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Small Business Health Benefit Plans

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									                                                        NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                           LIFE AND HEALTH DIVISION CHECKLIST

COMPANY NAME:                                                                                                                                                 Rev. 11/17/09

NAIC Code (#####):

Lead Form #:


   REVIEW
REQUIREMENTS REFERENCE                                                     COMMENTS                                                          REFERENCE

                                                                                                                                         Please specify location
                                                                                                                                    (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                explanation for an N/A response. If the
                                                                                                                                cell contains X's - then the issue is FYI.


                                              ITEMS RELATED TO NEW LEGISLATION ARE SHOWN IN BLUE.

FORMS
                                      The Standard and Basic plans have 5 versions, which include the Basic Indemnity,
                                      Standard Indemnity, Standard PPO, Basic HMO and Standard HMO. Please refer to
                                      the Deparment's web-site to obtain copies of the Outlines to be used when preparing
                     NCGS 58-50-125                                                                                                             XXXXX
                                      these forms. Please note that the outlines provide a detailed list of benefits and
                                      exclusions which must be included in the forms. Please refer to the outline when
                                      preparing the forms.

                                      A small employer carrier shall make an election under NCGS 58-50-125 or NCGS 58-
                                      50-126 pursuant to NGCS 58-50-127. The election required under NCGS 58-50-127
                     NCGS 58-50-126
                                      shall be submitted by February 1st and shall be in effect for a two year period.                          XXXXX
                     & 58-50-127
                                      Contact the Life & Health Division at landhdivision@ncdoi.net for a copy of the
                                      election form.


                                      Pursuant to the NC Revised Uniform Arbitration Act as found in NCGS 1-569.1 et
                                      seq., an arbitration decision can be confirmed, modified, denied, or vacated by a trial
                                      court. Please amend your arbitration provision to include a statement to this effect.
                     NCGS 1-569.1
                                      Suggested language is as follows: "You should be aware and understand that you
                                      may be giving up certain rights to have your dispute settled in and by a court of law,
                                      unless the law in your state provides for judicial review of arbitration proceedings."



                                                                                PAGE 1
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                           REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.


                                The definition of medically necessary must be a verbatim reproduction of the
                                statutory definition. The Department has taken the position that the statutory
                                definition governs any decision by an insurer to reimburse for a covered medically
                                necessary service. Basically, a covered service meeting the criteria as outlined in
               NCGS 58-3-200(b) NCGS 58-200(b) is an eligible charge. The contract language may not have any
                                language implying the insurer determines medically necessary services. Also,
                                contract language providing further clarification of the definition (i.e. services ordered
                                by a physician may not be considered medically necessary) must be separated by at
                                least three line spaces from the definition text.

               NCGS 58-50-         A definition of a small employer must be included in the policy and certificate. The
               110(22)             statutory definition must be followed as closely as possible.

               NCGS 58-50-         A definition of a self-employed individual must be included in the policy and
               110(21a)            certificate. The statutory definition must be followed as closely as possible.
                                   A definition of an eligible employee must be included in the policy and certificate.
               NCGS 58-50-         The statutory definition must be followed as closely as possible. The maximum
               110(10)             number of hours that an eligible employee must work in order to be eligible is 30
                                   hours per week on a regular basis.

               NCGS 58-50-         A definition of a late enrollee must be included in the policy and certificate. The
               110(14)             statutory definition must be followed as closely as possible.

               NCGS 58-50-
                                   Contains the standards for participation and contribution requirements.
               130(a)(4a)
                                   A provision explaining the penalties for late enrollment as specified in the statute
               NCGS 58-50-
                                   must be included in the policy and certificate. Only the penalties listed in the statute
               130(a)(4b)
                                   are permitted.




                                                                              PAGE 2
                                                   NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                      LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                      REFERENCE

                                                                                                                                Please specify location
                                                                                                                           (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                       complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                       explanation for an N/A response. If the
                                                                                                                       cell contains X's - then the issue is FYI.


                                 The rate revision provision must indicate that both initial and renewal rates are
               NCGS 58-50-       guaranteed for 12 months. A statement that changes related to the increasing age of
               130(b)(3)         an insured member of the group (attained age rate changes) will only be
                                 implemented at the plan anniversary following the change in age is required.

               NCGS 58-50-40     A written notice must be given to the insurance fiduciary stating the fiduciary
               and 58-50-45      responsibilities.

                                 Requires extension of eligibility for mentally retarded or physically handicapped
               NCGS 58-51-25
                                 children.


                                Pursuant to NCGS 58-51-25(b) as adopted in House Bill 1183 effective October
                                9, 2009, a health benefit plan that provides coverage of a dependent child shall
                                terminate upon a change in enrollment status of the child in a post-secondary
                                educational institution shall provide for the continued eligibility of the
               NCGS 58-51-25(b) dependent child during a medically necessary leave of absence from the
               - Michelle's Law educational institution in accordance with all applicable requirements of
                                federal Public Law 110-381, known as "Michelle's Law." Amend your form
                                accordingly. In addition, provide a certification signed by an officer of the
                                company that the plan's provisions related to this issue are in compliance with
                                the applicable standards of the federal law.




                                                                           PAGE 3
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                          REFERENCE

                                                                                                                                     Please specify location
                                                                                                                                (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                            complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                            explanation for an N/A response. If the
                                                                                                                            cell contains X's - then the issue is FYI.


                                  Provides the requirements for coverage for newborn infants, foster children, children
                                  covered due to a court or an administrative order, and adoptive children. The
                                  general statutes also requires the coverage of congenital defects or anomalies for
                                  this specific group of children. For NCGS 58-51-30 and 58-51-125, children must be
                                  covered from the moment of birth or date of placement if NO additional premiums
               NCGS 58-51-30,
                                  are required. If additional premiums are required to enroll the children, the member
               58-51-120, and 58-
                                  must pay the required premium by the stated enrollment period to avoid the
               51-125
                                  application of a late enrollee provision; such as non-coverage of pre-existing
                                  condition. For NCGS 58-51-120, the enrollment period is waived when a parent is
                                  required to enroll a child due to an administrative or a court order. Also, the section
                                  prohibits the contract from requiring the child be claimed as dependent on federal
                                  income tax return or requiring the child reside with the parent.

                                  Provides the requirements for coverage for newborn infants, foster children, children
                                  covered due to a court or an administrative order, and adoptive children. The
                                  general statutes also requires the coverage of congenital defects or anomalies for
                                  this specific group of children. For NCGS 58-51-30 and 58-51-125, children must be
                                  covered from the moment of birth or date of placement if NO additional premiums
               NCGS 58-51-30,
                                  are required. If additional premiums are required to enroll the children, the member
               58-51-120, and 58-
                                  must pay the required premium by the stated enrollment period to avoid the
               51-125
                                  application of a late enrollee provision; such as non-coverage of pre-existing
                                  condition. For NCGS 58-51-120, the enrollment period is waived when a parent is
                                  required to enroll a child due to an administrative or a court order. Also, the section
                                  prohibits the contract from requiring the child be claimed as dependent on federal
                                  income tax return or requiring the child reside with the parent.




                                                                            PAGE 4
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                            REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.


                                  Provides for enrollment of a child because a parent is required by a court or
                                  administrative order to provide health benefit plan cover for a child. The enrollment
                                  period is waived when a parent is required to enroll a child due to an administrative or
               NCGS 58-51-120
                                  a court order. The section also prohibits the contract from requiring the child be
                                  claimed as dependent on federal income tax return or requiring the child reside with
                                  the parent.


                                  Adopted children shall be treated as newborn infants from the moment of placement
               NCGS 58-51-125     in the adoptive home regardless of whether or not a final decree of adoption has
                                  become final.

                                  Effective 10/1/01, the group policy/certificate must indicate that the employee or
                                  member may elect continuation for a period of not fewer than 60 days after the date
               NCGS 58-53-10      of termination or loss of eligibility. The employee or member shall make the first
                                  contribution upon the election to continue coverage, and the coverage shall be
                                  retroactive to the date of termination or loss of eligibility.

               NCGS 58-53-45     Outlines requirements for conversion privileges. The certificate must contain an
               through 58-53-115 explanation of conversion rights.


                                  Contains the statutory definition of a preexisting condition. Particular attention should
               NCGS 58-68-
                                  be paid to the ending date for the “look back” period - it should be the enrollment date
               30(a)(1)
                                  of the individual and should be no longer than 6 months.

                                  Contains the statutory limitations on exclusion of preexisting conditions. The period
               NCGS 58-68-        cannot be longer than 12 months except in the case of late enrollees (as defined in
               30(a)(2)           NCGS 58-68-30(b)(2)) who may have up to an 18-month preexisting condition
                                  exclusion.



