As used in this Article unless the context clearly requires otherwise, the following definitions apply:

(1)        Authorized representatives who are assisting the State Health Plan Division staff. – Staff of the Department of the State Treasurer, staff of the Department of Justice, or persons providing internal auditing assistance required under N.C. Gen. Stat. § 143-746(b).

(1a)      Benefit period. – The period of time during which charges for covered services provided to a Plan member must be incurred in order to be eligible for payment by the Plan.

(2)        Chemical dependency. – The pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal.

(2a)      Claims Data Feed. – An electronic file provided by a Claims Processor that contains all claims processing data elements for every claim processed by the Claims Processor for the Plan, including Claim Payment Data for each claim.

(2b)      Claim Payment Data. – Data fields within a Claims Data Feed that reflect the provider and the amount the provider billed for services provided to a Plan member, the allowed amount applied to the claim by the Claims Processor, and the amount paid by the Plan on the claim. The term “Claim Payment Data” includes any document, material, or other work, whether tangible or electronic, that is derived from, is based on, or reflects any of the foregoing data fields or information contained therein. If the Claims Processor designates Claim Payment Data as a trade secret, the Claim Payment Data shall be treated as a trade secret as defined in N.C. Gen. Stat. § 66-152(3).

(3)        Claims Processor. – One or more administrators, third-party administrators, or other parties contracting with the Plan to administer Plan benefits.

(4)        Comprehensive group health benefit plan. – A comprehensive health benefit plan offered to an individual because of an employment, organizational, or other group affiliation.

(5)        Comprehensive health benefit plan. – Health care coverage that consists of inpatient and outpatient hospital and medical benefits, as well as other outpatient medical services, prescription drugs, medical supplies, and equipment that are generally available in the health insurance market.

(6)        Covered service; benefit; allowable expense. – Any medically necessary, reasonable, and customary items of service, including prescription drugs, and medical supplies included in the Plan.

(7)        Deductible. – The dollar amount that must be incurred for certain covered services in a benefit period before benefits are payable by the Plan.

(8)        Dependent. – An eligible Plan member other than the subscriber.

(9)        Dependent child. – Subject to the eligibility requirements of subsections (a) and (b) of N.C. Gen. Stat. § 135-48.41, any of the following up to the first month following the dependent child‘s 26th birthday:

a.         A natural or legally adopted child or children of the employee, whether or not the child is living with the employee.

b.         A foster child or children of the employee, whether or not the child is living with the employee.

c.         A child for which an employee is a court-appointed guardian.

d.         A stepchild of a member who is married to the stepchild’s natural parent.

e.         Repealed by Session Laws 2011-96, s. 3(a), effective July 1, 2011.

(10)      Employee or State employee. – Any permanent full-time or permanent part-time regular employee (designated as half-time or more) of an employing unit.

(11)      Employing Unit. – A North Carolina School System; Community College; State Department, Agency, or Institution; Administrative Office of the Courts; or Association or Examining Board whose employees are eligible for membership in a State-Supported Retirement System. An employing unit also shall mean (i) a charter school in accordance with Article 14A of Chapter 115C of the N.C. Gen. Stat. whose board of directors elects to become a participating employer in the Plan under N.C. Gen. Stat. § 135-48.54 or (ii) a local government unit that participates in the Plan under N.C. Gen. Stat. § 135-48.47 or under any other law. Bona fide fire departments, rescue or emergency medical service squads, and National Guard units are deemed to be employing units for the purpose of providing benefits under this Article.

(12)      Firefighter. – A member of the group “eligible firefighter” as defined in N.C. Gen. Stat. § 58-86-2.

(13)      Health Benefits Representative or HBR. – The employee designated by the employing unit to administer the Plan for the unit and its employees. The HBR is responsible for enrolling new employees and dependents in accordance with the eligibility requirements under this Article, reporting changes, explaining benefits, reconciling group statements, and remitting group fees. The State Retirement System is the Health Benefits Representative for retired State employees.

(14)      Plan or State Health Plan. – The North Carolina State Health Plan for Teachers and State Employees. Depending on the context, the term may refer to the entity created in N.C. Gen. Stat. § 135-48.2 or to the health benefit plans offered by the entity, in which case “Plan” includes all comprehensive health benefit plans offered under the Plan.

(15)      Plan member. – A subscriber or dependent who is eligible and currently enrolled in the Plan and for whom a premium is paid.

(16)      Predecessor plan. – The Hospital and Medical Benefits for the Teachers’ and State Employees’ Retirement System of the State of North Carolina and the North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan.

(17)      Rescue squad worker. – An “eligible rescue squad worker” as defined in N.C. Gen. Stat. § 58-86-30.

(18)      Retired employee (retiree). – Retired teachers, State employees, and members of the General Assembly who (i) are receiving monthly retirement benefits from the Teachers’ and State Employees’ Retirement System, the Consolidated Judicial Retirement System, the Legislative Retirement System, or the Optional Retirement Programs established under N.C. Gen. Stat. § 135-5.1 and N.C. Gen. Stat. § 135-5.4 and (ii) earned contributory retirement service in one of these retirement systems prior to January 1, 2021, and did not withdraw that service, so long as the retiree is enrolled.

