2010 North Carolina Code
Chapter 58 Insurance.
Article 50 - General Accident and Health Insurance Regulations.
58-50-190. Risk Pool rates and policy forms.

58‑50‑190. Risk Pool rates and policy forms.

(a) The Pool shall adopt and modify, as appropriate, rates, rate schedules, rate adjustments, expense allowances, agent referral fees, claim reserve formulas, and any other actuarial function appropriate to the operation of the Pool. Rates and rate schedules may be adjusted for appropriate factors such as age, sex, and geographic variation in claim cost and shall take into consideration appropriate rating factors in accordance with established actuarial and underwriting practices.

(b) The Pool shall determine the standard risk rate by considering the premium rates charged by other insurers offering health insurance coverage to individuals. The standard risk rate shall be established using reasonable actuarial techniques and shall reflect anticipated experience and expenses for the coverage. Pool rates shall be one hundred fifty percent (150%) to two hundred percent (200%) of rates established as applicable for individual standard rates and shall be adjusted annually, at the time of annual renewal.

(c) The Executive Director, with the approval of the Board and the Commissioner, may develop incentive programs with premium discounts. The Pool may provide for premium surcharges for covered individuals who are smokers. Premium surcharge rates shall be established by the Executive Director, in collaboration with the Board, subject to the approval of the Commissioner.

(d) Provider reimbursement rates under Pool coverage shall be limited to the rates allowed for providers under the Medicare Program for those services covered by Medicare. The Board shall establish reimbursement rates for services for which Medicare has not established an allowed rate. Providers rendering medical care to an insured shall accept payment of the amount established under this subsection, including any applicable deductible, coinsurance, or co‑payment amounts, as payment in full for services rendered.

(e) The Pool shall submit all premium rates and premium rate schedules and amendments to the Commissioner for approval. The Pool shall not use any premium rates, premium rate schedules, or amendments to the rates and schedules unless the Commissioner has approved them. The Commissioner, in evaluating the premium rates and premium rate schedules, shall consider the factors provided in this section. The Pool shall provide all individuals enrolled in the Pool with at least 45 days' notice of any change in Pool premium rates or premium rate schedules.

(f) The Pool shall submit all policy forms, riders, endorsements, and applications for coverage to the Commissioner for approval. The Pool shall not use any policy forms, riders, endorsements, or applications for coverages unless the Commissioner has approved them. Except for any provisions that are specifically treated otherwise under this Part, the provisions of this Chapter that apply to benefit plans and policy forms of health insurers generally shall apply to the benefit plans offered and policy forms used by the Pool. (2007‑532, s. 1.1.)