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North Carolina and Health Reform

The implementation of the Patient Protection and Affordable Care Act (PPACA) nationwide gave states two options: how to set up the health insurance exchange and whether or not to expand Medicaid. North Carolina took the Republican backseat on both choices, leaving thousands of low-income residents uninsured. Initially, the state began to move toward organizing a state-federal partnership exchange under the Governor Beverly Purdue, a Democrat, then a new governor took office and changed the course of the state’s exchange. Governor Pat McCrory, a Republican, decided against the partnership and opted for a federally-run exchange in February 2013, thus allowing the HHS and CMS to handle the majority of responsibilities, including enrollment through HealthCare.gov.

As for Medicaid expansion, Gov. McCrory signed a bill into legislation rejecting this portion of the law known as Obamacare. In doing so, he denied an approximate 500,000 low-income North Carolinians the right to low-cost health care, likely keeping them uninsured until a Democrat returns to office. Expanding the program under health reform would have allowed a new group to be eligible for Medicaid, adults who are currently unqualified due to not having children or a disability, and increases the income threshold for other groups. The program presently covers needy families, disabled persons, and the elderly.

The ACA has changed several aspects of health insurance since it was signed in 2010, creating limitations for insurers and protections for the insured. Over time, more consumer rights have been added in North Carolina. The laws with the largest impact become effective between 2014 and 2015, and will change insurance considerably. North Carolina insurers have been required to adopt various provisions that help policyholders stay covered, and a new addition to the individual and small group market has been created. Health reform regulations are not limited to insurers, however, as health insurance is mandatory for all North Carolina residents who can afford a plan.


Health Care Reforms in North Carolina: 2010-2013

Policyholders in North Carolina can benefit from the law preventing insurers to rescind benefits for any reason other than fraud, misrepresentation, or neglecting to pay premiums. If you are a responsible plan member, and you get sick while you have health insurance, the plan has no right to terminate your coverage. Young adults in the state can also stay covered for longer than they previously would, as the ACA extended dependent coverage from age 23 to 26. This right has helped insure thousands of North Carolinians since the law changed, making a large impact on this population.

Pre-existing conditions were also regarded slightly differently by insurers during the Obamacare transition period (pre-2014), permitting children up to age 18 to get insured no matter what medical problems they have. Although children could still have their premiums increased, an individual insurer was not allowed to reject them for coverage. Applicants over 18 with conditions were encouraged to enroll in the state risk pool, Inclusive Health, whose plans remained effective until 2014, when insurers became required to accept individuals with conditions regardless of age.

For those who have coverage through their job, risk pool, or an individual health plan, preventive care is now offered for free when using your health plan’s in-network providers. This portion of the law allows patients of all ages to receive annual exams, certain prescription medications, and a variety of screenings at no additional cost. The law also approved additional services for policyholders in the past several years, allowing them to stave off more illnesses and conditions through their health insurance, including pregnancy, cancer, and diabetes.


North Carolina Health Reform: 2014 and Later

North Carolina residents are required to enroll in health insurance or pay a penalty tax under the individual mandate, unless they cannot afford it or belong to a religion which is opposed to coverage. In order to make coverage more accessible for everyone subject to this tax, the individual health insurance market has a new facet offering financial assistance: the marketplace. While the exchange is facilitated by federal agencies, policies are sold by North Carolina insurers. Health plans are also available to small business owners in the state. Depending on your income, subsidies are provided to eligible applicants to reduce premium costs, and even medical expenses for some individuals.

To qualify for premium and cost sharing assistance, you must earn between 100 and 400 percent of poverty. The lower your income, the higher your subsidy amount. The exchange is highly beneficial to the state of North Carolina, especially due to its dense population of low-to-moderate income households.

In individual health insurance, many adjustments to underwriting have been made. Anyone can obtain coverage, and can only have their premiums increased if they are tobacco users or fall into a more expensive age group. Where you work, what conditions you have had, and what gender you are will not determine your premiums, as this is viewed as discriminatory. Insurers must comply with these guidelines and offer sufficient health insurance to all Americans.

On top of accepting more applicants, North Carolina insurance carriers must cover certain types of services in some of their policies. Ten categories of essential health benefits (EHBs) are covered by each insurance policy sold on the marketplace, and many individual plan outside of the marketplace.

As this is a basic outline of a long and detailed law, please view our additional resources explaining Obamacare.


Obamacare Links

Key Health Reform Provisions

Making Sense of the ACA

Obamacare Tax Provisions

ACA Out-Of-Pocket and Deductible Limits

Medicaid Expansion

HealthCare.gov History




1. Kaiser Health Reform. State Exchange Profiles: North Carolina.

2. Charlotte Observer. McCrory signs bill blocking Medicaid expansion.