on Project Jumpstart will have personal experience with mental illness, an addictive disorder, and/or a chronic disease, and will draw on these experiences to reach out to and help enroll this target population in new coverage options.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
[contact-form-7 id=”73″ title=”Contact form 1″]
Accountable Care Organizations in North Carolina
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- North Carolina Community Networks NC – Health Care Innovation Award
- Duke University NC – Health Care Innovation Award
- Mountain Area Health Education Center NC- Health Care Innovation Award
Health care facilities where Innovation Models are being tested
- Coastal Carolina Quality Care, Inc. New Bern, NC – Advance Payment ACO Model
- Blue Ridge Healthcare System-Grace Hospital Inc. Morganton, NC – BPCI Initiative: Model 2
- Blue Ridge Healthcare System-Valdese General Hospital Valdese, NC – BPCI Initiative: Model 2
- Duke University Hospital Durham, NC – BPCI Initiative: Model 2
- First Health Moore Regional Hospital Pinehurst , NC – BPCI Initiative: Model 2
- Amedisys Home Health Louisburg, NC – BCPI Initiative: Model 3
- Amedisys Home Health of Fayetteville Fayetteville, NC – BCPI Initiative: Model 3
- d/b/a/ Amedisys Home Health of Chapel Hill Chapel Hill, NC – BCPI Initiative: Model 3
- Access East Community-based Transitional Partnership Greenville, NC – Community-based Care Transition Program
- The Northwest Triad Care Transitions Community Program (NTCTCP) NC – Community-based Care Transition Program
- AccessCare Morrisville, NC – Community-based Care Transition Program
- Apex Family Medicine Apex, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Colerain Primary Care Colerain, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- First Choice Community Health Centers at Angier Medical Center Angier, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- First Choice Community Health Centers at Benhaven Medical Center Cameron, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Gaston Family Health Services-Bessemer City Health Care Center Bessemer City, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- James Bernstein Community Health Center Greenville, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Julian T. Pierce Health Center Pembroke, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Maxton Medical Center Maxton, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Metropolitan Community Health Services, Inc, aba Agape Clinic Washington, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- PHS – Charles Drew Community Health Center Burlington, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Rural Health Group at Whitakers Whitakers, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Rock Quarry Road Family Medicine Raleigh, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Rural Health Group at Norlina Norlina, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Rural Health Group at Twin County Hollister, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Snow Hill Medical Center Snow Hill, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- PHS – Prospect Hill Community Health Center Prospect Hill, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- OIC Family Medical Center Rocky Mount, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- First Choice Community Health Centers at Anderson Creek Medical Center Spring Lake, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Duke University Hospital Durham, NC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Frazier Mountain Community Health Center Lebec, CA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Doctors Making Housecalls, LLC Durham, NC – Independence at Home Demonstration
- Suzanne Landis MD, MPH Asheville, NC – Innovation Advisors Program
- Rod Baird MS Asheville, NC – Innovation Advisors Program
- Pamela Duncan PhD, PT, FAPTA, FAHA Winston-Salem, NC – Innovation Advisors Program
- Zeev Neuwirth MD, MHCM Charlotte, NC – Innovation Advisors Program
- Women’s Birth & Wellness Center Chapel Hill, NC – Strong Start for Mothers and Newborns Initiative
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in North Carolina
On November 15, 2012, Governor Beverly Perdue (D) declared the state’s intent to establish a state-federal partnership health insurance exchange.1 However, on February 12, 2013, newly-elected Governor Pat McCrory (R) issued a statement indicating that North Carolina will abandon efforts to establish a partnership exchange and will instead allow the federal government to operate the exchange.2
In 2011, Governor Perdue had signed into law HB 22 which indicated the General Assembly’s intent to establish and operate a state based health insurance exchange.3 Legislators introduced three bills to establish a state-based health insurance exchange in 2011; however, all failed at the close of the legislative session in July 2012.
In the absence of exchange legislation, the North Carolina Department of Insurance (NCDOI), the North Carolina Department of Health and Human Services (NCDHHS), and the North Carolina Institute of Medicine (NCIOM) led exchange planning in the state. As of January 2012, the Department of Insurance leads a Market Reform Technical Advisory Group (TAG) comprised of insurers, agents, consumers, and providers. The NCIOM Health Benefit Exchange and Insurance Oversight Workgroup released a final report in May 2012 on the impact of federal reform on the state.4
Contracting with Plans: In September 2012, the North Carolina Department of Insurance issued a Request for Proposals to solicit work on exchange plan management activities including, technical assistance and training; the Department intends for the contract to begin in October 2012.5 In the spring of 2012, the Department of Insurance’s TAG recommended that North Carolina initially defer to the federal risk adjustment model, but evaluate developing a state model in the future.6The TAG also suggested the state administer the reinsurance program, while deferring the responsibility of collecting contributions to the federal government. In April 2012, the NCIOM Workgroup explored the exchange’s authority to limit the number of plan designs per metal level in 2014.
Consumer Assistance and Outreach: In April 2012, the NCIOM Workgroup identified outstanding issues including, conflict of interest provisions for agents and brokers as well as patient Navigators.7 The Workgroup created a subcommittee to consider the role of Navigators in educating the public and helping them enroll in appropriate coverage.
North Carolina used federal funds to establish a pilot call center that became operational in August 2012. The call center fielded almost 3,000 calls in September and October about various issues, including assistance with enrolling in a health plan and questions about the Affordable Care Act. The call center collects data by county so that concerns can be identified by geographic regions to inform future consumer assistance efforts. The call center hired a Community Resource Manager in October 2012 to work with Navigators and Assisters.
