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North Carolina Health Insurance Marketplace

With most of the Affordable Care Act’s major provisions now in effect, the nation’s health insurance marketplace has undergone a significant transformation. Obamacare impacts individuals, families and small business owners alike. Most Americans are required to have minimum essential coverage unless they qualify for an exemption; however, the law is designed to make health insurance more accessible and affordable with income-based financial assistance and one-stop shopping via state-based and federally facilitated exchanges. Meanwhile, the private marketplace remains a place to shop for quality, affordable health insurance plans that meet ACA requirements.

The following guide offers a glimpse at the various types of ACA-compliant health insurance in Florida, including individual and family health plans, small group health plans, coverage for high-risk applicants, mini-COBRA continuation coverage, Medicaid, and CHIP.

Health and healthcare in North Carolina

North Carolina ranked 37th in United Health Foundation’s 2014 America’s Health Rankings.1 Its strengths included a low prevalence of binge drinking, a low incidence of pertussis (whooping cough) infections, and high immunization coverage among children. Challenges for North Carolina included a high incidence of chlamydia and salmonella infections, limited availability of dentists, and a high infant mortality rate and high prevalence of low birthweight.

North Carolina individual and family health insurance

When the Obamacare health insurance exchanges opened for 2014 enrollment, Florida defaulted to the federal health insurance marketplace, Individuals and families living in Florida may purchase health insurance coverage through the state’s federally facilitated exchange and in the private marketplace.

Those who buy health insurance through may be eligible for income-based subsidies, including premium tax credits that may be applied to any metal plan and cost-sharing subsidies that apply to silver plans. Individuals who go without health insurance may face a tax penalty known as the shared responsibility payment.

The U.S. Department of Health and Human Services reported that 357,584 individuals in North Carolina selected a marketplace plan through the exchange from Oct. 1, 2013, through April 19, 2014.2 In 2015, the number of individuals in North Carolina enrolled in a marketplace plan increased to 560,357 during the open enrollment period.3

North Carolina’s health insurance exchange:
North Carolina’s department of insurance:

North Carolina small group health insurance plans

In North Carolina, small businesses with 50 or fewer employees may purchase small group health insurance plans through the federally facilitated Small Business Health Options Program, SHOP Marketplace, at and in the private marketplace. Small businesses that use SHOP and have 25 or fewer employees may qualify for a Small Business Healthcare Tax Credit.

Self-employed individuals with no employees must apply for an individual health insurance plan on or away from

North Carolina state COBRA variations for small groups

The Consolidated Omnibus Reconciliation Act (COBRA) allows those employed by businesses with 20 or more employees to continue their group health insurance plan for a limited time should they lose coverage due to qualifying events such as termination of employment due to reasons other than gross misconduct, a reduction in work hours, divorce or legal separation, and loss of dependency status. To learn more about the federal COBRA program, visit

In some states, those who work for a small business and lose health insurance coverage due to a qualifying event may qualify for health insurance continuation through mini-COBRA programs. State mini-COBRA programs allow those who work for a small business and lose health insurance coverage due to a qualifying event to continue coverage, too. These programs generally work like the federal COBRA continuation coverage, but their terms may vary. North Carolina’s small group COBRA continuation variations are as follows:4

Mini-COBRA option Yes; state continuation coverage
Eligible group sizes 2 to 19
Maximum continuation period – standard 18 months
Maximum premium 29 months if determined disabled under the Social Security Act
Maximum premium increase Up to 102 percent of the full group rate
State legislation reference Article 53 of Chapter 58 of North Carolina General Statutes
More Information 800-546-5664 Consumer Guide to Health Insurance— Guide To Health Insurance_CHE1_SmPU.pdf
Additional notes Continuation is not required to include dental, vision care or prescription drug benefits, or benefits other than group hospital, surgical and major medical benefits.Employees or members must elect continuation of coverage within 60 days of termination or loss of eligibility.

North Carolina high-risk pools

It used to be that health insurance companies could deny applicants or charge them more based on health history and preexisting conditions. When the Affordable Care Act was passed in 2010, many states created federally funded preexisting condition insurance programs or accepted federal funding to assist with similar high-risk pool programs they already operated.5

The Affordable Care Act prohibits this practice for health insurance plans considered minimum essential coverage with effective dates beginning Jan. 1, 2014, and later.

North Carolina Medicaid

Medicaid is a state health insurance program for low-income individuals under age 65, pregnant women, children, disabled individuals, and seniors over age 65; it is partially funded by the federal government. In 2014, states were given the option to accept additional federal funding and expand their Medicaid program eligibility to those who make up to 133 percent of the federal poverty level (effectively 138 percent due to how it is calculated, according to

North Carolina did not expand its Medicaid program in 2014.7 A resulting coverage gap exists for those whose incomes are too high for Medicaid but too low to receive federal premium and cost-sharing assistance when shopping

The information below is specific to North Carolina’s Medicaid program:

Medicaid expansion No
Governing agency Centers for Medicare & Medicaid
Administrator NC Department of Health and Human Services
Where to apply |
Phone number 800-662-7030
More Information
Eligibility North Carolina resident, U.S. citizen or qualified non-citizen. Income and resource requirements vary by groups, which may include low-income parents, children, seniors and people with disabilities. There are different types of coverage for different needs.
Open-enrollment period Year-round in all states

North Carolina CHIP

The Children’s Health Insurance Program is a partnership between the states and federal government. CHIP provides health insurance to uninsured children who meet certain eligibility guidelines. The information below is specific to North Carolina’s CHIP program.

Program name North Carolina Health Choice for Children
Where to apply|
Phone number 888-988-6300
Eligibility8 Uninsured children ages 6 through 18 who are not eligible for Medicaid, Medicare or other federal government-sponsored health insurance; family incomes must be above 133 percent of the federal poverty level and below 211 percent of fpl; must be North Carolina residents and eligible under federal law.

1 United Health Foundation. 2014 America’s Health Rankings Annual Edition. “Annual State Health Rankings.”

2 Kaiser Family Foundation

3 Kaiser Family Foundation

4 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. Retrieved from .

5 National Conference of State Legislators. Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools. Updated April 2014. Retrieved from

6 Centers for Medicare & Medicaid Services. “Medicaid Expansion & What It Means for You.” N.D. Retrieved from

7 Centers for Medicare & Medicaid Services. “North Carolina.” N.D. Retrieved from

8 NC Department of Health and Human Services. NC Division of Medical Assistance. “Who is Eligible for North Carolina Health Choice for Children?” Last updated June 6, 2014. Retrieved from