GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1999

H	1 

HOUSE BILL 1813*

Short Title:  Expand NC Health Choice Elig.	(Public)

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Sponsors: Representatives Baddour; Alexander, Adams, Barefoot, Luebke, and Wainwright.

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Referred to:  Appropriations.

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May 30, 2000

A BILL TO BE ENTITLED
AN ACT TO EXPAND COVERAGE UNDER THE NORTH CAROLINA HEALTHCHOICE PROGRAM TO CHILDREN WHOSE FAMILY INCOME IS BETWEEN ONE HUNDRED EIGHTY-FIVE PERCENT AND THREE HUNDRED PERCENT OF THE FEDERAL POVERTY LEVEL; TO ENABLE CERTAIN PERSONS TO BUY COVERAGE UNDER THE NORTH CAROLINA HEALTHCHOICE PROGRAM; TO MAKE CONFORMING CHANGES TO THE GENERAL STATUTES; AND TO APPROPRIATE FUNDS FOR EXPANSION OF HEALTHCHOICE COVERAGE.
The General Assembly of North Carolina enacts:
Section 1.  G.S. 108A-70.18(8) reads as rewritten:
"§ 108A-70.18. Definitions.
As used in this Part, unless the context clearly requires otherwise, the term:
…
(8)	‘Uninsured' means the applicant for Program benefits is and was not covered under any private or employer-sponsored comprehensive health insurance plan for 60 days immediately preceding the date of application. The waiting periods required under this subdivision shall be waived if:
a.	The child has been enrolled in Medicaid and has lost Medicaid eligibility;
b.	The child has lost health care benefits due to cessation of a nonprofit organization program that provides health care benefits to low-income children;
c.	The child has lost employer-sponsored comprehensive health care coverage due to termination of employment, cessation by the employer of employer-sponsored health coverage, or cessation of the employer's business; or
d.	Health insurance benefits available to the family of a special needs child have been terminated due to a long-term disability or a substantial reduction in or limitation of lifetime medical benefits or benefit category. As used in this paragraph, ‘special needs child' has the definition applied in G.S. 108A-70.23(a)."
Section 2. G.S. 108A-70.21 reads as rewritten:
"§ 108A-70.21. Program eligibility; benefits; enrollment fee and other cost-sharing; coverage from private plans; purchase of extended coverage.
(a)	Eligibility. – The Department may enroll eligible children based on availability of funds. Following are eligibility and other requirements for participation in the Program:
(1)	Children must:
a.	Be under the age of 19;
b.	Be ineligible for Medicaid, Medicare, or other federal government-sponsored health insurance;
c.	Be uninsured;
d.	Be in a family that meets the following family income requirements:
1.	Infants under the age of one year whose family income is from one hundred eighty-five percent (185%) through three hundred percent (300%) of the federal poverty level;
2.	Children age one year through five years whose family income is above one hundred thirty-three percent (133%) through three hundred percent (300%) of the federal poverty level; and
3.	Children age six years through eighteen years whose family income is above one hundred percent (100%) through three hundred percent (300%) of the federal poverty level;
e.	Be a resident of this State and eligible under federal law; and
f.	Have paid the Program enrollment fee, premiums, and reenrollment penalties required under this Part.
(2)	Proof of family income and residency and declaration of uninsured status shall be provided by the applicant at the time of application for Program coverage. The family member who is legally responsible for the children enrolled in the Program has a duty to report any change in the enrollee's status within 60 days of the change of status.
(3)	If a responsible parent is under a court order to provide or maintain health insurance for a child and has failed to comply with the court order, then the child is deemed uninsured for purposes of determining eligibility for Program benefits if at the time of application the custodial parent shows proof of agreement to notify and cooperate with the child support enforcement agency in enforcing the order.
	   If health insurance other than under the Program is provided to the child after enrollment and prior to the expiration of the eligibility period for which the child is enrolled in the Program, then the child is deemed to be insured and ineligible for continued coverage under the Program. The custodial parent has a duty to notify the Department within 10 days of receipt of the other health insurance, and the Department, upon receipt of notice, shall disenroll the child from the Program. As used in this paragraph, the term "responsible parent”means a person who is under a court order to pay child support.
(4)	Except as otherwise provided in this section, enrollment shall be continuous for one year. At the end of each year, applicants may reapply for Program benefits.