                                                                            PAGE 5
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                             REFERENCE

                                                                                                                                         Please specify location
                                                                                                                                    (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                explanation for an N/A response. If the
                                                                                                                                cell contains X's - then the issue is FYI.

                                  The preexisting condition portability provision should refer to a reduction in the
                                  preexisting condition exclusion period for the aggregate of the periods of creditable
               NCGS 58-68-        coverage applicable to the individual as of the enrollment date as long as there has
               30(a)(3)           not been a significant break in coverage as defined in NCGS 58-68-30(c)(2)a, i.e., a
                                  63 day period during all of which the individual was not covered under any creditable
                                  coverage.

               NCGS 58-68-        Contains the statutory definition of enrollment date. Enrollment date is defined as “the
               30(b)(1)           date of enrollment, or if earlier, the first day of the waiting period for the enrollment.”

                                   The definition of a late enrollee for a large employer group accident and health
               NCGS 58-68-         insurance plan (51 or more eligible employees) must comply with NCGS 58-68-
               30(b)(2) and 58-50- 30(b)(2). The definition of a late enrollee for a small employer group accident and
               110(14).            health insurance plan (50 or less eligible employees) must comply with NCGS 58-68-
                                   30(b)(2) AND 58-50-110(14).

                                  The definition of creditable coverage must comply with NCGS 58-68-30(c)(1).
                                  Note that the definition was amended effective October 1, 2009 by House Bill
                                  1183. Amend your form accordingly. The Department suggest the following
               NCGS 58-68-
                                  be used in place of the term "a group health plan as defined in G.S. 58-68-
               30(c)(1)
                                  25(a)(4b)" as found in G.S. 58-68-30(c)(1)a.: "An employee welfare benefit plan
                                  to the extent that the plan provides medical care to employees and/or their
                                  dependents directly or through insurance, reimbursement, or otherwise."
                                  Language which indicates that a waiting period for any coverage under a group
               NCGS 58-68-
                                  health insurance plan shall not be considered a significant break in coverage must be
               30(c)(2)b
                                  included.




                                                                             PAGE 6
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                              REFERENCE

                                                                                                                                          Please specify location
                                                                                                                                     (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                 complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                 explanation for an N/A response. If the
                                                                                                                                 cell contains X's - then the issue is FYI.


                                  Language which indicates that time spent on a short term limited duration health
                                  insurance plan is not a significant break in coverage if the time spent on the policy is
               NCGS 58-68-        12 months or less should be included. Note that the Federal register does consider
               30(c)(2)c          short term limited duration major medical insurance as creditable coverage and
                                  therefore insureds should get credit for time spent on such coverage just like other
                                  types of creditable coverage.

                                  Insurer may elect to provide portability by the alternative method (based on classes
               NCGS 58-68-        or categories of benefits). If the insurer makes this election, they must disclose to
               30(c)(3)b          the employer the election and its affect at the time of the offer or sale of the
                                  coverage.


                                  The policy/certificate of coverage must include a statement in the creditable coverage
               NCGS 58-68-
                                  provision that indicates there is no time limit related to the presentation of a certificate
               30(c)(5)b
                                  of creditable coverage or other evidence of creditable coverage.


                                  A statement that newborn, foster, and adoptive children are not subject to a pre-
               NCGS 58-68-30(d)
                                  existing condition waiting period must be included.

               NCGS 58-68-        A statement that a pregnancy can never be considered a preexisting condition must
               30(d)(3)           be included.

                                A provision which explains what the certification of periods of creditable coverage is,
                                when the insurer will automatically provide it, and when the insured may request a
               NCGS 58-68-30(e)
                                copy must be included. The content, format and delivery of Certification of Period of
                                Creditable Coverage must comply with NCGS 58-68-30(k).




                                                                              PAGE 7
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                   COMMENTS                                                            REFERENCE

                                                                                                                                         Please specify location
                                                                                                                                    (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                explanation for an N/A response. If the
                                                                                                                                cell contains X's - then the issue is FYI.


               NCGS 58-68-
                                   A provision which outlines the special enrollment period for individuals losing other
               30(f)(1) and 58-68-
                                   coverage must be included. The individual must request enrollment within 30 days
               30(f)(1)c. (i)
                                   from the date of the triggering events.
               through (iii)

                                   A provision which outlines the special enrollment period for the eligible employee who
               NCGS 58-68-
                                   has not previous enrolled even though eligible, when they obtain a new dependent
               30(f)(2)
                                   must be included.

                                   A provision which outlines the special enrollment period for a new dependent
                                   (spouse, newborn or adoptee) as required by NCGS 58-68-30(f)(2)b. must be
               NCGS 58-68-         included. Coverage for the new dependent shall be as of the qualifying event if they
               30(f)(2)b           are enrolled within 30 days of the qualifying event. NOTE: Due to NCGS 58-51-30,
                                   this provision must include a period for foster children to be enrolled consistent with
                                   the period provided to newborn children.

                                   The policy/certificate of coverage must contain a statement in the special enrollment
                                   provision that indicates that if an individual requests enrollment while the individual is
               NCGS 58-68-
                                   entitled to special enrollment, the individual is a special enrollee even if the requests
               30(f)(3)a
                                   coincides with a late enrollment opportunity under the plan. Refer to NCGS 58-68-
                                   30(f)(3)a.

                                   A provision which outlines the special enrollment period for individuals whose
                                   eligibility for Medicaid or a State's Children's Health Insurance program has
                                   been terminated or who has become eligible for employment assistance under
                                   Medicaid or a State's Children's Health Insurance Pogram as found in NCGS 58-
               NCGS 58-68-
                                   68-30(f)(4) must be included. The provision should indicate that the individual
               30(f)(4)
                                   must request enrollment within 60 days from the date of the triggering events.
                                   Note that this special enrollment is 60 days and not the standard 30 days.
                                   Refer to G.S. 58-68-30(f)(4) as adopted in House Bill 1183, effective October 1,
                                   2009.

                                                                              PAGE 8
                                                        NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                           LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                    COMMENTS                                                         REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.


                                      A statement that the policy is renewable at the option of the employer except for the
               NCGS 58-68-45
                                      stated reasons must be included.

               NCGS 58-68-            The ability to terminate an employer’s plan because the employer is no longer a
               45(b)(1) through       member of an association is reserved for plans provided to bona-fide associations
               (5) and 58-68-         only. Therefore, plans for use with non-bona fide associations may not use this as a
               25(a)(1)               reason for termination.

               NCGS 58-68-            The renewability/termination provisions must comply with the exceptions to
               45(b)(1) through       guaranteed renewability. The exceptions should follow the language set out in the
               (6), 58-68-45(c)(1),   statute as much as possible. NOTE: The reference in NCGS 58-68-45(b)(3) should
               58-68-45(c)(2) and     say 58-68-40(d) instead of 58-68-40(e) and the reference in NCGS 58-68-45(b)(5)
               58-68-45(d)            should say 58-68-40(b)(1)a. instead of 58-68-40(c)(1)a.

                                      The contract provision must address the notice requirements of discontinuance of
               NCGS 58-68-45(c)
                                      coverage.

               T11 NCAC               Requires that complications of pregnancy must be covered as any other illness. A
               12.0323                non-elective cesarean section is considered a complication of pregnancy.


                                      Prohibits a contract from excluding coverage for work-related injuries or sickness
               T11 NCAC
                                      unless benefits are paid or payable under Chapter 97 of the General Statues of North
               12.0325
                                      Carolina. The words "paid or payable" must be used in the contractual language.


               T11 NCAC               Certificates issued under a group accident and health policy must contain all
               12.0511                exclusions that are set out in the master policy.

               T11 NCAC
                                      Provides a uniform order for the Coordination of Benefits Provisions.
               12.0514

                                                                               PAGE 9
                                                       NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                          LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                     COMMENTS                                                            REFERENCE

                                                                                                                                           Please specify location
                                                                                                                                      (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                  complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                  explanation for an N/A response. If the
                                                                                                                                  cell contains X's - then the issue is FYI.


               T11 NCAC              Group certificates containing an exclusion for pre-existing conditions must have
               12.0543               cautionary notice affixed to the face page.

               T11 NCAC              Policies or certificates subject to termination must display a cautionary notice on the
               12.0557               face page.

               T11 NCAC              Benefit contracts requiring precertification must contain a disclosure of penalties
               12.0559               assessed because the member failed to comply with precertification requirements.


