Includes whereas clauses.
Part I.
Sets out NCGA findings on healthcare costs.
Adds new Article 94, Low-Cost Health Plan Option, to GS Chapter 58, providing as follows.
Defines low-cost health plan option as a qualified health plan, or group of qualified health plans, made available through a State-facilitated arrangement and ordered on the Exchange in accordance with this Article for the purpose of increasing competition, improving affordability, and expanding consumer choice. Defines reference-based rate as a reimbursement rate benchmarked to Medicare or another objective schedule adopted under the Article.
Requires the Department of Health and Human Services (DHHS) to consult with the Department of Insurance (DOI) and State Treasurer in establishing and administering the North Carolina Low-Cost Health Plan Option (Option). Requires the Option to be offered on the Exchange statewide. Allows using one or more participating carriers or third-party administrators to underwrite, administer, and operate the Option.
Requires DHHS to set procurement requirements to reduce premiums and out-of-pocket costs. Allows DHHS to require participating carriers to use value-based payment, tiered networks, advanced primary care models, or other designs consistent with affordability and quality. Allows DHHS to set reference-based rates for provider reimbursement under the Option, including rates expressed as a percentage of Medicare, with adjustments for rural access, critical access hospitals, and other essential providers. Requires that DHHS, beginning with the initial plan year and for each plan year thereafter, ensure that the Option meets specified affordability outcomes for premiums, administrative expenses, and out-of-pocket costs. Sets out steps that must be taken when DHHS determines that an affordability outcome cannot be met due to network adequacy requirements, provider participation, federal restrictions, or other constraints outside of DHHS control.
Requires that the Option be financed primarily through premiums and other revenues associated with plan operations. Allows requesting appropriations for specified functions and expenses.
Requires DHHS to report annually to the specified NCGA committee and division on enrollment, premiums, claims, administrative costs, network adequacy, consumer satisfaction, quality outcomes, and any recommended statutory changes.
Requires that the Option be offered on the Federally Facilitated Marketplace, or Exchange, beginning with the plan year 2028, unless DHHS certifies in writing to the Joint Legislative Oversight Committee on Health and Human Services that an earlier plan year is feasible.
Requires DHHS to begin planning, procurement, and implementation of this Part when this Part becomes effective.
Part II.
Adds new Article 85, Public Health Consortium, to GS Chapter 143, providing as follows.
Establishes the Public Health Purchasing Consortium (Consortium) to coordinate, aggregate, and strategically align the healthcare purchasing power of public entities in the state. Makes the State Treasurer the chair of the Consortium and sets out membership requirements. Sets out the Consortium’s six duties, including developing model procurement standards for carriers, Third-Party Administrators, Pharmacy Benefit Managers, and other vendors; coordinating strategies to improve competition, transparency, and affordability; and supporting implementation of the Option created under Article 94 of GS Chapter 58. Allows establishing a secure data- sharing framework, with data disclosed only for public purchasing purposes. Allows a county, municipality, or other political subdivision to participate in Consortium initiatives upon approval by its governing board and execution of a participation agreement, which may address specified topics. Requires an annual report to the specified NCGA committees.
Part III.
Requires that DHHS, the Department of Insurance, and the Department of State Treasurer enter into interagency agreements to implement Parts I and II. Allows DHHS to issue requests for information and requests for proposals and take actions necessary to ensure that the Option is operational by the date required.
Effective July 1, 2026, appropriates $25 million in recurring funds from the General Fund to DHHS and $10 million in nonrecurring funds for 2026-27 to implement the Plan and Consortium.
Part IV.
Appropriates $175 million in recurring funds and associated receipts for 2026-27 from the General Fund to DHHS, Division of Health Benefits (DHB), to continue and expand Health Opportunities Pilots activities to promote chronic disease prevention, reduce avoidable healthcare utilization, and improve health outcomes through interventions addressing health-related social needs. Sets out for allowable uses of the funds, with priority given to interventions and program designs expected to reduce the incidence or severity of chronic disease. Prohibits using funds to supplant existing state funding for similar purposes, unless expressly authorized by the NCGA.
Requires DHB to report annually, beginning in 2027, while funds remain available to the specified NCGA committees and division on the specified items related to the Healthy Opportunities Pilots.
Effective July 1, 2026.
Part V.
Adds Parts to Article 11B, Transparency in Health Care Costs, of GS Chapter 131E and makes the following changes.
Amends GS 131E-214.13 governing pricing disclosure for frequently reported Diagnostic Related Group (DRG), Current Procedural Technology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Adds CPT, DRG, HCPCS, and statewide data processor to the defined terms. Changes the reporting requirements in subsections (b) and (d) to now require hospitals to quarterly (was, annually) report to the statewide data processor (was, the Department of Health and Human Services (DHHS)) specified information about (1) the 100 most frequently reported admissions by DRG for inpatients and (2) total costs for the 20 most common surgical procedures and the 20 most common imaging procedures performed in outpatient settings or ambulatory surgical facilities (facilities) along with CPT and HCPCS codes. Specifies that when calculating the amount, each hospital or facility must include charges for each billable item and service associated with the DRG or procedure regardless of whether a physician or nonphysician practitioner performed the service. Reorganizes the rulemaking provisions and adds that the Medicare Care Commission (Commission) must establish procedures for the statewide data processor to receive and submit data reported to DHHS for publication on its website. Makes conforming changes.
