HB 714 creates a state-run universal healthcare benefit plan administered by North Carolina's Commissioner of Insurance. It requires the plan to offer sliding-scale premiums based on household income, covering residents whose incomes exceed Medicaid eligibility but who cannot afford private insurance. The bill mandates the Commissioner to develop the plan by January 1, 2026, with a report to the legislature detailing implementation steps. It also appropriates $100,000 for initial planning in the 2025-2026 fiscal year and ensures coverage meets or exceeds federal Affordable Care Act standards.
HB 736 allows North Carolina pharmacists to perform simple tests (like for flu, COVID-19, or strep throat) and provide treatment for those conditions using approved medications, within specific guidelines. It requires health insurance plans to cover these pharmacist-provided services if they would cover the same service from a doctor or nurse, and ensures pharmacists aren't excluded from provider networks solely because they are pharmacists. Pharmacists cannot treat conditions with controlled substances (Schedules I-IV) and must follow statewide protocols for patient referrals. The bill takes effect October 1, 2025, expanding pharmacist roles to improve access to basic care.
Senate Bill 335 allows pharmacists to order and perform CLIA-waived tests to treat influenza, provided they follow statewide protocols and do not use controlled substances. The bill mandates that health benefit plans cover healthcare services provided by pharmacists if the services are within their licensed scope of practice and would be covered if performed by another healthcare provider. It also ensures consistent application of prescription drug and pharmacy service coverage requirements across insurers, third-party administrators, and pharmacy benefits managers. These changes aim to expand access to certain healthcare services through pharmacists, affecting patients, pharmacists, and health insurance providers. Most provisions become effective October 1, 2025.
HB 558 updates how North Carolina selects Medicaid health plans by limiting statewide contracts to four and allowing up to 12 regional contracts through local health providers. It requires the state to prioritize bids from local providers and those with high provider satisfaction scores from existing contracts. The bill also mandates staggered contract terms (3-5 years) to prevent coverage gaps during transitions. These changes directly affect Medicaid health plan contractors and the Division of Health Benefits, aiming to stabilize coverage and improve provider relationships.
SB 287 prohibits health insurers from using artificial intelligence algorithms as the sole basis to deny, delay, or modify healthcare services based on medical necessity. The bill requires that only licensed and qualified healthcare providers make these determinations, and insurers must verify that third-party contractors (like pharmacy benefits managers) comply with this rule. It directly affects health insurers, pharmacy benefits managers, and the North Carolina State Health Plan for teachers and state employees, which must review its contracts and practices for compliance. The law takes effect 30 days after enactment and focuses on ensuring human medical judgment remains central to coverage decisions.
SB 316 requires North Carolina hospitals and ambulatory surgical facilities to publicly disclose detailed pricing information for common medical services, including full charges, negotiated rates, and reimbursements from Medicaid, Medicare, and major insurers. Beginning in 2015, these facilities must submit quarterly reports to the state health department on the 100 most frequent inpatient diagnoses (DRGs) and common surgical/imaging procedures. The data will be made publicly available online, enabling patients and employers to compare costs and make informed healthcare decisions. This bill directly affects healthcare providers by mandating transparency but does not alter insurance coverage or set price limits. Its key mechanism is standardized reporting of pricing data to foster competition and affordability in the healthcare market.
House Bill 820 requires health benefit plans in North Carolina to provide coverage for early refills of prescription eye drops. This means insurers cannot deny a refill for a 30-day supply if at least 21 days have passed since the last fill, or if the patient has used 70% of the medication according to their healthcare provider's instructions. The bill also specifies that the requested refill must not exceed the total number of refills indicated on the original prescription. These requirements apply to all health benefit plans, including the State Health Plan, with an effective date of October 1, 2025, or the subsequent plan year.
House Bill 635 requires certain large group health benefit plans to provide coverage for fertility diagnostic care, treatment, and preservation services. This bill directly affects individuals covered by these plans, aiming to increase their access to fertility-related medical care. Key provisions include mandatory coverage for at least three in vitro fertilization (IVF) cycles per insured, provided procedures follow American Society of Reproductive Medicine guidelines and are performed at licensed facilities. However, the requirements do not apply to plans offered by religious institutions or self-insured group health plans, and explicitly exclude experimental procedures or nonmedical costs for donor gametes or surrogacy.
HB 634 updates North Carolina laws to enhance parity in health insurance coverage for mental health and addiction recovery. It requires all health benefit plans to provide benefits for mental health conditions that are no less favorable than those for physical illnesses, including applying the same financial limits. A key provision mandates that medical necessity determinations for substance use disorders must rely solely on the most recent American Society of Addiction Medicine criteria. The bill also requires the State Health Plan for Teachers and State Employees to comply with these new utilization review standards and updates terminology from "chemical dependency" to "substance use disorder" in relevant statutes.
HB 152 aims to regulate how health benefit plans in North Carolina cover Transcranial Magnetic Stimulation (TMS) services. If an insurer chooses to cover TMS, the bill requires them to cover all procedures performed by properly licensed healthcare providers, regardless of their medical specialty, as long as TMS is within their scope of practice. It prohibits insurers from penalizing providers solely based on their specialty when submitting TMS claims. However, the bill maintains that insurers retain discretion over whether to cover TMS, for which conditions, and at what reimbursement rates.