                                     Policies and certificates issued for delivery to persons eligible for Medicare must
               T11 NCAC
                                     contain a notice printed or attached to the first page of the outline of coverage
               12.0843 and
                                     delivered to insureds under the policy; or if no outline of coverage is delivered, to the
               Section 17.E of the
                                     first page of the policy or certificate. The notice shall be in no less than 12 point type
               NAIC Medicare
                                     and shall contain the following language: "THIS [POLICY OR CERTIFICATE] IS
               Supplement
                                     NOT A MEDICARE SUPPLEMENT [POLICY OR CERTIFICATE]. If you are eligible
               Minimum
                                     for Medicare, review the Guide to Health Insurance for People with Medicare, which
               Standards Act
                                     is available from the company."

ADDITIONAL REQUIREMENTS FOR ARTICLE 51 SUBJECT INSURERS
               NCGS 58-38-           The statements “this is a legal contract” and "read your policy carefully" must appear
               20(a)(1)              on the cover, first, or insert page of the policy.
               NCGS 58-38-
                                     The policy must have an index (table of contents) of major provisions.
               20(a)(2)
               NCGS 58-38-30         A certified minimum Flesch Score of 50 is required to be submitted

               NCGS 58-51-
                                     The entire money and other considerations for the policy must be expressed therein.
               5(a)(1)




                                                                                PAGE 10
                                                 NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                    LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                              COMMENTS                                                         REFERENCE

                                                                                                                                 Please specify location
                                                                                                                            (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                        complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                        explanation for an N/A response. If the
                                                                                                                        cell contains X's - then the issue is FYI.


               NCGS 58-51-     The time at which the insurance policy takes effect and termination must be
               5(a)(2)         expressed therein.

               NCGS 58-51-     A definition of who is covered under the policy, including dependents and a definition
               5(a)(3)         of such, must be included in the policy.

                               The exceptions and reductions of indemnity must be included either with the benefit
               NCGS 58-51-
                               provision to which they apply or under an appropriate caption "EXCEPTIONS" or
               5(a)(5)
                               "EXCEPTIONS AND REDUCTIONS".
                               Each form, including riders, endorsements and applications, must be identified by an
                               unique form number located in the lower left-hand corner of the first page. A form
               NCGS 58-51-
                               number may not be used more than once; however, the form number may be
               5(a)(6)
                               amended with a suffix or revision date to distinguish it from a previously approved
                               version.

               NCGS 58-51-
                               An Entire Contract/Changes provision must be included in policy/certificate,
               15(a)(1)

                               A Time Limit on Certain Defenses provision must be included in policy/certificate.
               NCGS 58-51-
                               Fraudulent misstatments may not be contested in an accident only policy/certificate
               15(a)(2)
                               after the coverage has been in force for more than two (2) years.

               NCGS 58-51-
                               A Grace Period provision must be included in policy/certificate.
               15(a)(3)
               NCGS 58-51-
                               A Reinstatement provision must be included in polic/certificate.
               15(a)(4)
               NCGS 58-51-
                               A Notice of Claim provision must be included in policy/certificate.
               15(a)(5)
               NCGS 58-51-
                               A Claim forms provision must be included in policy/certificate
               15(a)(6)


                                                                        PAGE 11
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                        REFERENCE

                                                                                                                                    Please specify location
                                                                                                                               (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                           complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                           explanation for an N/A response. If the
                                                                                                                           cell contains X's - then the issue is FYI.

               NCGS 58-51-         A Proofs of Loss provision must be included in the policy and certificate. Note that
               15(a)(7)            the time period for submitting proof of loss is 180 days.
               NCGS 58-51-
                                   A Time of Payment of Claims provision must be included in policy/certificate.
               15(a)(8)
               NCGS 58-51-
                                   A Payment of Claims provision must be included in policy/certificate.
               15(a)(9)
               NCGS 58-51-
                                   A Physical Examinations and Autopsy provision must be included in policy/certificate.
               15(a)(10)

               NCGS 58-51-
                                   A Legal Actions provision must be included in policy/certificate.
               15(a)(11)

               NCGS 58-51-
                                   A Change in Beneficiary provision must be included in policy/certificate.
               15(a)(12)

                                The standard contractual provisions required by NCGS 58-51-15(a) and (b), or any
                                provisions used in lieu thereof, shall be printed in the consecutive order specified in
               NCGS 58-51-15(d) the statute, or as a unit provided that the resulting policy shall not be in whole or in
                                part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to
                                whom the policy offered, delivered or issued.

                                Effective October 1, 2009, pursuant to G.S. 58-51-15(i) as adopted in House Bill
                                1183, all certificates of coverage issued under group policies that are delivered
                                or issued for delivery in this State shall include the appropriate standard
               NCGS 58-51-15(i)
                                provisions as outlined in G.S. 58-51-15. This includes certificates of coverage
                                issued under policies issued and delivered to a trust or association outside of
                                this State that cover persons in this State.




                                                                            PAGE 12
                                                       NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                          LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                    COMMENTS                                                         REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.

                                     Insurers must afford coverage for active medical treatment in tax-supported
                                     institutions. This includes a prohibition against policies that exclude payment for
                  NCGS 58-51-40      charges of a duly licensed State tax-supported institution because of it being a
                                     specialty facility for one particular type of illness or because it does not have an
                                     operating room and relate equipment for the performance of surgery.

                  NCGS 58-51-80(g) All rate adjustments shall be proceeded by a 45-day notice to the policyholder.

                                     All policy cancellations, outside of the HIPPA notice requirements in NCGS 58-68-45,
                  NCGS 58-51-80(g)
                                     must be proceeded by a 45-day written notice to the policyholder.

                                     Requires the replacing insurer to cover all eligible members validly covered under the
                  NCGS 58-51-110
                                     prior plan upon the effective of the new benefit plan.
ADDITIONAL REQUIREMENTS FOR ARTICLE 65 SUBJECT INSURERS (MEDICAL SERVICE CORPORATIONS)
               NCGS 58-65-45  Changes in rates must be preceeded by a 30-day notice to the policyholder.

                  NCGS 58-65-60      Contains the required and prohibited provisions for subscriber contracts.

                  NCGS 58-66-        The statements “this is a legal contract” and "read your policy carefully" must appear
                  20(a)(1)           on the cover, first, or insert page of the policy.

                  NCGS 58-66-
                                     The policy must have an index (table of contents) of major provisions.
                  20(a)(2)

                  NCGS 58-66-30      A certified minimum Flesch Score of 50 is required to be submitted




                                                                               PAGE 13
                                                      NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                         LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                   COMMENTS                                                          REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.

ADDITIONAL REQUIREMENTS FOR ARTICLE 67 SUBJECT INSURERS (HMOs)
                  NCGS 58-67-
                                    Contains the required and prohibited provision for an evidence of coverage.
                  50(a)(3)
                  NCGS 58-67-       Effective 10/1/01, group rate revisions must be guaranteed for one year and at least
                  50(b)(3)          forty-five (45) days written notice must be given prior to a rate increase.

                  NCGS 58-67-85     Contains the required and prohibited provisions for master group contracts.

                  NCGS 58-38-       The statements “this is a legal contract” and "read your policy carefully" must appear
                  20(a)(1)          on the cover, first, or insert page of the policy.
              NCGS 58-38-
                             The policy must have an index (table of contents) of major provisions.
              20(a)(2)
              NCGS 58-38-30  A certified minimum Flesch Score of 50 is required to be submitted
MANDATED BENEFITS FOR STATUTORY PLANS
                                    The Statutory Plans developed under NCGS 58-50-125 are not required to provide
                                    coverage that meets the requirements of other provisions of Chapter 58 that
                  NCGS 58-50-       mandate either coverage or the offer of coverage by the type or level of health care
                                                                                                                                              XXXXX
                  125(c)            services or health care provider. Note: Pursuant to the plans' designs as approved
                                    by the Commissioner and/or specific statutory language, the plans may provide
                                    certain mandated benefits. Refer to the plans' designs for more information.

                  NCGS 58-50-       The Commissioner has the authority to give due consideration to cost-effective and
                                                                                                                                              XXXXX
                  155(b)            life-saving health care services in approving the Statutory Plans' designs.

                                    All Statutory Plans must follow the appropriate plan design for thebenefits provided,
                  NCGS 58-50-125    the levels and limitations on the benefits provided, the level of cost-sharing, and the                   XXXXX
                                    exclusions utilized.




                                                                             PAGE 14
                                                 NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                    LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                              COMMENTS                                                         REFERENCE

                                                                                                                                 Please specify location
                                                                                                                            (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                        complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                        explanation for an N/A response. If the
                                                                                                                        cell contains X's - then the issue is FYI.


                                All Statutory Plan submissions shall include a cross reference of the insurer's
               NCGS 58-50-125                                                                                                           XXXXX
                                exclusions with the appropriate plans' exclusions.