(19)      Subscriber. – A Plan member who is not a dependent. ?(2008-168, s. 3(e); 2009-16, s. 3(a); 2009-281, s. 1; 2010-120, s. 1; 2011-85, ss. 1.7(a), 1.10(c), 2.6(b), 2.10; 2011-96, s. 3(a); 2011-183, s. 102; 2011-326, s. 19.3; 2012-173, s. 1; 2014-75, s. 1; 2014-97, s. 5(a); 2014-101, s. 7; 2016-104, s. 1; 2017-57, s. 35.21(c); 2017-135, s. 5; 2021-125, s. 5.)

Terms Used In North Carolina General Statutes 135-48.1

  • Benefit period: The period of time during which charges for covered services provided to a Plan member must be incurred in order to be eligible for payment by the Plan. See North Carolina General Statutes 135-48.1
  • Chemical dependency: The pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. See North Carolina General Statutes 135-48.1
  • Claim Payment Data: includes any document, material, or other work, whether tangible or electronic, that is derived from, is based on, or reflects any of the foregoing data fields or information contained therein. See North Carolina General Statutes 135-48.1
  • Claims Data Feed: An electronic file provided by a Claims Processor that contains all claims processing data elements for every claim processed by the Claims Processor for the Plan, including Claim Payment Data for each claim. See North Carolina General Statutes 135-48.1
  • Claims Processor: One or more administrators, third-party administrators, or other parties contracting with the Plan to administer Plan benefits. See North Carolina General Statutes 135-48.1
  • Comprehensive group health benefit plan: A comprehensive health benefit plan offered to an individual because of an employment, organizational, or other group affiliation. See North Carolina General Statutes 135-48.1
  • Comprehensive health benefit plan: Health care coverage that consists of inpatient and outpatient hospital and medical benefits, as well as other outpatient medical services, prescription drugs, medical supplies, and equipment that are generally available in the health insurance market. See North Carolina General Statutes 135-48.1
  • Deductible: The dollar amount that must be incurred for certain covered services in a benefit period before benefits are payable by the Plan. See North Carolina General Statutes 135-48.1
  • Dependent: An eligible Plan member other than the subscriber. See North Carolina General Statutes 135-48.1
  • Dependent: A person dependent for support upon another.
  • Dependent child: Subject to the eligibility requirements of subsections (a) and (b) of N. See North Carolina General Statutes 135-48.1
  • Employee: shall mean all full-time employees, agents or officers of the State of North Carolina or any of its departments, bureaus and institutions other than educational, whether such employees are elected, appointed or employed: Provided that the term "employee" shall not include any person who is a member of the Consolidated Judicial Retirement System, any member of the General Assembly or any part-time or temporary employee. See North Carolina General Statutes 135-1
  • Employer: shall mean the State of North Carolina, the county board of education, the city board of education, the State Board of Education, the board of trustees of the University of North Carolina, the board of trustees of other institutions and agencies supported and under the control of the State, or any other agency of and within the State by which a teacher or other employee is paid. See North Carolina General Statutes 135-1
  • Employing Unit: A North Carolina School System. See North Carolina General Statutes 135-48.1
  • Firefighter: A member of the group "eligible firefighter" as defined in N. See North Carolina General Statutes 135-48.1
  • following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Health Benefits Representative or HBR: The employee designated by the employing unit to administer the Plan for the unit and its employees. See North Carolina General Statutes 135-48.1
  • Member: shall mean any teacher or State employee included in the membership of the System as provided in N. See North Carolina General Statutes 135-1
  • month: shall be construed to mean a calendar month, unless otherwise expressed; and the word "year" a calendar year, unless otherwise expressed; and the word "year" alone shall be equivalent to the expression "year of our Lord. See North Carolina General Statutes 12-3
  • Plan: includes all comprehensive health benefit plans offered under the Plan. See North Carolina General Statutes 135-48.1
  • Plan member: A subscriber or dependent who is eligible and currently enrolled in the Plan and for whom a premium is paid. See North Carolina General Statutes 135-48.1
  • Plan or State Health Plan: The North Carolina State Health Plan for Teachers and State Employees. See North Carolina General Statutes 135-48.1
  • Predecessor plan: The Hospital and Medical Benefits for the Teachers' and State Employees' Retirement System of the State of North Carolina and the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan. See North Carolina General Statutes 135-48.1
  • Rescue squad worker: An "eligible rescue squad worker" as defined in N. See North Carolina General Statutes 135-48.1
  • Retirement System: shall mean the Teachers' and State Employees' Retirement System of North Carolina as defined in N. See North Carolina General Statutes 135-1
  • Service: shall mean service as a teacher or State employee as described in subdivision (10) or (25) of this section. See North Carolina General Statutes 135-1
  • state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories, so called; and the words "United States" shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
  • Subscriber: A Plan member who is not a dependent. See North Carolina General Statutes 135-48.1