Small Business Health Options Program (SHOP) Exchange: In March 2011, a subcontractor for the Department of Insurance released a report including insurance market analysis of the impact of health reform on enrollment and premiums, the impact of merging the individual and small group health markets, the impact of allowing large groups to participate in the exchange beginning in 2014, and recommended strategies to mitigate adverse selection.8 A year later, the Insurance Department’s TAG recommended that the small group and individual exchange markets maintain separate risk pools and only employers with 50 or fewer employees be allowed participate in the SHOP until the state is required to open the SHOP to employers with 100 or fewer employees in 2016.9
Information Technology (IT): In December 2008, North Carolina hired a contractor to provide a commercial off-the-shelf (COTS) software package that replaced its existing eligibility determination and case management system. The new system, called North Carolina Families Accessing Services Through Technology (NC FAST), currently provides electronic Medicaid/CHIP application, eligibility, and enrollment functionality. North Carolina plans to expand upon the existing system to develop a multiple-service eligibility system to include the Exchange and other public programs.
NCDOI had used federal funding to hire contractors to develop a RFP for all non-eligibility related Exchange systems, including financial management, plan selection functionality, plan management, Navigator/assister management, call center operations, data warehousing, and SHOP eligibility. These services will be required to be interoperable with NC FAST for both Exchange and Medicaid/CHIP functions.10
Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Department of Insurance released an analysis of benchmark plan options for the state in May 2012; the report found that all of the state’s options except for the federal employee health benefit plan covered all state mandates, there was relatively little difference in the cost among benchmark plans, and all benchmark options needed to be supplemented for pediatric oral and vision care.11Therefore, the state was comfortable with defaulting to the largest small-group plan, Blue Cross Blue Shield of North Carolina- Blue Options, PPO.
In September 2011, the North Carolina Department of Insurance received a federal Exchange Planning grant of $1 million. The Department, working in partnership with the North Carolina Department of Health and Human Services, then received a $12.4 million federal Level One Establishment grant on August 12, 2011. North Carolina will use the grant to engage stakeholders, prepare analyses of outstanding policy decisions, and expand the existing eligibility system of the North Carolina Department of Health and Human Services to accommodate the exchange. In January 2013, North Carolina was awarded a second Level One grant of $74 million to develop an IPA program and support implementation of the HCR Module, including integration of the module with current state IT systems and federal data sources.12
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
North Carolina is not participating in Medicaid expansion.
The federal government will assume full responsibility for running a health insurance exchange in North Carolina in 2014.
Additional information about North Carolina’s exchange Workgroup meetings can be found at:
More information on the state’s exchange planning can also be found at:http://www.ncdoi.com/lh/LH_Health_Care_Reform_ACA.aspx
1. “Gov Perdue chooses state-federal partnership.” The News-Herald. November 16, 2012.http://www.roanoke-chowannewsherald.com/2012/11/16/gov-perdue-chooses-state-federal-partnership/
2. “Governor McCrory Recommends Healthcare Implemenation Strategy.” State of North Carolina Governor’s Office. February 12, 2013. http://www.governor.state.nc.us/newsroom/press-releases/20130212/governor-mccrory-recommends-healthcare-implementation-strategy
3. House Bill 22. “An Act to Make Technical, Clarifying, and other Modifications to the Current Operations and Capital Improvements Appropriations Act.” Session Law 2011-391.http://www.ncga.state.nc.us/Sessions/2011/Bills/House/PDF/H22v4.pdf
4. Examining the Impact of the Patient Protection and Affordable Care Act in North Carolina. Draft Final Report Pending US Supreme Court Decision. May 2012. North Carolina Institute of Medicine.http://www.nciom.org/wp-content/uploads/2012/05/Full-Report-Online-Pending.pdf
5. North Carolina Health Insurance Rate Review and Health Benefit Exchange Plan Management Projects. Request for Proposals Issued September 5, 2012. NC Dept. of Insurance.https://www.ips.state.nc.us/ips/AGENCY/PDF/09194300.pdf
6. Risk Adjustment and Reinsurance Issues and Recommendations from the Market Reform Technical Advisory Group. Issue Brief #3. Department of Insurance. Spring 2012.http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/Issue%20Brief%203%20-%20Risk%20Adjustment%20and%20Reinsurance%20Issues.pdf
7. HBE Workgroup: Outstanding Discussion Questions. April 13, 2012. North Carolina Institute of Medicine. http://www.nciom.org/wp-content/uploads/2012/04/Outstanding-Discussion-Questions.pdf
8. Milliman Report for the North Carolina DOI. March 31, 2011. http://www.nciom.org/wp-content/uploads/2010/12/Health-Benefits-Exchange-Study-DRAFT-4-2011-03-31-FULL-REPORT.pdf
9. Selected Small Group Market Issues and Recommendations from the Market Reform Technical Advisory Group. Issue Brief #1. Department of Insurance. Spring 2012.http://www.ncdoi.com/lh/Documents/HealthCareReform/ACA/Issue%20Brief%201%20-%20Small%20Group%20Issues.pdf
10. North Carolina Exchange Establishment Level I: Project Narrative. North Carolina Department of Insurance. December 19, 2012.http://www.ncdoi.com/Smart/Documents/November%202012%20Level%20One%20Exchange%20Establishment%20Cooperative%20Agreement%20Application.pdf
11. Analysis of Benchmark Plan Options for the Essential health Benefits Package in North Carolina. Prepared for the Dept. of Insurance. May 14, 2012. Oliver Wyman and Manatt Health Solutions.http://www.ncdoi.com/lh/Documents/HealthCareReform/Analysis%20of%20Benchmark%20Plan%20Options%20Study%20Report.pdf
12. North Carolina Affordable Insurance Exchange Grants Awards Listhttp://cciio.cms.gov/archive/grants/states-exchanges/nc.html
Also of interest
Provided by the Henry J. Kaiser Family Foundation