(b)	Benefits. – Except as otherwise provided for eligibility, premiums, fees, deductibles, copayments, and other cost-sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan, including optional prepaid plans. Prescription drug providers shall accept as payment in full, for outpatient prescriptions filled, ninety percent (90%) of the average wholesale price for the prescription drug or the amounts published by the Health Care Financing Administration plus a fee established by the provider not to exceed the amount authorized under subsection (d) of this section. All other health care providers providing services to Program enrollees shall accept as payment in full for services rendered the maximum allowable charges under the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan for services less any copayments assessed to enrollees under this Part. No child enrolled in the Plan's self-insured indemnity program shall be required by the Plan to change health care providers as a result of being enrolled in the Program.
In addition to the benefits provided under the Plan, the following services and supplies are covered under the Health Insurance Program for Children established under this Part:
(1)	Dental: Oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, fluoride applications twice during a 12-month period, sealants, simple extractions, therapeutic pulpotomies, prefabricated stainless steel crowns, and routine fillings of amalgam or other tooth-colored filling material to restore diseased teeth. No benefits are to be provided for services under this subsection that are not performed by or upon the direction of a dentist, doctor, or other professional provider approved by the Plan nor for services and materials that do not meet the standards accepted by the American Dental Association.
(2)	Vision: Scheduled routine eye examinations once every 12 months, eyeglass lenses or contact lenses once every 12 months, routine replacement of eyeglass frames once every 24 months, and optical supplies and solutions when needed. Optical services, supplies, and solutions must be obtained from licensed or certified opthamologists, optometrists, or optical dispensing laboratories. Eyeglass lenses are limited to single vision, bifocal, trifocal, or other complex lenses necessary for a Plan enrollee's visual welfare. Coverage for oversized lenses and frames, designer frames, photosensitive lenses, tinted contact lenses, blended lenses, progressive multifocal lenses, coated lenses, and laminated lenses is limited to the coverage for single vision, bifocal, trifocal, or other complex lenses provided by this subsection. Eyeglass frames are limited to those made of zylonite, metal, or a combination of zylonite and metal. All visual aids covered by this subsection require prior approval of the Plan. Upon prior approval by the Plan, refractions may be covered more often than once every 12 months.
(3)	Hearing: Auditory diagnostic testing services and hearing aids and accessories when provided by a licensed or certified audiologist, otolaryngologist, or other hearing aid specialist approved by the Plan. Prior approval of the Plan is required for hearing aids, accessories, earmolds, repairs, loaners, and rental aids.
(c)	Annual Enrollment Fee. – There shall be no enrollment fee for Program coverage for enrollees whose family income is at or below one hundred fifty percent (150%) of the federal poverty level. The enrollment fee for Program coverage for enrollees whose family income is above one hundred fifty percent (150%) of the federal poverty level and at or below two hundred percent (200%) of the federal poverty level shall be fifty dollars ($50.00) per year per child with a maximum annual enrollment fee of one hundred dollars ($100.00) for two or more children. The enrollment fee shall be collected by the county department of social services and retained to cover the cost of determining eligibility for services under the Program. County departments of social services shall establish procedures for the collection of enrollment fees.
(c1)	Premiums. – Premiums shall be collected for enrollees whose family income is above two hundred percent (200%) of the federal poverty level and at or below two hundred fifty percent (250%) of the federal poverty level at the rate of twenty-five dollars ($25.00) per month per child or three hundred dollars ($300.00) per year per child.  Premiums shall be collected for enrollees whose family income is above two hundred fifty percent (250%) of the federal poverty level and at or below three hundred percent (300%) of the federal poverty level at the rate of thirty-five dollars ($35.00) per month per child or four hundred twenty dollars ($420.00) per year per child.  Families with two or more children shall pay the premium established for families with two children.  Premiums shall be collected through the Claims Processing Contractor of the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan.  Failure to pay premiums within 30 days of the due date shall result in disenrollment from the Program.  Families who lose benefits due to failure to pay premiums shall be denied reenrollment in the Program for a period of two months.  Coverage shall not be effective and claims shall not be paid for services rendered during the period for which premiums were not paid.  After the two months' disenrollment period, the family may reenroll in the Program as new enrollees upon payment of the reenrollment penalty plus the premium for the first month of reenrollment.  The reenrollment penalty is:
(1)	$50.00 for reenrollees whose family income is above two hundred percent (200%) and at or below two hundred fifty percent (250%) of the federal poverty level.
(2)	$70.00 for reenrollees whose family income is above two hundred fifty percent (250%) and at or below three hundred percent (300%) of the federal poverty level.
(d)	Cost-Sharing. –
(1)	There shall be no deductibles, copayments, or other cost-sharing charges for families covered under the Program whose family income is at or below one hundred fifty percent (150%) of the federal poverty level.
(2)	Families covered under the Program whose family income is above one hundred fifty percent (150%) of the federal poverty level and at or below two hundred percent (200%) of the federal poverty level shall be responsible for copayments to providers as follows:
	a.	Five dollars ($5.00) per child for each visit to a provider, except that there shall be no copayment required for well-baby, well-child, or age-appropriate immunization services;
	b.	Five dollars ($5.00) per child for each outpatient hospital visit;
	c.	A six-dollar ($6.00) fee for each outpatient prescription drug purchased;
	d.	Twenty dollars ($20.00) for each emergency room visit unless:
	1.	The child is admitted to the hospital, or
	2.	No other care was reasonably available as determined by the Claims Processing Contractor of the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan.
(3)	Families covered under the Program whose family income is above two hundred percent (200%) of the federal poverty level and at or below three hundred percent (300%) of the federal poverty level shall be responsible for copayments to providers as follows:
a.	Ten dollars ($10.00) per child for each visit to a provider, except that there shall be no copayment required for well-baby, well-child, or age-appropriate immunization services;
b.	Ten dollars ($10.00) per child for each outpatient hospital visit;
c.	Ten dollars ($10.00) per child for each outpatient prescription drug purchased;
d.	Fifty dollars ($50.00) for each emergency room visit unless:
1.	The child is admitted to the hospital, or
2.	No other care was reasonably available as determined by the Claims Processing Contractor of the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan.
Copayments required under this subsection for prescription drugs apply only to prescription drugs prescribed on an outpatient basis.
(e)	Cost-Sharing Limitations. – The total annual aggregate cost-sharing, including annual enrollment fees, or premiums with respect to all children in a family with an income at or below three hundred percent (300%) of the federal poverty level shall not exceed five percent (5%) of the family's income for the year involved. To assist the Department in monitoring and ensuring that the limitations of this subsection are not exceeded, the Executive Administrator and Board of Trustees of the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan shall provide data to the Department showing cost-sharing paid by Program enrollees.
(f)	Coverage From Private Plans. – The Department shall, from funds available for the Program, pay the cost for dependent coverage provided under a private insurance plan for persons eligible for coverage under the Program if all of the following conditions are met:
(1)	The person eligible for Program coverage requests to obtain dependent coverage from a private insurer in lieu of coverage under the Program and shows proof that coverage under the private plan selected meets the requirements of this subsection;
(2)	The dependent coverage under the private plan is actuarially equivalent to the coverage provided under the Program and the private plan does not engage in the exclusive enrollment of children with favorable health care risks;
(3)	The cost of dependent coverage under the private plan is the same as or less than the cost of coverage under the Program; and
(4)	The total annual aggregate cost-sharing, including fees, paid by the enrollee under the private plan for all dependents covered by the plan, do not exceed five percent (5%) of the enrollee's family income for the year involved.
The Department may reimburse an enrollee for private coverage under this subsection upon a showing of proof that the dependent coverage is in effect for the period for which the enrollee is eligible for the Program.
(g)	Purchase of Coverage. –Children whose family income is above three hundred percent (300%) of the federal poverty level and who are uninsured may be enrolled in the Program at full premium cost to be established by the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan.  The premium shall be actuarially determined based on actual experience of the members in the Program.  The same benefits, copayments, and penalty for nonpayment of premiums that apply to enrollees who have family incomes between two hundred percent (200%) and three hundred percent (300%) of the federal poverty level shall apply to this group.