Enacts GS 131E-214.18 to authorize DHHS to assess civil penalties for violations of Article 11B in addition to any federal penalty. Sets the daily penalty at no less than .01% of the annual salary of the CEO of the noncompliant hospital or facility or more than $2,000.
Adds receipt of data from hospitals and facilities reported pursuant to GS 131E-214.13, as amended, to the duties of a statewide data processor set forth in GS 131E-214.4 and requires submitting the data to DHHS.
Makes the above changes effective on the later of January 1, 2027, or the date rules adopted by the Commission regarding uniform reporting pursuant to GS 131E-214.13(d) becomes effective. Directs the Commission to notify the Revisor of Statutes when rules pursuant to GS 131E-214.13(f1)(1) and (2) become effective. 
Part VI.
Enacts GS 131E-214.30, as follows. Requires at the time a health service facility participating in an insurer's healthcare provider network (1) treats an insured individual for anything other than screening and stabilization; (2) admits an insured individual to receive emergency services; (3) schedules a procedure for non-emergency services for an insured individual; or (4) seeks prior authorization from an insurer for the provision of nonemergency services to an insured individual, to provide the insured individual with a written disclosure pertaining to billing, out-of-network services, and consumer protections, as described.  Requires emergency services facilities to disclose to an insured individual if it does not have a contract for services with the insured’s insurer, and to provide information about consumer protections, as described, as soon as practicable after the facility begins providing emergency services.
Enacts GS 131E-214.31, as follows. Requires at the time a healthcare provider not participating in the insured’s network (1) treats an insured individual for anything other than screening and stabilization; (2) schedules a procedure for non-emergency services for an insured individual; or (3) seeks prior authorization from an insurer for the provision of non-emergency services to an insured individual, to provide the insured individual with a written disclosure that warns the insured that the healthcare provider is not in the insured’s healthcare provider network and provides consumer protection information, as described.
Designates failure to comply with the above requirements as an unfair and deceptive trade practice. Clarifies that nothing in Article 11B of GS Chapter 131E forecloses other remedies available under law or equity.
Repeals the definition of health benefit plan in GS 58-3-200(a)(1) and insurer in GS 58-3-200(a)(2) (definitions section of provisions pertaining to miscellaneous insurance and managed care coverages and networks). Adds definition of terms clinical laboratory, and healthcare provider.
Requires an insurer upon request under GS 58-3-200(d) (services outside provider networks), to determine whether a healthcare provider able to meet the needs of the insured is available to the insured without unreasonable delay by reference to the insured's location and the specific medical needs of the insured.
Applies to healthcare services provided on or after October 1, 2026, and to contracts issued, renewed, or amended or after that date.
Part VII.
Adds new Article 11C to GS Chapter 131E, entitled “Fair Billing and Collection Practices for Hospitals and Ambulatory Surgical Facilities," as follows. Recodifies GS 131E-91(fair billing and collections practices for hospitals and ambulatory surgical facilities) as GS 131E-214.50, and reorganizes that provision into new Article 11C. Requires a hospital or ambulatory surgical facility to first present an itemized list of charges to the patient detailing the specific nature of the charges or expenses incurred by the patient before referring the bill to collection as another required collections practice under new GS 131E-214.50. Enacts new GS 131E-214.52 (patient’s right to a good faith estimate) as part of new Article 11C, as follows. Defines CMS, facility (licensed hospital or ambulatory surgical facility), items and services, service package, and shoppable service (a non-urgent service that can be scheduled by the patient in advance). Requires a facility to provide, upon a patient's request, a good faith estimate for a shoppable service as described. Limits a patient’s final bill from exceeding more than 5% of the good faith estimate. Requires DHHS to adopt rules to implement the statute. Directs DHHS to notify the Revisor when the rules required under GS 131A-214.52 take effect.
Effective on the later of January 1, 2027, or the date the rules adopted by DHHS become effect. Applies to acts occurring after the effective date. 
Part VIII.
Adds new GS 131E-214.54 (concerning facility fees) to Article 11C, as follows. Defines ambulatory surgical facility, campus, facility fee (any fee charged or billed by a health care provider for outpatient services provided in a hospital-based facility that is (i) intended to compensate the health care provider for the operational expenses of the health care provider, (ii) separate and distinct from a professional fee, and (iii) charged regardless of the modality through which the health care services were provided), health care provider, health systems, hospital, hospital-based facility, professional fee, and remote location of a hospital.
Places the following limits on facility fees: (1) prevents a health care provider from assessing a charge, bill, or collecting a facility fee unless the services are provided on a hospital's main campus, at a remote location of a hospital, or at a facility that includes an emergency department or ambulatory surgical center and (2) regardless of where the services are provided, no health care provider can assess a charge, bill, or collect a facility fee for outpatient evaluation and management services, or any other outpatient, diagnostic, or imaging services identified by DHHS. Requires DHHS to annually identify those services. 
