North Carolina Medical Society
Sentinel Benefits Consulting

Health Plan Information

The NCMS Plan offers an array of Health Plan options designed to meet the needs of any sized practice. Plan offerings include 4 different plan types: Traditional PPO, PPO 1-2-3 Plans, High-deductible Health Plans (HDHPs), and High-performance Network Plans (HPNs).

The NCMS Plan partners with Blue Cross Blue Shield of North Carolina.  BCBSNC acts as the NCMS Plan’s provider which means leveraging BCBS’ network, systems & tools to administer our benefits.

All NCMS Plan products meet the ACA minimum value and minimum essential coverage requirement. NCMS Plan Groups are allowed to elect multiple plan offerings with options varying by group size:

Benefit Terminology



Benefit Period

12 months from the original effective date.

Effective Date

Date which coverage for a member begins.

Creditable Coverage

Accepted health insurance coverage carried prior to the plans coverage.


The North Carolina Medical Society Employee Benefit Plan.

Plan Administrator

Medical Mutual Insurance Company of North Carolina - Discretionary authority and responsibility to manage and direct the operation of the plan.


Person eligible for coverage under the health benefit plan due to employment and who is enrolled.


Employee or dependent currently enrolled in plan.


Spouse or Domestic Partner and/or Child (biological, stepchild, adopted, foster or under your legal guardianship) to age of 26. Intellectually or physically disable, incapable of self-support may continue coverage regardless of age if the condition exists prior to turning 26 (Disability must be medically certified by the child's physician).


A copay is a flat fee that you pay on the spot each time you go to your doctor of fill a prescription. Example: If your copay is $25, every time you go you will pay that $25 copay. 


The amount you pay for covered health care services before your insurance plan starts to pay. Example: If your deductible is $2,000 you are responsible for covering the first $2,000 dollars worth of covered services.


Is a portion of the medical cost you pay after your deductible has been met. Example: If your coinsurance is 20%, you pay 20% of your medical expenses after you have reached your deductible. You will continue to pay that 20% until you have reached your out-of-pocket maximum.

Out-of-Pocket Max (OOPM)

The out-of-pocket maximum is the most you can will pay for covered medical expenses in a given plan year. Example: If you have a hospital bill for $100,000 your OOPM is $7,500 the most you will be obligated to pay is $7,500. deductible and coinsurance also apply, but you will not pay more than $7,500 during that plan year. 

Total Out-of-Pocket Limit

Maximum amount payable by the member in a benefit period before BCBS NC pays 100% of covered services.

Life Time Maximum

The benefit maximum of certain covered services, that will be reimbursed on behalf of a member while covered under the plan. Services in excess of lifetime maximum are not covered services and member is responsible for entire provider bill.

Allowed Amount

Maximum amount is the negotiated amount that a physician has agreed to accept as payment and considered reasonable for covered services provided to a member by the Blue Cross NC.


Designated as participating in the Blue Options network.

In-Network Provider

Health care professional and facilities that are designated, contracted and participating providers.


Not designated as participating in the Blue Options network.

Out-of-Network Provider

Health care professional and facilities that are not designated, contracted and participting providers.

Waiting Period

Amount of time that must pass before a member is eligible to be covered for benefits under the terms of the plan.

Prior Authorization

Required to obtain before.


Date on which member receives the service, drug, equipment or supply for which a charge is made.


Determination by BCBS NC that a service covered under the plan satisfies the requirements for medically necessary services.


Adverse benefit determination by BCBS NC that a service covered under the plan was reviewed and does not meet the requirements for medical necessity.

Inpatient Care

Requires patient to be admitted and stay in a hospital overnight.

Outpatient Care

Is when a patient is seen and released from care without being admitted or having an overnight stay.

Medically Necessary

Covered services or supplies that are provided for or are necessary and appropriate to a diagnosis, treatment, cure or relief of a health condition (illness, injury or disease).

Preventive Care

Medical services provided that detect disease early in patients such as Immunizations, medications that delay or prevent disease, screenings and counseling services.


