Health Reform FAQs

Has the state of North Carolina created a health benefit exchange?

No. In 2013, the North Carolina General Assembly passed Senate Bill 4, a bill that clearly states that North Carolina will not create a state-based exchange and will not expand Medicaid as proposed by the Affordable Care Act.

If you live in North Carolina and are seeking insurance from an exchange or marketplace, visit to view your options and sign up for coverage.

Has the State of North Carolina expanded Medicaid services as proposed by the Affordable Care Act?

No. The June 2012 Supreme Court ruling made Medicaid expansion optional for states. Following this ruling, the North Carolina General Assembly passed Senate Bill 4, a bill that clearly states that North Carolina will not create a state-based exchange and will not expand Medicaid as proposed by the Affordable Care Act.

As of January 2014, NC Medicaid eligibility for non-disabled adults is limited to parents with incomes below 43% of poverty, or about $10,100 a year for a family of four. Non-disabled adults without dependent children remain ineligible regardless of income. Children with family incomes up to 216% of poverty (about $50,600 for a family of four) are eligible for Medicaid or CHIP.

Is there any financial assistance available to North Carolinians who cannot afford coverage?

Under the ACA, people with incomes between 100% and 400% of the federal poverty level may be eligible for premium tax credits when they purchase coverage in a marketplace. This subsidy is based on income and approximately one in three uninsured North Carolinians will qualify.

Approximately 300,000 individuals who do not qualify for Medicare or Medicaid and do not qualify for these subsidies may fall into what is called “the coverage gap” and will see no change in coverage following full implementation of the ACA in North Carolina.

Am I Eligible for a Primary Care Bonus Payment?

The ACA provides for a ten percent bonus payment on top of the fee schedule payments for certain primary care services furnished by primary care physicians from now until calendar year 2015. In order to receive this bonus, you must be self-designated in a primary care specialty of general internal medicine, family medicine, pediatrics or geriatrics. Obstetrics and gynecology is not covered under the bonus payment and hospitalists do not normally qualify.  Additionally 60 percent of your Medicare allowable charges must be for designated primary care services. The Centers for Medicare and Medicaid Services (CMS) will determine if you qualify and will distribute payments quarterly.

What is the Sunshine Act and how does it affect physicians?

The Physician Payments Sunshine Act is part of the ACA and requires drug and device manufacturers participating in federal health care programs to report certain payments or gifts to physicians and teaching hospitals.  Residents, nurse practitioners and office staff are not covered under the Sunshine Act and reporting of payments or gifts to these individuals is not required.

Manufacturers of drugs or medical devices will report this information to CMS on an annual basis. Typical items that must be reported include the cost of meals provided to physicians, payments made to physicians in exchange for services such as speaking at an event or consulting, and travel expenses.

Do I have to report what drug samples my office receives?

As of 2012, each manufacturer and authorized distributor of record of an applicable drug shall report the name, quantity and dosage of all drug samples given to physician offices as well as the date samples were provided. The name, address, professional designation and authorized signature for the practitioner receiving the drugs must also be reported.  Manufacturers or distributors of record are also required to report any theft of samples.  It is important to note that under the ACA, the Secretary of Health and Human Services can require that any other category of information also be reported.  The ACA does not direct new requirements on individual physicians or practices to report information regarding drug samples. However, it is possible that the increased reporting requirements for manufacturers and distributors of drug samples may result in additional administration obligations for medical practices.

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