Requires each hospital and health system to submit a report annually to DHHS by July 1st on the six specified matters. Specifies that all violations of the statute are an unfair trade practice. Subjects health care providers that violate the statute to a civil penalty of not more than $1,000 per occurrence.
Requires DHHS to adopt rules to implement new GS 131E-214.54. Effective on the later of January 1, 2027 or the date DHHS adopts the rules discussed above. Requires DHHS to notify the Revisor when the rules adopted under GS 131E-214.54 take effect.
Part IX.
Expands the State Auditor’s responsibilities under GS 147-64.6 to include a periodic review of health service facilities that: (1) receive State funds and (2) are licensed under GS Chapter 122C that are recipients of State funds for information on the prices these facilities charge out-of-network or uninsured patients and their transparency about those prices. Requires that the State Auditor report findings to the specified NCGA committee by April 1, 2027, and periodically thereafter as specified.
Part X.
Expands the obligations pertaining to non-expedited appeals under GS 58-50-61(k) to include utilization review organizations (currently just insurers). Requires providing contact information for the insurer instead of the coordinator. Makes clarifying and technical changes. Requires an insurer to provide their contact information as part of the written information they `must provide as part of a first-level grievance review (currently have to provide review contact information for the coordinator) and makes technical changes to GS 58-50-62(e) (concerning first-level grievance reviews). Requires the insurer to provide information on how and where to submit written material for a second-level grievance review and contact information for the insurer (currently, just have to provide the coordinator's contact information) in GS 58-50-62(f) (second-level grievance reviews).
Part XI-A.
Amends GS 131E-176 (the definitions pertaining to certificates of need) so that rehabilitative health services; rehabilitation health service facilities; rehabilitation health service facility beds; rehabilitation facility hospitals for rehabilitation of injured, disabled, or sick persons and nursing provided at a non-inpatient rehabilitation facility for the rehabilitation of sick, injured, or disabled individuals are no longer included in the definitions. Amends term rehabilitation facility so that it means a facility that has been classified and designated as an inpatient rehabilitation facility by the Centers for Medicare and Medicaid Services (currently, means a public or private inpatient facility which is operated for the primary purpose of assisting in the rehabilitation of individuals with disabilities through an integrated program of medical and other services which are provided under competent, professional supervision).
Part XI-B.
Adds new Article 9B, Essential Rural Health Services Protection Act, to GS Chapter 131E, providing as follows. Defines essential rural health services as any of the following services when provided in a rural county or when reasonably necessary to maintain access for residents of a rural county: emergency services; obstetrical services, including labor and delivery; inpatient services; surgical services necessary for emergency stabilization or urgent intervention; behavioral health services, including inpatient psychiatric services; dialysis services; diagnostic imaging or laboratory services necessary for emergency diagnosis or treatment; primary care services, if the Department determines that loss or material reduction of the service would likely leave a rural county without reasonable local access; and any other service designated by the Department by rules adopted pursuant to this Article as essential to preserving access to care in rural counties. Defines rural county as one with a population density of 250 or fewer persons per square mile. Defines additional terms used in the Article.
Prohibits implementing a material change (as defined, including closure of an essential rural health service, reduction in hours or capacity, or relocation of essential services) affecting essential rural health services unless notice is given to DHHS at least 120 days before the proposed effective date of the material change. Sets out what must be included in the notice.
After receiving a notice, DHHS must evaluate whether the proposed material change is reasonably likely to do one or more of the seven listed scenarios, including materially reducing access to an essential rural health service for residents of a rural county; reduce the availability of emergency services, obstetrical services, behavioral health services, primary care, inpatient services, or other essential rural health services in a rural county; increase patient travel times or care delays beyond levels reasonably consistent with maintaining meaningful rural access; or create or worsen discriminatory admission, transfer, referral, staffing, or contracting practices that shift disproportionate burdens to essential rural providers. Sets out issues DHHS must consider in conducting the review and requires getting public input when DHHS determines it is necessary to complete its evaluation.
Requires DHHS to adopt rules establishing one or more financial viability thresholds for essential rural providers. If an essential rural provider falls below those thresholds, requires DHHS to initiate a rural financial viability review, reviewing specified issues. Allows DHHS, upon finding that continued access to essential rural health services is reasonably likely to be materially impaired as a result of an essential rural provider's financial viability status, to impose reporting requirements on the essential rural provider, impose a mitigation plan, or take other enforcement action.
Requires DHHS to do one of the following within 60 days of determining that a notice meets the statutory requirements: (1) issue a written notice that no further action is required; (2) approve the proposed material change subject to a mitigation plan that satisfies this statute’s criteria; or (3) issue a written determination prohibiting the proposed material change if DHHS finds that, even with a mitigation plan, (i) essential rural health services would not be adequately protected in the affected service area or (ii) the proposed material change is reasonably likely to materially destabilize the financial viability of an essential rural provider. Sets out actions that may be included in a mitigation plan, including a requirement to phase in proposed material changes over time, requirement to maintain a financial assistance polity for uninsured and underinsured patients, and reporting and monitoring requirements. Allows extending the time for making the determination o