§ 58-50-180. Risk Pool established; board of directors; plan of operation.
§ 58‑50‑180. RiskPool established; board of directors; plan of operation.
(a) There is herebycreated a nonprofit entity to be known as the North Carolina Health InsuranceRisk Pool. Notwithstanding that the Pool may be supported in whole or in partfrom State funds, the Pool is not an instrumentality of the State. The Poolshall operate under the supervision and control of the Board.
(b) The Board of theNorth Carolina Health Insurance Risk Pool shall consist of the Commissioner,who shall serve as an ex officio nonvoting member of the Board, and 11 membersappointed as follows:
(1) One member whorepresents an insurer, as appointed by the Governor.
(2) Two members of thegeneral public who are not employed by or affiliated with an insurance companyor plan, group hospital, or other health care provider and can reasonably beexpected to qualify for coverage in the Pool. Members of the general publicinclude individuals whose only affiliation with health insurance or health carecoverage is as a covered member. The two members of the general public shall beappointed by the General Assembly, as follows:
a. One member upon therecommendation of the President Pro Tempore of the Senate.
b. One member upon therecommendation of the Speaker of the House of Representatives.
(3) Eight membersappointed by the Commissioner, as follows:
a. One insurer whosells individual health insurance policies.
b. One who representsthe insurance industry, as recommended by the insurer who covers the largestnumber of persons in the State.
c. One who is licensedto sell health insurance in this State.
d. Two who representthe medical provider community, one as recommended by the North CarolinaMedical Society, and one as recommended by the North Carolina HospitalAssociation.
e. One who representsbusiness, as recommended by the North Carolina Chamber.
f. One who representssmall business, as recommended by the National Federation of IndependentBusiness.
g. One who is either ahealth policy researcher or a health economist with experience relating to theoperation of health insurance risk pools.
(c) The initialappointments by the Governor and the General Assembly upon the recommendationof the Speaker of the House of Representatives and the President Pro Tempore ofthe Senate shall serve a term of three years. The initial appointments by theCommissioner under sub‑subdivisions a., b., and d. of subdivision (b)(3)of this section shall be for a term of two years. The initial appointments bythe Commissioner under sub‑subdivisions c., e., f., and g. of subdivision(b)(3) of this section shall be for a term of one year. All succeedingappointments shall be for terms of three years. Members shall not serve formore than two successive terms.
A Board member's term shallcontinue until the member's successor is appointed by the original appointingauthority. Vacancies shall be filled by the appointing authority for theunexpired portion of the term in which they occur. A Board member may beremoved by the appointing authority for cause.
The Board shall meet at leastquarterly upon the call of the chair. A majority of the total membership of theCommission shall constitute a quorum.
The Commissioner shall appointa chair to serve for the initial two years of the Plan's operation. Subsequentchairs shall be elected by a majority vote of the Board members and shall servefor two‑year terms. Board members shall receive travel allowances underG.S. 138‑5 when traveling to and from meetings of the Board or forofficial business of the Pool, but shall not receive any per diem undersubdivision (a)(1) of that section.
(d) The Board shallsubmit to the Commissioner a Plan of Operation for the Pool and any amendmentsnecessary or suitable to assure the fair, reasonable, and equitableadministration of the Plan of Operation. The Plan of Operation shall becomeeffective upon approval in writing by the Commissioner consistent with the dateon which the coverage under this Part must be made available. If the Boardfails to submit a suitable Plan of Operation within 180 days after theappointment of the Board, or at any time thereafter fails to submit suitableamendments to the Plan of Operation, the Commissioner shall adopt temporaryrules necessary or advisable to effectuate the provisions of this section. Therules shall continue in force until modified by the Commissioner or supersededby a Plan of Operation submitted by the Board and approved by the Commissioner.The Plan of Operation shall:
(1) Establish proceduresfor operation of the Pool.
(2) Establish proceduresfor selecting a Pool Administrator in accordance with G.S. 58‑50‑185.
(3) Establish proceduresto create a fund for administrative expenses, which shall be managed by theBoard.
(4) Establish proceduresfor the collection, handling, disbursing, accounting, and auditing of assets,monies, and claims of the Pool and the Pool Administrator.
(5) Develop andimplement a program to publicize the existence of the Pool, the eligibilityrequirements, procedures for enrollment, and availability of State premiumsubsidies and to maintain public awareness of the Pool.
(6) Establish proceduresunder which applicants and participants may have grievances reviewed by agrievance committee appointed by the Executive Director in accordance with G.S.58‑50‑230.
