2012 North Carolina General Statutes
Chapter 58 - Insurance.
Article 50 - General Accident and Health Insurance Regulations.
Section 58-50-175 - Definitions.

58-50-175. Definitions.

The following definitions apply to this Part:

(1) "Administrator" The Pool Administrator selected by the Executive Director in accordance with this Part.

(2) "Benefit plan" The coverage offered by the Pool to eligible individuals.

(3) "Board" The Board of Directors of the Pool.

(4) "Commissioner" The Commissioner of Insurance of North Carolina or the Commissioner's authorized designee.

(5) "Covered person" Any individual resident of this State, excluding dependents, who is receiving or is eligible to receive medical care benefits from any insurer.

(6) "Creditable coverage" The same meaning as defined in G.S. 58-68-30(c)(1).

(7) "Dependent" A resident spouse, an unmarried child under the age of 19 years, a child who is a full-time student under the age of 23 years and who is financially dependent upon the parent or guardian, a child who is over 18 years of age and for whom a person may be obligated to pay child support, or a child of any age who is disabled and dependent upon the parent or guardian.

(8) "Executive Director" The individual selected by a majority vote of the Board members and hired to serve as the Executive Director of the Pool.

(9) "Federally defined eligible individual" The same meaning as the defined term "eligible individual" in G.S. 58-68-60(b).

(9a) "Fund." The North Carolina Health Insurance Risk Pool Fund.

(10) "Health insurance coverage" The same meaning as defined in G.S. 58-68-25(a)(5) but does not include benefits described in G.S. 58-68-25(b).

(11) "Insurance arrangement" The plan, program, contract, or other arrangement through which medical care is provided by an employer to its officers or employees but does not include medical care covered through an insurer.

(12) "Insured" An individual who is eligible to receive benefits from the Pool.

(13) "Insurer" Any entity, other than the Pool, that provides medical care benefits, including excess or stop-loss insurance, that covers medical care or administers medical care on any individual in this State. For the purposes of this Part, insurer includes:

a. An insurance company;

b. A hospital or medical service corporation;

c. A health maintenance organization;

d. A multiple employer welfare arrangement;

e. A third-party administrator or claims processor; and

f. Any other nongovernmental entity providing a health benefit plan subject to State insurance regulation.

Insurer does not include an entity to the extent the entity provides excepted benefits as defined in G.S. 58-68-25(b).

(14) "Medical care" All of the following:

a. The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;

b. Transportation primarily for and essential to medical care referred to in sub-subdivision a. of this subdivision; and

c. Insurance covering medical care referred to in sub-subdivisions a. and b. of this subdivision.

(15) "Plan of Operation" The articles, bylaws, and operating rules and procedures adopted by the Board in accordance with this Part.

(16) "Pool" The North Carolina Health Insurance Risk Pool.

(17) "Provider" An individual or entity that provides medical care to individuals residing in this State.

(18) "Resident" An individual who has legal status in the United States and who:

a. Has been legally domiciled in this State for a period of at least 30 days, except that for a federally defined eligible individual, there shall not be a 30-day requirement;

b. Is legally domiciled in this State on the date of application to the Pool and who is eligible for enrollment in the Pool as a result of the Health Insurance Portability and Accountability Act of 1996; or

c. Is legally domiciled in this State on the date of application to the Pool and is eligible for the credit for health insurance costs under section 35 of the Internal Revenue Code of 1986.

(19) Recodified as G.S. 58-50-175(9a).

(20) "Trade Adjustment Assistance Program" (TAA) Title II of the Trade Act of 2002, P.L. 107-210. (2007-532, s. 1.1; 2008-118, s. 3.2(a).)