               NCGS 58-50-      All Standard plans shall provide coverage for mammograms and tests for cervical
               155(a)(1)        cancer screening.
               NCGS 58-50-
                                All Standard plans shall provide coverage for prostate-specific antigent (PSA) tests.
               155(a)(2)

                                All Standard plans shall provide coverage for reconstructive breast surgery resulting
               NCGS 58-50-
                                from a mastectomy. All Basic Plans must provide a similar benefit as required by
               155(a)(3)
                                the Federal Women's Health and Cancer Rights Act.

                                All Standard plans shall provide coverage for scientifically proven bone mass
               NCGS 58-50-
                                measurement for the diagnosis and evaluation of osteoporosis or low bone mass for
               155(a)(4)
                                all qualified individuals.

               NCGS 58-50-      All Standard plans shall provide coverage for prescribed contraceptive drugs or
               155(a)(5)        devices that prevent pregnancy.


               NCGS 58-50-      All Standard plans shall provide coverage for colorectal cancer examinations and
               155(a)(6)        laboratory tests.


               NCGS 58-50-      All Standard plans shall provide coverage for surveillance tests for women age 25
               155(a)(7)        and older at risk for ovarian cancer.




                                                                        PAGE 15
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                          REFERENCE

                                                                                                                                    Please specify location
                                                                                                                               (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                           complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                           explanation for an N/A response. If the
                                                                                                                           cell contains X's - then the issue is FYI.


                                  All Standard plans shall provide coverage for the treatment of mental illness that is
                                  at least equal to the coverage required by G.S. 58-3-220. Refer to the plan designs
               NCGS 58-50-
                                  as updated and approved by the Commissioner for guidance on the benefit
               155(a)(8)
                                  limitations. You may obtain a copy of the current plan designs from the Life & Health
                                  Division by sending an email to landhdivision@ncdoi.net.

                                  All Standard plans shall provide that a cancer drug approved by the FDA and
                                  prescribed for an unrelated cancer must be covered to the extent required by NCGS
               NCGS 58-50-156     58-51-59. Effective June 26, 2009, House Bill 986 amended the compendia
                                  referenced in the statute. If your form actually lists the compendia, please amend the
                                  form accordingly.

                                  Maternity coverage must be included in all Statutory Plans as provided in the plans'
               Maternity Benefits designs as approved by the Commissioner in July of 1996, or later amended. The
                                  benefits provided must comply with NCGS 58-3-169 and 58-3-170.

                                  Coverage for emergencies must be included in all Statutory Plans as provided in the
               Emergency
                                  plans' designs as approved by the Commissioner in July of 1996, or later amended.
               Benefits
                                  The benefits provided must comply with NCGS 58-3-190.

                                  The Basic Indemnity Plan shall provide coverage for oral contraceptives regardless
               Oral
                                  of their prescribed use as provided in the plan's design as approved by the
               contraceptives
                                  Commissioner in July of 1996, or later amended.

                                  The Standard Indemnity, Basic Indemnity and Standard PPO plans shall provide
               Voluntary Family   coverage for voluntary family planning services limited to tubal ligations and
               Planning           vasectomies as provided in the plans' designs as approved by the Commissioner in
                                  July of 1996, or later amended.




                                                                          PAGE 16
                                                   NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                      LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                        REFERENCE

                                                                                                                                  Please specify location
                                                                                                                             (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                         complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                         explanation for an N/A response. If the
                                                                                                                         cell contains X's - then the issue is FYI.

UTILIZATION REVIEW AND APPEALS PROCEDURES
                                  Statute contains the utilization review and appeals process requirements.
               NCGS 58-50-61      General authority for the placement of the information in the                                          XXXXX
                                  policy/certificate/evidence of coverage is found in NCGS 58-50-61(m).

                                  Contains definitions of terms associated with utilization review, appeals and
               NCGS 58-50-61(a)
                                  grievances. The statutory definitions must be followed as closely as possible.

                                A policy/certificate/evidence of coverage that contains UR requirements must include
                                a description of patient rights with respect to UR procedures as required under
               NCGS 58-50-61(d)
                                NCGS 58-50-61(m), including a right to a timely UR decision (within 3 business days
                                of receipt of all necessary information - NCGS 58-50-61(f))

               NCGS 58-50-61(d) A policy/certificate/evidence of coverage that contains UR requirements must include
               and (e)          a description of the insurers responsibilities in regard to utilization review.

                                A policy/certificate/evidence of coverage that contains UR requirements must include
               NCGS 58-50-61(d) a statement that the insurer will obtain all information required to make the UR
                                decision, including pertinent clinical information.
                                  A policy/certificate/evidence of coverage that contains UR requirements must include
               NCGS 58-50-
                                  a toll-free telephone number for members and providers to access the UR review
               61(e)(3)
                                  staff at all times the health benefit plan requires pre-certification
                                  A policy/certificate/evidence of coverage that contains UR requirements must include
               NCGS 58-50-
                                  a statement that the insurer will limit information requests to that information
               61(e)(4)
                                  necessary to certify the service in question.




                                                                          PAGE 17
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                          REFERENCE

                                                                                                                                      Please specify location
                                                                                                                                 (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                             complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                             explanation for an N/A response. If the
                                                                                                                             cell contains X's - then the issue is FYI.


                                A policy/certificate/evidence of coverage that contains UR requirements shall state
                                that the notification of UR decisions will be consistent with NC law and the
                                insurer's policies. The following must be conveyed in the forms: that decisions will
                                be provided within 3 days of receipt of all necessary information as required by
               NCGS 58-50-61(f)
                                NCGS 58-50-61(f); that certifications will be communicated to the provider; and that
                                noncertifications will be communicated to the provider and the covered person. An
                                insurer may utilize written or electronic confirmation of noncertification when
                                communicating with the insured.

                                   A policy/certificate/evidence of coverage that contains UR requirements must
               NCGS 58-50-         contain a description of the insurer's policies and procedures regarding failure
               61(e)(6)            or inability of a provider or covered person to provide information necessary to
                                   review process.

                                A policy/certificate/evidence of coverage that contains UR requirements must contain
                                a statement that, for concurrent reviews, the insurer remains responsible for health
                                care services until covered person has been notified of the noncertification (i.e.,
               NCGS 58-50-61(f) decertification does not become effective until notice is provided to the covered
                                person). The policy/certificate/evidence of coverage must specify how such a notice
                                will be effectuated (e.g., via facility staff, U.S. mail, hand delivery, etc.). The method
                                described should appear reasonably effective for accomplishing such notice.


                                A policy/certificate/evidence of coverage that contains UR requirements must contain
                                a statement that the insurer will provide retrospective review determinations within
               NCGS 58-50-61(g) 30 days of receipt of all necessary information and that written notice of
                                noncertifications will be provided to the provider and the covered person within 5
                                business days after the determination is made.




                                                                            PAGE 18
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                          REFERENCE

                                                                                                                                      Please specify location
                                                                                                                                 (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                             complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                             explanation for an N/A response. If the
                                                                                                                             cell contains X's - then the issue is FYI.


                                A policy/certificate/evidence of coverage that contains UR requirements which
                                includes an informal reconsideration process, then the form must indicate that the
                                informal process is voluntary, include a description of the process to be followed for a
               NCGS 58-50-61(i)
                                reconsideration and a statement that the process will be conducted between the
                                insured's provider and a medical doctor licensed to practice medicine in the State of
                                North Carolina as designated by the insurer.

                                A policy/certificate/evidence of coverage that contains UR requirements shall contain
                                a description of the noncertification appeal procedures. The description of the
                                procedure must clearly state that: the procedure is voluntary on the part of the
               NCGS 58-50-61(j)
                                member and that an appeal may be initiated and/or proposed by the covered person
                                or a person acting on behalf of the insured such as a relative or other representative
                                of the patient, including his/her provider

                                   If the insurer does not make the appeal procedure available for denials based solely
                                   on the basis that the health benefit plan does not provide benefits for the health care
                                   service in question where such exclusion is clearly stated in the policy form, then the
               NCGS 58-50-         policy form must clearly state this policy. Sample acceptable language: "The
               61(a)(13)           appeal process described in this section does not apply to noncertifications
                                   rendered solely basis that [the Plan] does not provide benefits for the health
                                   care services performed or being requested, as outlined in this [evidence of
                                   coverage]." Other language of similar impart is acceptable.

                                A policy/certificate/evidence of coverage that contains UR requirements shall contain
                                a description of the nonexpedited appeal process. The description of the
               NCGS 58-50-61(k)
                                procedure must clearly state that: the procedure is voluntary on the part of the
                                member and provide an explanation of the insurer's obligations.




                                                                            PAGE 19
                                                   NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                      LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                               COMMENTS                                                         REFERENCE

                                                                                                                                  Please specify location
                                                                                                                             (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                         complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                         explanation for an N/A response. If the
                                                                                                                         cell contains X's - then the issue is FYI.


