North Carolina Health Insurance

Health insurance plays a pivotal role in an individual’s life. With the rising healthcare costs, it is wise to assess all your future risks and its effect on your financial standing. Purchasing suitable health insurance coverage for your family is definitely expensive; however, health coverage should be your top priority to save you from unexpected medical costs. More than 47 million Americans are uninsured, majority of whom are the working families. These families, especially children, have to pay the price of the lack of proper health coverage. For those families who are not covered under their employers’ group plan, there are low-cost state sponsored health insurance programs.

According to the United Health Foundation’s 2008 Health Rankings, North Carolina has steadily maintained its 36th spot since last three years. However, the state struggles to battle against high percentage of children under the age of 18 in poverty, the high prevalence of smoking, high infant mortality rate and high rate of uninsured population. The state of North Carolina, having the population of more than eight million residents, boasts of both private-market and public health insurance alternatives. The private-market health insurance comprises of numerous types of health plans including family, Medicare supplemental, short-term, student, group and dental. Additionally, the state and federal government sponsored programs provide low-priced health coverage to the uninsurable residents of North Carolina who meet specific eligibility requirements such as age, income, etc.

The North Carolina Department of Insurance is in charge for regulating all types of insurance sold in the state of North Carolina including health insurance policies offered by private-market health insurers or public health coverage programs. However, approximately 17.2% of the population remains uninsured; this is the biggest debate among the North Carolina lawmakers. According to the Censor Bureau’s 2007 and 2008 Current Population Survey, approximately 34.2% uninsured North Carolinian residents come under the above 200% FPL category.

Choosing a health plan is not as easy as it used to be before. To secure your family’s medical and financial future and to maximize on the benefits of appropriate health insurance, get in touch with a licensed health insurance agent/broker in your region.

Individual/Family Health Insurance

Below is the guidelines for applying for and obtaining individual health insurance in the state of North Carolina. These regulations apply to all insurance companies offering individual or family health insurance in North Carolina.

Medical Underwriting Yes
Pre-Existing Condition Exclusion Period 12 months
Look Back Period 12 months
Look Back Standard Objective
Mandatory Benefits Cancer screening for women including breast, ovarian and cervical cancer screening, IP mastectomy stay as determined by the physician, reconstructive surgery after mastectomy, direct access to OB/GYNs, osteoporosis screening, eating disorder parity
Market Rate Restrictions None
Guaranteed Issue Options None

Small Group Health Insurance

Below is the guidelines for small group health insurance in the state of North Carolina. These regulations apply to all insurance companies offering small group health insurance in North Carolina:

Small Group Size 1-50
Employee Qualifications Two employees must work for at least 6 months out of the year, and work 20 hours per week
Guaranteed Issue Yes
Premium Rating Factors Rate Bands
Rate Adjustment Factors 20%
Look-Back Period 6 months
Pre-existing condition exclusionary period 12 months
Mandatory Benefits Same as individual

State Cobra Variations for Small Groups

Below are the COBRA guidelines for small groups in the state of North Carolina. For employer groups of more than 20 employees, refer to the federal COBRA guidelines:

Mini-Cobra Option Yes
Eligible Group Sizes 2-19
Extension of Benefits Period – Standard 18 months
Extension of Benefits Period – Disabled 18 months
Maximum Premium Increase 102%
State Legislation Reference Article 53 of Chapter 58 of North Carolina General Statutes
Additional Notes Notification of election to enroll must be made within 60 days.

State Sponsored Health Insurance Programs

There are several state sponsored health insurance programs in the State of North Carolina to assist those without insurance in obtaining adequate coverage.

High-Risk Pools

Some states offer special state sponsored health insurance plans for qualified persons that are not eligible for individual health insurance due to pre-existing medical conditions. The guidelines for enrollment in these programs vary by state. The high-risk pool in the State of North Carolina is summarized in the chart below:

Plan Name North Carolina Health Insurance Risk Pool (NCHIRP) or Inclusive Health
Phone Number 866-665-2117
HIPPA Eligibility Required? Yes
Available Carriers MedCost
Pre-Existing Condition Waiting Period 6 months
Enrollment Periods Currently Open to New Enrollment
Premium Limits Between 150% to 200% of standard rate
Lifetime Maximum Benefit $ 1 million
Special Notes To be eligible, you should not have access to group coverage as an employee or as a dependent of an employee; you should not qualify for a government program such as Medicare or Medicaid; you must be federally-qualified, HIPAA-eligible individual

Children’s Health Insurance Program

Through shared funding from the federal government, the State of North Carolina provides health insurance for uninsured children that meet certain eligibility guidelines. A summary of this program is outlined in the chart below:

Program Name North Carolina Health Choice
Phone Number 800-662-7030, 919-855-4400
Apply Online Yes
Age Limits Under 19 (21 in some cases)
Insurance Carrier Blue Cross Blue Shield of North Carolina
Length of Coverage 12 months
Residency Requirements North Carolina resident and U.S. citizen, qualified immigrants
Other Eligibility Requirements The child must not be eligible for Medicaid
Family’s monthly income must be equal to or less than 200% of FPL.
Pre-Existing Condition Exclusions None
Cost $0-$100 enrollment fee; $1-$20 co-pays depending on service; $1 for generic or brand name drugs ($3-$10 for a brand name drug for which there is a generic version available)


Medicaid is a state program partially funded through the federal government. Qualification guidelines, as well as the types of people that are eligible, will vary by state. The chart below provides a summary of the Medicaid programs in the State of North Carolina:

Governing Agency NC Department of Health and Human Services
Phone Number 800-662-7030, 919-855-4400
Residency Requirements North Carolina resident and U.S. citizen, qualified immigrant
Federal Poverty Line Income Limits Pregnant women and infants age 0-1: 185% FPL
Children (ages 1-5): 200% FPL,
ages 6-19: 100% FPL (also aged, blind and disabled)
SSI recipients: 74% FPL
Working parents with incomes up to 57% FPL, non-working parents up to 42% FPL
Medically Needy Individual: 34% FPL
Medically Needy Couple: 3% FPL

Additional Resources

North Carolina Health Care Options Matrix™ Guide

Provided by the Foundation for Health Coverage Education, the guide is a quick reference guide prepared by the non-profit Foundation for Health Coverage Education that outlines North Carolina’s public and private health care choices for individuals and groups with various demographic profiles.

Family Health Insurance Guide by

The guide created by provides useful information regarding health insurance coverage such as individual/family health insurance, group health insurance, separate child health insurance and state-sponsored programs that are available for low to middle income families.

North Carolina: At-A-Glance

Provides all-inclusive health data of North Carolina. is a project of the Henry J. Kaiser Family Foundation and is designed to provide free, up-to-date, and easy-to-use health data on all 50 states.