Service or supply that BCBS NC does not recognize as standard medical care of a condition, disease, illness or injury.


Dissatisfaction with any decisions, policies or actions related to availability, delivery or quality of health care services

Aggregate Deductible

The limit deductible a policyholder would be required to pay on claims during a given period of time.

Embedded Deductible

No single individual on a family plan will have to pay a deductible higher than the individual deductible amount. 

NCMS Eligibility Requirements

All groups participating in NCMS Plan benefits must agree to eligiblity requirements for managing your employee population. Below is a summary of key eligibility requirements:


The NCMS Employee Benefit Plan is a service offered only to members of the North Carolina Medical Society. 

Any medical practice in North Carolina must enroll and maintain membership status with the North Carolina Medical Society for 100% of the practicing physicians (MD & DO) owning or employed by the practice.  

Practices owned or run by Physician Assistants (PA’s) are also eligible following the same requirement criteria.


Requirement: Employer must contribute 50% or more of employee cost. Supported options for employer contribution are:

1. Percentage Contribution

2. Fixed Contribution Amount


Probationary Period, also known as waiting period, is the time between an employee’s Date of Hire and the effective date of their Health Plan coverage. Groups have the following options to choose from:




Retiree Eligibility

Retirees are eligible to stay on NCMS plan until age 65 or Medicare eligibility, whichever is first. Physicians can continue NCMS plan coverage after closing practice, as long as, NCMS membership is maintained. Spouse of Retiree is eligible to stay on NCMS plan until age 65, or Medicare eligibility, whichever is first.

Must be on plan prior to retirement and can retire from practice remaining in the plan until eligible for Medicare.
Must be on plan prior to retirement, be 55 years of age, and employed by group a minimum of 10 years.
Spouse of Retiree
Must be on plan prior to spouse retirement.

Dependent Requirements

Your spouse, under an existing marriage that is legally recognized under any state law.

Each person is eighteen (18) years of age or older;

  • Neither person is married;
  • Neither person has had another domestic partner within 12 months prior to the date you enroll the domestic partner under this group policy;
  • You and your domestic partner have shared the same residence for at least 12 months prior to the date you enroll the domestic partner under this group policy;
  • You and your domestic partner are not related by blood in a manner that would bar your marriage in the jurisdiction in which you reside;
  • You and your domestic partner have an exclusive mutual commitment to share the responsibility for each other’s welfare and financial obligations which commitment existed
    for at least 12 months prior to the date you enroll the domestic partner under this group policy, and such commitment is expected to last indefinitely


Two (2) or more of the following exist as evidence of joint responsibility for basic financial obligations:

  • A joint mortgage or lease;
  • Designation of the domestic partner as beneficiary for life insurance or retirement benefits;
  • Joint wills or designation of the domestic partner as executor and/or primary beneficiary;
  • Designation of the domestic partner as durable power of attorney or health care proxy;
  • Ownership of a joint bank account or credit card, or other evidence of joint financial responsibility; or
  • Other evidence of economic interdependence

A child, until the end of the month of their 26th birthday, who is either:

  1. the EMPLOYEE’S biological child, stepchild, legally adopted child (or child placed with the EMPLOYEE and/or spouse or domestic partner for adoption), FOSTER CHILD, or
  2. a child for whom legal guardianship has been awarded to the EMPLOYEE and/or spouse or domestic partner, or
  3. a child for whom the EMPLOYEE and/or spouse or domestic partner is required by court or administrative order to provide coverage.

The spouse or children of a DEPENDENT CHILD are not considered DEPENDENTS.

Children under age 18;

i) for whom a guardian has been appointed by a clerk of superior court of any county in North Carolina, or

ii) whose primary or sole custody has been assigned by court or administrative order with proper jurisdiction and who are residing with a person appointed as guardian or custodian for so long as the guardian or custodian has assumed the legal obligation for total or partial support of the children with the intent that the children reside with the guardian or custodian on more than a temporary or short-term basis.