(h)	No State Funds for Voluntary Participation. – No State or federal funds shall be used to cover, subsidize, or otherwise offset the cost of coverage obtained under subsection (g) of this section."
Section 3. G.S. 135-42 reads as rewritten:
"§ 135-42. Undertaking.
(a)	The State of North Carolina undertakes to make available a health insurance program for children (hereinafter called the ‘Program') to provide comprehensive acute medical care to low-income, uninsured children who are residents of this State and who meet the eligibility requirements established for the Program under Part 8 of Article 2 of Chapter 108A of the General Statutes. The Executive Administrator and Board of Trustees of the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan (hereinafter called the ‘Plan') shall administer the Program under this Part and shall carry out their duties and responsibilities in accordance with Parts 2 and 3 of this Article and with applicable provisions of Part 8 of Article 2 of Chapter 108A. The Plan's self-insured indemnity program shall not incur any financial obligations for the Program in excess of the amount of funds that the Plan's self-insured indemnity program receives for the Program.
(b)	The benefits provided under the Program shall be equivalent to and made available through the Plan pursuant to Articles 2 and 3 of this Chapter and as provided under G.S. 108A-70.21(b) and administered by the Plan's Executive Administrator and Board of Trustees. To the extent there is a conflict between the provisions of Part 8 of Article 2 of Chapter 108A and Part 3 of this Article pertaining to eligibility, fees, premiums, deductibles, copayments, and other cost-sharing charges, the provisions of Part 8 of Article 2 of Chapter 108A shall control. In administering the benefits provided by this Part, the Executive Administrator and Board of Trustees shall have the same type of powers and duties that are provided under Part 3 of this Article for hospital and medical benefits.
(c)	The benefits authorized by this Part are available only to children who are residents of this State and who meet the eligibility requirements established for the Program under Part 8 of Article 2 of Chapter 108A of the General Statutes."
Section 4.  G.S. 105-151.27(f) reads as rewritten:
"(f)	Definitions. – The following definitions apply in this section:
(1)	Comprehensive health insurance plan. – Any of the following plans, policies, or contracts that provide health benefits coverage for dependent children for inpatient and outpatient hospital services, physicians' surgical and medical services, and laboratory and X-ray services: accident and health insurance policy or certificate; hospital or medical service corporation contract; HMO subscriber contract; plan provided by a MEWA or plan provided by another benefit arrangement, to the extent permitted by ERISA, and the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan established under Part 3 of Article 3 of Chapter 135 of the General Statutes. "Comprehensive health insurance plan”does not mean any plan implemented or administered through the Department of Health and Human Services.
(2)	Dependent child. – A child under the age of 19 for whom the taxpayer is allowed to deduct a personal exemption under section 151(c)(1)(B) of the Code for the taxable year.
(3)	Family size. – The number of individuals for whom the taxpayer is entitled to deduct a personal exemption under the Code for the taxable year.
(4)	Health insurance premium. – An amount paid by the taxpayer for insurance coverage of the taxpayer's dependent children under a private or employer-sponsored comprehensive health insurance plan and an amount paid to purchase extended coverage or coverage under the Health Insurance Program for Children pursuant to G.S. 108A-70.21(g). The term does not include, however, amounts deducted from or not included in the taxpayer's gross income for the taxable year, as calculated in subsection (d) of this section. The term also does not include an amount paid for coverage under the Health Insurance Program for Children pursuant to G.S. 108A-70.21(c1)."
Section 5. There is appropriated from the General Fund to the Department of Health and Human Services the sum of one million four hundred thirteen thousand two hundred twenty-five dollars ($1,413,225) for the 2000-2001 fiscal year.  These funds shall be used to provide coverage for children under the North Carolina HealthChoice for Children Program whose family income is above two hundred percent (200%) and at or below three hundred percent (300%) of the federal poverty level, as enacted by this act.
Section 6. Section 5 of this act becomes effective July 1, 2000.  Health insurance coverage for children whose family income is above two hundred percent (200%) and at or below three hundred percent (300%) of the federal poverty level, as enacted by this act, shall become effective no earlier than October 1, 2000.  The remainder of this act is effective when it becomes law.