                                A policy/certificate/evidence of coverage that contains UR requirements shall include
                                an explanation of the insurer's obligations with regard to nonexpedited appeals
               NCGS 58-50-61(k) including that within 3 business days of receipt of appeal request the insurer will
                                provide the name, address and phone number of the appeal coordinator and
                                instructions for submitting written material for consideration to the covered person.


                                A policy/certificate/evidence of coverage that contains UR requirements shall include
                                an explanation of the insurer's obligations with regard to nonexpedited appeals
               NCGS 58-50-61(k)
                                including providing a written notice of the appeal decision to the covered person (or
                                representative ) and the physician within 30 days of receipt of appeal request

                                A policy/certificate/evidence of coverage that contains UR requirements shall indicate
                                that an expedited appeal will be made available when a nonexpedited appeal “would
               NCGS 58-50-61(l) reasonably appear to seriously jeopardize the life or health of a covered person or
                                jeopardized the covered person’s ability to regain maximum function.” The quoted
                                language must be utilized in the plan document.
                                A policy/certificate/evidence of coverage that contains UR requirements shall contain
               NCGS 58-50-61(l) the insurer's requirements, if any, for medical justification for an expedited
                                appeal.

                                A policy/certificate/evidence of coverage that contains UR requirements must
               NCGS 58-50-61(l) disclose that the expedited review must take place in consultation with a
                                medical doctor.

                                A policy/certificate/evidence of coverage that contains UR requirements must
                                disclose that the decision on an expedited appeal shall be communicated in writing
               NCGS 58-50-61(l)
                                to the covered person and the provider as soon as possible but not later than 4 days
                                after receiving information justifying an expedited review.



                                                                          PAGE 20
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                         REFERENCE

                                                                                                                                   Please specify location
                                                                                                                              (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                          complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                          explanation for an N/A response. If the
                                                                                                                          cell contains X's - then the issue is FYI.


                                A policy/certificate/evidence of coverage that contains UR requirements must contain
                                a statement that for appeals of concurrent reviews, the insurer remains
                                responsible for health care services until covered person has been notified of the
                                determination on the appeal (i.e., decertification does not become effective until
               NCGS 58-50-61(l)
                                notice provided to covered person). The policy/certificate/evidence of coverage must
                                specify how such notice will be effectuated (e.g., via facility staff, U.S. mail, hand
                                delivery, etc.). Method described should appear reasonably effective for
                                accomplishing such notice.

                                A policy/certificate/evidence of coverage that contains UR requirements should
               NCGS 58-50-61(l) indicate whether or not expedited appeals are provided for retrospective
                                noncertifications.

                                  Pursuant to House Bill 744, effective October 1, 2003, NCGS 58-50-61(m) was
                                  amended to require the certificate of coverage and member handbook to include
                                  disclosure of the availability of assistance from the Managed Care Patient Assistance
               58-50-61(m) -
                                  Program (MCPAP). The contact information for MCPAP is: Managed Care Patient
               MCPAP
                                  Assistance Program, Consumer Protection Division, Office of Attorney General, PO
                                  Box 629, Raleigh, NC 27602. Phone: (919) 733-6272, (866) 867-6272 (Toll Free),
                                  (919) 733-6276 (fax)


                                  The Department has published a position paper on U. S. Department of Labor (DOL)
                                  Claim Rules. The document entitled “Guidance On North Carolina Law as Affected
               Department of
                                  by U. S. DOL Claims Rules” is available on the Department’s website,
               Labor Claims
                                  http://www.ncdoi.com/LH/News/Documents/USDOLClaimRules.pdf . Companies are
               Rules for ERISA
                                  expected to revise benefit contract language that conflicts with the DOL Claims
               Groups
                                  Rules. The changes were required as July 1, 2002, which is the effective date of the
                                  DOL Claims Rules.




                                                                          PAGE 21
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                         REFERENCE

                                                                                                                                    Please specify location
                                                                                                                               (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                           complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                           explanation for an N/A response. If the
                                                                                                                           cell contains X's - then the issue is FYI.

GRIEVANCE PROCEDURES
                                  Statute contains the requirements for an insurer's grievance procedures. General
                                  authority for requiring a description of the grievance process in the
                                  policy/certificate/evidence of coverage is found in NCGS 58-50-62(c) (a description of
                                  the grievance procedures shall be set forth in or attached to the certificate of
                                  coverage and member handbook). Any such “attachment” must be an endorsement
               NCGS 58-50-62                                                                                                               XXXXX
                                  to ensure that it is a legally binding part of the contract between the Health Benefit
                                  Plan and the covered person. Pursuant to the definition of "grievance" found in
                                  NCGS 58-50-61(a)(6), even plans that do not have any UR requirements must
                                  contain a grievance procedure since a grievance does not have to be related to
                                  a UR decision.

                                  A policy/certificate/evidence of coverage must contain a description of the
               NCGS 58-50-62(b)
                                  insurer's grievance process.

                                A policy/certificate/evidence of coverage must indicate that the grievance process is
               NCGS 58-50-62(b) available for review of any policy, decision or action of the insurer that affects
                                the covered person.

                                  A policy/certificate/evidence of coverage must indicate if the insurer has an
               NCGS 58-50-62(b)
                                  immediate, informal reconsideration process of a grievance.

                                  A policy/certificate/evidence of coverage must indicate that the grievance process
               NCGS 58-50-62(b)
                                  shall provide for first and second-level grievance reviews.
                                A policy/certificate/evidence of coverage that contains UR requirements, shall
               NCGS 58-50-62(b) indicate that appeals of noncertification appeal determinations shall enter the
                                grievance process as second-level grievances

                                  A policy/certificate/evidence of coverage must indicate that the grievance process is
               NCGS 58-50-62(c)
                                  voluntary.




                                                                           PAGE 22
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                          REFERENCE

                                                                                                                                     Please specify location
                                                                                                                                (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                            complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                            explanation for an N/A response. If the
                                                                                                                            cell contains X's - then the issue is FYI.


                                A policy/certificate/evidence of coverage must indicate the availability of the
                                Commissioner’s office for assistance, including telephone number and address of
                                Consumer Division. Sample acceptable language: "The North Carolina
               NCGS 58-50-62(c) Department of Insurance is available to assist insurance consumers with
                                insurance related problems and questions. You may inquire in writing to the
                                Department at 1201 Mail Service Center, Raleigh, NC 27699 or by telephone at
                                1-800-546-5664 “ (Other similar language will be acceptable.)

                                  A policy/certificate/evidence of coverage must include a description of the first level
               NCGS 58-50-62(e)
                                  grievance procedure.

                                A policy/certificate/evidence of coverage must indicate that a grievance must be
               NCGS 58-50-62(e) submitted by the covered person (includes insured and his/her authorized
                                representative) or the provider.

                                A policy/certificate/evidence of coverage must indicate whether the insurer permits
               NCGS 58-50-62(e) the covered person to attend the first level review. (The insurer does NOT have
                                to allow such attendance at the first level review.)

                                  A policy/certificate/evidence of coverage must indicate that the covered person may
               NCGS 58-50-62(e)
                                  submit written material for consideration by the first level reviewer(s).

                                A policy/certificate/evidence of coverage must indicate that within 3 business days of
                                receipt of the grievance, the insurer will provide the covered person the name,
               NCGS 58-50-62(e)
                                address and telephone number of the grievance coordinator and instructions
                                on submitting written material.

                                A policy/certificate/evidence of coverage must indicate that a written decision will be
               NCGS 58-50-62(e) issued to covered person and provider (if applicable) within 30 days of receipt of the
                                grievance.




                                                                           PAGE 23
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                          REFERENCE

                                                                                                                                     Please specify location
                                                                                                                                (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                            complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                            explanation for an N/A response. If the
                                                                                                                            cell contains X's - then the issue is FYI.


                                   A policy/certificate/evidence of coverage must include a description of the second
               NCGS 58-50-62(f)
                                   level grievance procedure.

                                A policy/certificate/evidence of coverage must indicate that the second level
               NCGS 58-50-62(f) grievance review is available to covered persons dissatisfied with the first level
                                grievance review or with a UR appeal decision.

                                A policy/certificate/evidence of coverage must indicate that within 10 days of receipt
               NCGS 58-50-62(f) of request for second level review, the insurer will provide the covered person with
                                information on the grievance process and the covered person's rights.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
               NCGS 58-50-62(f) of coverage shall indicate that the name, address and telephone number of the
                                grievance review coordinator will be provided to the covered person.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
               NCGS 58-50-62(f) of coverage shall indicate the covered person has a right to request and receive
                                from the insurer all information relevant to the case.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
               NCGS 58-50-62(f) of coverage shall indicate the covered person has a right to present his/her case to
                                the review panel.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
               NCGS 58-50-62(f) of coverage shall indicate the covered person has a right to submit supporting
                                material prior to and at the review meeting.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
               NCGS 58-50-62(f) of coverage shall indicate the covered person has a right to ask questions of any
                                member of the panel.




