FAQs About Health Insurance

There are many factors to determine what type of insurance you may qualify for and the type of insurance you had before you relocated. After relocating to NC, you have 60 days from the last day of coverage to find coverage in NC.

To start, you may want to contact the Federal Health Insurance Marketplace if you do not qualify for Medicaid and/or Medicare to see if you qualify for a subsidy to assist you with healthcare coverage.  The Federal Health Insurance Marketplace Consumer Call Center contact number is 1-800-318-2596.

If you do not qualify for a subsidy, there are several private insurance companies you may contact for information about health insurance depending on which county you are located. You may also contact an independent agent that can assist you in shopping around for benefit and quote information.

To find out if you qualify for a tax credit, you should contact the Federal Health Insurance Marketplace Consumer Call Center at 1-800-318-2596. If you qualify for a subsidy, your monthly premium amount will be reduced by your approved subsidy amount.  

The Department of Insurance Consumer Services Division can provide Customer Service contact information for the company so that you can advise them that you have not received your insurance cards.  They can be reached at 855-408-1212. You may also be able to print a temporary card directly from the health insurer’s website, as well as request a new/replacement card. If you continue to have trouble with receiving a card, you may fill out a request for assistance form with our office, so we can contact the company on your behalf.

Contact the company directly to confirm they have the correct policy and coverage in place for you as well as to discuss the discrepancy with you billing statement.  If you have done that and you still have an issue, we have a Request for Assistance form that you can complete that will allow an analyst to go to the company on your behalf.  You can access the form by contacting Consumer Services Division at 855-408-1212 or by submitting it electronically on the Department of Insurance website.

Viewing new policies may be delayed on the insurance company system.  We suggest that you contact your insurance carrier to confirm coverage is in place and verify when you will be able to view your policy online. If the company has advised that they do not have record of your policy, there could be several reasons why. If the policy was purchased through the Federal Marketplace, you would need to contact them directly at 800-318-2596 to check the status. If the policy was purchased outside of the Federal Marketplace, you can complete a Request for Assistance form with our office and a Life & Health Analyst will contact to the company on your behalf. 

North Carolina law provides consumers with a right to challenge or appeal your carrier's decision through an appeal and/or grievance. The Department can review your benefit determination notice with you and discuss your rights under North Carolina law as well as assist you with the appeal process. Call 855-408-1212 for assistance.  

Open enrollment is the annual period when you may enroll or change health insurance coverage. The coverage is guaranteed issue during this period. This is the only time that you may apply for major medical coverage, unless you have had a qualifying or life event such as marriage, birth of a child or loss of coverage. Contact the Federal Marketplace at 1-800-318-2596 for open enrollment dates.

Employer group plans may have different Open Enrollment period; therefore, you would need to check with your employer directly for those annual dates.

Most companies do not offer major medical insurance outside of open enrollment.  If there is a qualifying life event such as marriage, birth of a child or loss of coverage, this will allow a Special Enrollment Period (SEP). There may be some temporary plans that are available in the interim, however you need to get detailed info from the coverage providers to confirm that they will provide you what you need and that they are ACA compliant. 

Coordination of benefits is a method of coordinating benefits that are payable under more than one group health insurance plan so that the insurance benefits provided by multiple group plans do not exceed allowable medical expenses or eliminate patient incentives to contain cost. This only applies to group plans issued in North Carolina per NC Administrative code 11 NCAC 12 .0514. 

Self-funded plans and plans issued out of other states may also include a Coordination of Benefits clauses.

Embedded deductibles have two components: the individual deductibles for each family member and the total family deductible. When a family member meets his or her individual deductible, the insurance company will begin paying according to the plan’s coverage for that member. Once the total family deductible is met, all family members will have medical expenses paid according to the plan’s coverage, even if all family members have not met their own individual deductibles.

Group coverage can terminate as of the last day of employment (the day group eligibility ends.)  Options are to contact the Federal Marketplace regarding a SEP Special Enrollment Period or COBRA Continuation or the employer directly regarding State Continuation for groups less than 20.

COBRA - The Consolidated Omnibus Budget Reconciliation Act, more commonly known as COBRA, covers employees working for employers with 20 or more employees who lose coverage due to "qualifying events." Qualifying events include voluntary resignation from employment, layoffs and termination of employment, unless for gross misconduct. COBRA requires that employers notify employees within 14 days after the qualifying event that results in loss of coverage of the right to continue their medical coverage. Additional information regarding COBRA can be obtained at the US Dept. of Labor Employee benefits Security Administration (EBSA) at 866-275-7922.

State Continuation - Our state continuation laws allow terminated employees and members to continue coverage under their employer’s group health plan when they terminate employment or lose their eligibility under the plan. State Continuation applies to fully insured plans with less than 20 employees that are not governed by Federal COBRA Continuation Laws.

According to the Affordable Care Act, you are not eligible for a subsidy if your spouse’s employee only premium for the lowest priced plan that would cover the employee is 9.66% or less of the household income. 

The Affordable Car Act requires that major medical health insurance plans include certain services called Essential Health Benefits. Maternity and newborn care are considered an essential health benefit, no matter your gender.  Other required Essential Health Benefits are: Doctor Visits and other outpatient services, Emergency services, Hospitalization, Mental Health and Substance use disorder services, Prescription Drugs, Rehabilitative and Habilitative services and Devices, Laboratory services, Preventative services and Chronic disease management, Oral and Vision care for Children.

If you are turning 65 and must consider your health insurance options, contact the Seniors Health Insurance Information Program (SHIIP) to assist with educating on the steps needed to prepare for the initial enrollment into Medicare. They can be reached at 855-408-1212.