(7) Establish proceduresfor identifying and confirming income levels of applicants for Pool coveragewho are eligible to receive a State premium subsidy, if a State premium subsidyis available.
(8) Provide for othermatters as may be necessary and proper for the execution of the ExecutiveDirector's powers, duties, and obligations under this Part.
(e) The Pool shall havethe general powers and authority granted under the laws of this State to healthinsurers and the specific authority to do all of the following:
(1) Enter into contractsas are necessary or proper to carry out the provisions and purposes of thisPart, including the authority, with the approval of the Executive Directoracting upon the approval or authorization of the Board, to enter into contractswith similar plans of other states for the joint performance of commonadministrative functions or with persons or other organizations for theperformance of administrative functions.
(2) Sue or be sued.
(3) Take legal action asnecessary to:
a. Avoid the payment ofimproper claims against the Pool or the coverage provided by or through thePlan.
b. Recover any amountserroneously or improperly paid by the Plan.
c. Recover any amountspaid by the Pool as a result of mistake of fact or law.
d. Recover otheramounts due the Pool.
(4) Establish rates andrate schedules in accordance with this Part.
(4a) Provide premiumsubsidies if federal grant funds are available for individuals with incomes upto three hundred percent (300%) of the federal poverty guidelines and the Boarddeems it is fiscally prudent to do so.
(5) Issue policies ofinsurance in accordance with the requirements of this Part.
(6) Appoint appropriatelegal, actuarial, and other committees as necessary to provide technicalassistance in the operation of the Pool, policy, and other contract design, andany other function within the Pool's authority.
(7) Establish policies,conditions, and procedures for reinsuring risks of participating healthinsurers, as defined in G.S. 58‑68‑25(a), desiring to issue Poolcoverage in their own name. Provision of reinsurance shall not subject the Poolto any of the capital or surplus requirements, if any, otherwise applicable toreinsurers.
(8) Employ and fix thecompensation of employees.
(9) Prepare and distributecertificate of eligibility forms and enrollment instruction forms to insuranceproducers and to the general public.
(10) Provide forreinsurance for the Pool.
(11) Issue additionaltypes of health insurance policies to provide optional coverage, includingMedicare supplemental insurance coverage.
(12) Provide for andemploy cost containment measures and requirements including preadmissionscreening, second surgical opinion, concurrent utilization review, diseasemanagement, individual case management, health and wellness programs includinga smoking cessation initiative, and other commonly used benefit plan designfeatures for the purpose of making health insurance coverage offered by thePool more cost‑effective.
(13) Design, utilize,contract, or otherwise arrange for the delivery of cost‑effective healthcare services, including establishing or contracting with preferred providerorganizations, health maintenance organizations, and other limited networkprovider arrangements.
(14) Adopt bylaws, policies,and procedures as may be necessary or convenient for the implementation of thisPart and the operation of the Pool.
(f) The ExecutiveDirector, with the approval of the Board, shall operate the Pool in a manner sothat the estimated cost of providing the benefit plans offered during anycalendar year is not anticipated to exceed the total income the Pool expects toreceive from policy premiums and other revenue available to the Pool. The Boardmay impose a cap on enrollment or may suspend enrollment for an indefiniteperiod if the Board finds that estimated costs are anticipated to exceedincome, except that any enrollment cap or suspension shall not apply tofederally defined eligible individuals who are eligible to enroll in the Poolpursuant to G.S. 58‑50‑195(a)(5).
(g) The ExecutiveDirector shall make an annual report to the Speaker of the House ofRepresentatives, the President Pro Tempore of the Senate, the Commissioner, theJoint Legislative Health Care Oversight Committee, and the Committee on EmployeeHospital and Medical Benefits. The report shall summarize the activities of thePool in the preceding calendar year, including the net written and earnedpremiums, benefit plan enrollment, the expense of administration, and the paidand incurred losses.
(h) Neither the Boardnor the employees of the Pool are liable for any obligations of the Pool. Thereshall be no liability on the part of, and no cause of action of any natureshall arise against, the Pool or its agents or employees, the Board, theExecutive Director, or the Commissioner or the Commissioner's representativesfor any action taken by them in good faith in the performance of their powersand duties under this Part.
(i) The members of theBoard are public servants under G.S. 138A‑3(30) and are subject to theprovisions of Chapter 138A of the General Statutes. (2007‑532, s. 1.1;2008‑124, ss. 6.1, 6.2; 2009‑286, s. 1; 2009‑570, s. 8(a).)