                                                                           PAGE 24
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                          REFERENCE

                                                                                                                                     Please specify location
                                                                                                                                (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                            complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                            explanation for an N/A response. If the
                                                                                                                            cell contains X's - then the issue is FYI.

                                As part of the explanation of the covered person's rights, a policy/certificate/ evidence
                                of coverage shall indicate the covered person has a right to be assisted or
               NCGS 58-50-62(f)
                                represented by a person of the covered person’s choosing, including a family
                                member, employer representative or attorney.
                                   A policy/certificate/evidence of coverage shall indicate that the second level
               NCGS 58-50-
                                   grievance review meeting will held within 45 days of receipt of the second level
               62(g)(1)
                                   review request.

               NCGS 58-50-         A policy/certificate/evidence of coverage shall indicate that the covered person will
               62(g)(2)            receive at least 15 days notice of the second level review meeting date.

                                   A policy/certificate/evidence of coverage shall indicate that the insurer will not
               NCGS 58-50-
                                   condition the covered person’s right to full review on his/her attendance at the
               62(g)(3)
                                   second level review meeting.

                                A policy/certificate/evidence of coverage shall contain a statement that the insurer's
               NCGS 58-50-62(h) written decision to the covered person and provider (if applicable) shall be issued
                                within 7 business days after the second level review meeting.

                                A policy/certificate/evidence of coverage shall include a statement that expedited
                                second level review is available whether or not initial review was expedited.
               NCGS 58-50-62(i)
                                The insurer shall provide for the expedited review when medically justified in
                                accordance with 58-50-61(l).

                                A policy/certificate/evidence of coverage must contain a statement that expedited
                                review will meet the requirements for non-expedited review as described in the
               NCGS 58-50-62(i)
                                insurer's grievance procedures and in accordance with NCGS 58-50-62(f), (g),
                                and (h) with changes to the time table.




                                                                           PAGE 25
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                 COMMENTS                                                         REFERENCE

                                                                                                                                    Please specify location
                                                                                                                               (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                           complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                           explanation for an N/A response. If the
                                                                                                                           cell contains X's - then the issue is FYI.

                                A policy/certificate/evidence of coverage must contain a statement that an
                                expedited second level review proceeding must take place and the decision
               NCGS 58-50-62(i)
                                communicated to covered person within 4 days of receiving all necessary
                                information.
                                A policy/certificate/evidence of coverage shall indicate that the expedited second
               NCGS 58-50-62(i) level review meeting may take place via conference call or through the
                                exchange of written information.
EXTERNAL REVIEW
                                  An insurer shall notify the covered person in writing of the covered person's right to
               NCGS 58-50-77      request an external review. The notice shall be as specified in statute and shall be
                                  submitted to L&H for informational purposes.

                                  An insurer shall include in the evidence of coverage an explanation of the exhaustion
               NCGS 58-50-79      of the internal grievance process and the impact of such on the rights to request an
                                  external review.

                                  An insurer shall include in the evidence of coverage a statement that a
                                  standard external review must be initiated with 120 days of the receipt of the
               NCGS 58-50-80
                                  notice required by NCGS 58-50-77. Note the change in the time period from 60
                                  day to 120 days as amended in House Bill 1183 effective Octobe 1, 2009.


                                  An insurer shall include in the evidence of coverage a statement explaining how a
               NCGS 58-50-82
                                  covered may request an expedited external review.




                                                                            PAGE 26
                                                 NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                    LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                              COMMENTS                                                          REFERENCE

                                                                                                                                  Please specify location
                                                                                                                             (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                         complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                         explanation for an N/A response. If the
                                                                                                                         cell contains X's - then the issue is FYI.

                               An insurer shall include a statement in the evidence of coverage that the external
                               review decision is binding upon the insurer and the covered person to the extent the
                               covered person has other remedies under applicable federal or State law. Also an
               NCGS 58-50-84   statement that a covered person may not file a subsequent request for an external
                               review involving the same noncertification appeal decision or second level grievance
                               review decision for which the covered person has already received an external
                               review decision.

                               Each insurer shall include a description of the external review procedures in or
                               attached to the policy, certificate, membership booklet, outline of coverage , or other
               NCGS 58-50-93
                               evidence of coverage it provided to covered persons. The statement shall include
                               the Department's address and phone number.




                                                                        PAGE 27
                                                NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                   LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                           COMMENTS                                                       REFERENCE

                                                                                                                            Please specify location
                                                                                                                       (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                   complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                   explanation for an N/A response. If the
                                                                                                                   cell contains X's - then the issue is FYI.


                                Pursuant to standards in Part IV of Article 50 (Health Benefit Plan External
                                Review) of Chapter 58 of the North Carolina General Statutes, all health benefit
                                plans must inform a covered person of their right to request an external review
                                of certain decisions made by their insurer. Your evidence of coverage /
                                certificate of coverage / policy form must include a description of the external
                                review process found in NCGS 58-50-75 through 58-50-95. To assist you in
                                complying with this requirement, the Department has developed model
                                language that provides the required information. You may find the model
                                language on the Department's website at
               NCGS 58-50-75-
                                www.ncdoi.com/ER/IndustryInfo/er_contract_model_language.asp . The
               58-50-95
                                Department will view forms using the suggested model language without
                                modification as complying with this requirement. You are not required to use
                                the model language and may develop your own. However, please note that the
                                use of language other than the suggested model language is subject to the
                                Department's interpretation and possible disapproval. Should you wish to
                                develop your own language, you are urged to review the model language to
                                understand what items to include and the type of explanation expected.
                                Please note that some of the time periods associated with External Review
                                were amended in House Bill 1183, effective October 1, 2009.




                                                                      PAGE 28
                                                       NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                          LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                    COMMENTS                                                          REFERENCE

                                                                                                                                        Please specify location
                                                                                                                                   (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                               complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                               explanation for an N/A response. If the
                                                                                                                               cell contains X's - then the issue is FYI.

GENERAL INFORMATION ONLY - FORMS
                              The business of insurance must be transacted in the full and complete licensed
              NCGS 58-3-50                                                                                                                     XXXXX
                              name.
                                     Requires that all forms must be submitted to and approved by the Commissioner
                                     prior to marketing, selling or issuing the insurance contract in this State. As used in
                  NCGS 58-3-150                                                                                                                XXXXX
                                     this section, form includes policies, certificates, applications, endorsements, riders,
                                     and amendments.
                                   Prohibits insurers from retracting coverage determinations. A health benefit plan is
                  NCGS 58-3-200(c) not permitted to have a disclaimer stating that “certification is not a guarantee of                        XXXXX
                                   benefits”.
                  NCGS 58-3-225(f) Outlines the requirements for submittal and prompt payment of claims.                                       XXXXX
                  NCGS 58-38-10 & Contract must be readable by a person of average intelligence, experience, and
                                                                                                                                               XXXXX
                  58-66-5          education.
                                     Adverse Underwriting Decision Notices must be approved by the Commissioner. The
                                     applicant has a right to the medical information used to decline coverage. The notice
                  NCGS 58-39-55                                                                                                                XXXXX
                                     must specifically contain references to the time frames contained in NCGS 58-39-
                                     55(b).

                                     Specifies when a health benefit plan (individual or group) is subject to the NC Small
                                     Employer Group Health Coverage Reform Act. A health benefit plan is subject to the
                                     act if any of the following conditions are met: 1) any part of the premiums or benefits
                                     are paid by a small employer or if any individual is reimbursed, through wages or
                  NCGS 58-50-115     otherwise, by a small employer for any portion of the premium; 2) the health benefit                      XXXXX
                                     plan is treated by the employer or any of the covered self-employed individuals as
                                     part of a plan or program for the purpose of sections 106, 125 or 162 of US Internal
                                     Revenue Code; or 3) the small employer or self-employed individual has permitted
                                     payroll deductions for the eligible enrollees for the health benefit plans.




                                                                               PAGE 29
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                             REFERENCE

                                                                                                                                         Please specify location
                                                                                                                                    (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                explanation for an N/A response. If the
                                                                                                                                cell contains X's - then the issue is FYI.


                                  Carriers are required to offer the Basic and Standard health plans to small employers
                                  and self employed individuals. (Please refer to the Department's outlines for the
                                  benefits and exclusions which must be included in the Basic and Standard health
                                  plans.) Also, please note that these plans must be approved as a condition of
               NCGS 58-50-125
                                  transacting small employer group business in North Carolina, pursuant to NCGS 58-                             XXXXX
               (a)
                                  50-125 (d). It is important to also note that if the insurer markets non-statutory PPO
                                  plans, a Standard PPO plan approved by the Department. An Indemnity carrier
                                  may be exempt from filing the PPO plan if they certify that they do not sell any
                                  PPO plans to small employers.

               NCGS 58-50-
                                  Contains the standards for participation and contribution requirements.                                       XXXXX
               130(a)(4a)

                                  Carriers must have the Basic and Standard Health benefit plans (the statutory plans)
               NCGS 58-50-
                                  approved as a condition of transacting small employer group health insurance                                  XXXXX
               125(d)
                                  business in this State.
               NCGS 58-50-
                                  A small employer carrier shall only issue “whole group coverage”.                                             XXXXX
               130(a)(6)

               NCGS 58-50-       The disclosure of certain information is available upon request pursuant to NCGS 58-
               130(d) and 58-68- 68-50 & 58-50-130(d). All advertising materials shall disclose the availability of the                         XXXXX
               50                information required by the statute.

                                  No health insurer shall take into account that an individual is eligible for or is provided
                                  medical assistance in this or any other state under Medicaid in insuring that individual
               NCGS 58-51-115                                                                                                                   XXXXX
                                  or making payments under its health benefit plan for benefits to that individual or on
                                  that individual's behalf.
                                  An employee terminated due to gross misconduct is entitled to continuation privileges
               NCGS 58-53-35      under North Carolina Law. Continuation privileges must be at least eighteen (18)                              XXXXX
                                  months.


                                                                             PAGE 30
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                        REFERENCE

                                                                                                                                  Please specify location
                                                                                                                             (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                         complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                         explanation for an N/A response. If the
                                                                                                                         cell contains X's - then the issue is FYI.


                                  Requires the conversion rate and adjustments to the conversion rate be filed with
               NCGS 58-53-60      and approved by the Commissioner. Outlines requirements for a conversion rate                          XXXXX
                                  filing and prohibits a rate revision more often than once a year.

                                Third Party Administrators (TPA) involved in the marketing and administration
                                of a plan must have a valid TPA license issued by the Commissioner. Note
                                that Pursuant to amendments to G.S. 58-56-26(c) as adopted in House Bill
               NCGS 58-56-51(a)
                                1183, as of July 1, 2010, all insurers who contract with third party                                     XXXXX
               and 58-56-26(c)
                                administrators, as defined in G.S. 58-56-2(5) shall annually file with the
                                Department a certification of completion of the audits required by G.S. 58-56-
                                26(c).

                                The notice relating to coverage under the NC Life & Health Guaranty
                                Association as required by G.S. 58-62-86 that was included in your submission
                                does appear to be consistent with the most recently approved notice as
               NCGS 58-62-86 & included in Bulletin 09-B-03 issued October 16, 2009. You may access the
                                                                                                                                         XXXXX
               Bulletin 09-B-03 bulletin and the revised notice on the Department's website at:
                                http://www.ncdoi.com/LS/ls_bulletins.asp . Insurers must use the amended
                                notice with affected policies that are delivered on or after December 15, 2009
                                (60 days after approval of the notice).
                                  Defines unfair methods of competition and unfair and deceptive acts or practices in
               NCGS 58-63-15      the business of insurance. This general statute also prohibits unfair discrimination                   XXXXX
                                  among classes of individuals

               NCGS 58-63-
                                   Prohibits the offering or arranging of extra-contractual benefits when the
               15(8), 58-33-85,                                                                                                          XXXXX
                                   inducements and rebates are provided at no cost or below their market value.
               and Bulletin 99-B-2




                                                                          PAGE 31
                                                      NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                         LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                   COMMENTS                                                              REFERENCE

                                                                                                                                           Please specify location
                                                                                                                                      (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                  complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                  explanation for an N/A response. If the
                                                                                                                                  cell contains X's - then the issue is FYI.


                                A written general notice regarding the plan’s preexisting condition exclusion must be
                                provided to participants as part of written application materials. If written application
                                materials are not utilized, the notice shall be provided by the earliest date following a
               NCGS 58-68-30(h)                                                                                                                   XXXXX
                                request for enrollment. Use of the sample language from the Final Regulations for
                                Health Coverage Portability as found in the Federal Register dated December 30,
                                2004 shall satisfy this requirement.


                                An individual notice of the period of any remaining pre-existing condition exclusion
                                must be provided to an indivdual after evidence of creditable coverage has been
               NCGS 58-68-30(i) provided. The notice by the earliest date following a determination that the group                                XXXXX
                                health insurer can provide the notice. The notice shall include the information
                                outlined in the statute.

                                   Employer group accident and health insurance plans shall not include any provision
                                   or statement which establish rules for eligibility for medical benefits for any individual
                                   based upon health status-related factors. Rules for eligibility include rules defining
                                   any applicable waiting period (or affiliation) for such enrollment and rules relating to
               NCGS 58-68-35       late and special enrollment. This also includes prohibitions on establishing different                         XXXXX
                                   premium payments or contribution for an individual based upon a health status-
                                   related factor. The insurer may “rate up” an entire group based upon underwriting but
                                   they cannot single out an individual with health status-related factors for a different
                                   premium because of those factors.

                                   Prohibition on the use of health status-related factors in establishing rules for
                                   eligibility or continued eligibility includes a prohibition on exclusion of services related
               NCGS 58-68-35                                                                                                                      XXXXX
                                   to or as a result of self-inflicted injuries when such injuries are caused by or related to
                                   a mental illness or condition.




                                                                              PAGE 32
                                                 NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                    LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                               COMMENTS                                                          REFERENCE

                                                                                                                                   Please specify location
                                                                                                                              (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                          complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                          explanation for an N/A response. If the
                                                                                                                          cell contains X's - then the issue is FYI.


                               All small group health plans are guaranteed-to-issue. A small employer carrier may
                               only refuse to issue a health benefit plan to a small employer for the reasons listed in
               NCGS 58-68-40   the statute. Any references to coverage being underwritten, issued at the option of                        XXXXX
                               the insurer, or any other provisions that might imply the coverage does not have to be
                               issued or that coverage is based upon health status related factors are prohibited.

                               The filing letter must include a unique identifying form number of each form
               T11 NCAC
                               submitted and it's descriptive title. A properly completed NAIC Adopted Uniform                            XXXXX
               12.0329(1)(d)
                               Transmittal Document will be accepted in lieu of a filing letter.
               T11 NCAC        All forms must be identified by a form number in the lower left-hand corner of the first
                                                                                                                                          XXXXX
               12.0329(3)(d)   page.
                               Alll variable text and benefit ranges in a form shall be identified by the use of
               T11 NCAC
                               brackets. An explanation of the limits and extent of variability for each bracketed                        XXXXX
               12.0329(3)(a)
                               area must be included
               T11 NCAC        Rates must be filed by age and mode of payment accompanied by an Actuarial
                                                                                                                                          XXXXX
               12.0329(3)(c)   Memorandum for each form requiring a premium.

                               A red-line comparison shall be provided with the initial submission of a form that is a
               T11 NCAC        revision of a previously approved form. The submission shall include a signed
                                                                                                                                          XXXXX
               12.0329(3)(g)   statement by an Officer of the Company certifying that no other changes, other than
                               those red-lined, were made to the form(s).

               T11 NCAC        If an application, rider or endorsement is filed separately, the policy form(s) with
                                                                                                                                          XXXXX
               12.0329(3)(b)   which the submitted form is to be used must be identified.
               T11 NCAC        The term "prudent person" or other terms of similar meaning are prohibited in
                                                                                                                                          XXXXX
               12.0317         defining a pre-existing condition.
               T11 NCAC
                               Prohibits subrogation in all health insurance policy forms.                                                XXXXX
               12.0319
               T11 NCAC        Prohibits HIV and AIDS discrimination and requires that HIV infection and AIDS must
                                                                                                                                          XXXXX
               12.0324         be treated at any other illness.


                                                                         PAGE 33
                                                        NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                           LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                     COMMENTS                                                         REFERENCE

                                                                                                                                        Please specify location
                                                                                                                                   (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                               complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                               explanation for an N/A response. If the
                                                                                                                               cell contains X's - then the issue is FYI.

                  T11 NCAC
                                      Contains regulations pertaining to small employer group health coverage.                                 XXXXX
                  12.1300, et seq
              T11 NCAC
                              The classing of eligible employees is prohibited.                                                                XXXXX
              12.1305(c)
GENERAL INFORMATION ONLY - ASSOCIATION PLANS
              NCGS 58-51-
                              Contains valid definitions of association groups.                                                                XXXXX
              80(b)(1a)

                                      If the employer coverage is provided through a non-bona-fide association of which
                  NCGS 58-68-
                                      the employer is a member, the plan must still comply with all of the HIPAA standards,                    XXXXX
                  25(a)(1)
                                      including the prohibition on discrimination based upon a health status-related factor.

                                      If the employer coverage is provided through a bona-fide association of which the
                                      employer is a member, then the plan must still comply with all of the HIPAA
                  NCGS 58-68-
                                      standards except NCGS 58-68-35 (discrimination based upon health status-related
                  25(a)(1) and 58-68-                                                                                                          XXXXX
                                      factor). The discrimination statute does not apply because the definition of a bona
                  35
                                      fide association requires that coverage be provided to all members (or individuals
                                      eligible for coverage through a member) regardless of health status-related factors.
PPO ISSUES
                  NCGS 58-3-176       All clinical treatment options must be discussed with the patient.
                                      Emergency services received from a non-participating provider must be treated as in-
                  NCGS 58-3-190
                                      network rate benefits.

                                      Outlines the insurer duties to disclose certain information upon request from plan
                  NCGS 58-3-191(b)
                                      participants and bona fide prospective participants.

                  NCGS 58-3-          Requires that the Prescription Drug Benefit must disclose the formulary listing
                  191(b)(4)           (including prior approval prescription drugs) is available upon request.




                                                                               PAGE 34
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                       REFERENCE

                                                                                                                                 Please specify location
                                                                                                                            (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                        complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                        explanation for an N/A response. If the
                                                                                                                        cell contains X's - then the issue is FYI.


                                The insured is entitled to receive covered services from out-of-network providers at
               NCGS 58-3-200(d) the in-network benefit level in cases where in-network providers are not able to meet
                                the health needs of the insured without an unreasonable delay.

                                  Contains the statutory requirements for marketing a PPO product, which
                                  include a requirement that insurers offering services on a fee-for-service or
               NCGS 58-50-56      discounted fee-for-service basis demonstrate compliance with regulations
               (b) through (h)    pertaining to provider networks. Note: Evidence of satisfactory completion of
                                  requirements of 11 NCAC 20.0100 through 20.0400 is a prerequisite
                                  requirement before the PPO health plan may be marketed in this State.


               NCGS 58-50-56(a) Contains the statutory definitions of terms related to PPO Plans.

                                  All PPO enrollees may obtain covered health care services from a provider who does
               NCGS 58-50-56(i)
                                  not participate in the PPO Plan.
GENERAL INFORMATION ONLY - PPO ISSUES
                                Requires a listing of participating providers be made available to insureds and
               NCGS 58-50-56(j) contracting parties. The listing must include participating physician assistants and                    XXXXX
                                their supervising physicians.

                                  Publications or advertisements of preferred provider benefit plans may not refer to
               NCGS 58-50-56(k)                                                                                                         XXXXX
                                  the quality or efficiency of the services of non-participating providers.

                                  Health insurers entering into contracts with health care providers for discounted
               T11 NCAC
                                  services or capitated negotiated fees shall base deductibles or copayments on the                     XXXXX
               12.0561
                                  negotiated fee or the ordinary charge if less than the negotiated fee.
GENERAL INFORMATION ONLY - RATES
               T11 NCAC           Rates must be filed by age and mode of payment accompanied by an Actuarial
                                                                                                                                        XXXXX
               12.0329(3)(c)      Memorandum for each form requiring a premium.

                                                                           PAGE 35
                                                     NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                        LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                  COMMENTS                                                           REFERENCE

                                                                                                                                       Please specify location
                                                                                                                                  (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                              complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                              explanation for an N/A response. If the
                                                                                                                              cell contains X's - then the issue is FYI.

                                   Small group health benefit plans must be rated utilizing the adjusted community
               NCGS 58-50-
                                   rating methodology found in the statute. The rates must be accompanied by an                               XXXXX
               130(b)
                                   actuarial certification.
                                   All group accident and health policy forms shall be accompanied by the premium
               NCGS 58-51-85                                                                                                                  XXXXX
                                   rates for the plan and shall be structured on an actuarially sound basis.
APPLICATIONS
                                   When a religious employer rejects coverage of contraceptive drugs and devices, the
               NCGS 58-3-178(e)
                                   enrollment application must have cautionary notice informing applicant.
                                   A notice of insurance information practices is required to be given to all applicants in
               NCGS 58-39-25
                                   connection with insurance transactions.

               NCGS 58-39-25       Contains the requirements for the notice of insurance information practices and the
               and 58-39-35        content of the disclosure authorization forms.

               NCGS 58-39-35(7) Specifies the length of time a signed authorization is valid.

                                   Questions regarding previous adverse underwriting notices or previous obtaining of
               NCGS 58-39-60       insurance through a residual market mechanism are prohibited unless the reasons
                                   for the previous decisions are also requested.

                                   Applications that contain the Acronyms AIDS or HIV must also contain a definition of
               T11 NCAC
                                   such abbreviations. The Life and Health Division will accept as a valid definition the
               12.0324
                                   full and proper phrase for which the acronym stands.
GENERAL INFORMATION ONLY - APPLICATIONS
                                   Collection of genetic information (including family medical history) prior to or
                                   in connection with enrollment, or for underwriting purposes, is prohibited for
               NCGS 58-3-215                                                                                                                  XXXXX
                                   plans pursuant to the Genetic Information Nondiscrimination Act as adopted
                                   by reference into G.S. 58-3-215(d) in House Bill 1183.

                                   The business of insurance must be transacted in the full and complete licensed
               NCGS 58-3-50                                                                                                                   XXXXX
                                   name.

                                                                             PAGE 36
                                                   NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                      LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                COMMENTS                                                         REFERENCE

                                                                                                                                   Please specify location
                                                                                                                              (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                          complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                          explanation for an N/A response. If the
                                                                                                                          cell contains X's - then the issue is FYI.


                                  Adverse Underwriting Decision Notices must be approved by the Commissioner. The
                                  applicant has a right to the medical information used to decline coverage. The notice
               NCGS 58-39-55                                                                                                              XXXXX
                                  must specifically contain references to the time frames contained in NCGS 58-39-
                                  55(b).

                                Adverse underwriting decisions may not be based in whole or in part upon the fact
               NCGS 58-39-65(1) of a previous adverse underwriting decision or the fact that an individual obtained                       XXXXX
                                insurance coverage through a residual market mechanism.

                                Adverse underwriting decisions may not be based in whole or in part on personal
               NCGS 58-39-65(2) information received from an insurance-support organization whose primary source                          XXXXX
                                of information is insurance institutions.

                                  Prohibits sex discrimination on applications. References to only certain genders
               T11 NCAC
                                  being required to fill out a question, or references to female or male are not                          XXXXX
               12.0304
                                  permitted.

               T11 NCAC           Applications may not contain a question asking if the applicant is in sound or good
                                                                                                                                          XXXXX
               12.0320            health unless the term is defined.

                                  Applications may not include questions related to membership in substance or
               T11 NCAC           chemical dependency support groups. The application may require the applicant to
                                                                                                                                          XXXXX
               12.0326(b)         complete questions related to actual medical treatment, confinement, or diagnosis of
                                  such conditions.

                                  Applications used in the solicitation of accident and health insurance on a mass
               T11 NCAC
                                  marketed basis may not require information one pre-existing conditions dating back                      XXXXX
               12.0506
                                  further than five years prior to the date of the application.




                                                                           PAGE 37
                                                    NORTH CAROLINA DEPARTMENT OF INSURANCE
                                                       LIFE AND HEALTH DIVISION CHECKLIST

   REVIEW
REQUIREMENTS REFERENCE                                                     COMMENTS                                                                     REFERENCE

                                                                                                                                                    Please specify location
                                                                                                                                               (Form/Page/Paragraph/Other) of
TYPE of FILING: SMALL GROUP STATUTORY PLANS - BASIC INDEMNITY, STANDARD INDEMNITY, STANDARD
                                                                                                                                           complying provision/language or attach
PPO, BASIC HMO, STANDARD HMO
                                                                                                                                           explanation for an N/A response. If the
                                                                                                                                           cell contains X's - then the issue is FYI.



                                A detailed reason or explanation as to why a requirement is not
                               applicable must be provided on a separate page for those
                               requirements referenced by N/A

                               I, the filer, acknowledge that I have prepared the submitted form(s) in
                               accordance with the checklist and to the best of my knowledge this file
                               is in substantial compliance with all of the above listed reference
                               point’s.


                               Signature of Filer                                                                                          Date

                               The Life and Health Division checklist is intended to expedite the Departments overall review time of new
                               form filings. The checklist serves as a basic guide to assist the Industry in preparation of new form
                               filings prior to submission. The checklist is not a substitute for Departmental review. All forms must
                               comply with State Insurance Law.




                                                                                 PAGE 38

								
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