AN ACT RELATING TO REQUIREMENTS OF MEDICAID AND HEALTH CHOICE PROVIDERS. Summarized in Daily Bulletin 3/31/11, 6/6/11, and 6/14/11. Enacted July 25, 2011. GS 108C-5, as enacted by Section 1, is effective July 25, 2011. GS 108C-6, as enacted by Section 1, and Section 4 are effective January 1, 2012. The remainder is effective July 25, 2011.
Summary date: Jul 25 2011 - View summary
Summary date: Jun 14 2011 - View summary
House committee substitute makes the following changes to 2nd edition. Amends proposed new GS 108C-2 to modify the definitions of managing employee and owner and/or operator to conform with federal regulations.
Amends proposed new GS 108C-3(d), (f), and (h) to specify that when the North Carolina Department of Health and Human Services (NCDHHS) designates a provider as a “limited,” “moderate,” or “high” categorical level of risk, the NCDHHS must conduct the screening functions required by federal law.
Amends proposed GS 108C-3(e) to add personal care services or in-home care services to the list of provider types that are designated as moderate categorical risk.
Amends proposed GS 108C-3(g) to specify that prospective (newly enrolling) agencies providing personal care services or in-home care services are designated as high categorical risk.
Amends proposed GS 108C-5(n)(4) to make a clarifying change.
Amends proposed GS 108C-9 to delete provision specifying that the approval or acceptance of a Medicaid administrative participation or enrollment agreement by NCDHHS that grants Medicaid billing privileges or allows a provider to furnish services in accordance with federal regulations requires compliance by the provider and the NCDHHS with the terms of the Medicaid administrative participation or enrollment agreement.
Effective January 1, 2012, amends GS 108-54.2 to (1) direct the NCDHHS to adopt rules to develop, amend, and adopt medical coverage policy in accordance with the statutory requirements; and (2) to define a medical coverage policy.
Amends GS 108A-54 to authorize the NCDHHS to adopt temporary and permanent rules to implement or define the federal laws and regulations, the North Carolina State Plan of Medical Assistance, and the North Carolina State Plan of the Health Insurance Program for Children, the terms and conditions of eligibility for applicants and recipients of the Medical Assistance Program and the Health Insurance Program for Children, audits and program integrity, the services, goods, supplies, or merchandise made available to recipients of the Medical Assistance Program and the Health Insurance Program for Children, and reimbursement for the services, goods, supplies, or merchandise made available to recipients of the Medical Assistance Program and the Health Insurance Program for Children. Makes other clarifying changes.
Summary date: Jun 6 2011 - View summary
Senate committee substitute makes the following changes to 1st edition. Rewrites proposed GS 108C-2 to include adverse determination, managing employee, and owner and/or operator as defined terms. Removes Affordable Care Act and payment suspension as defined terms, and makes other clarifying changes. Amends proposed GS 108C-3(c) by removing Transplants and Transplant-related services and vision providers from the list of limited risk provider types. Amends GS 108C-3(e) to remove from the moderate risk category the following providers: 1) revalidating agencies providing behavioral health services and 2) revalidating agencies providing HIV case management. Makes other clarifying and technical changes. Removes proposed provisions GS 108C-3(k)-(n), relating to Department of Health and Human Services’ (DHHS) verification and confirmation of provider licensure, revalidation of licensure, and inspection of providers. Directs DHHS to return the provider to the original risk category not later than 12 months after completion of the provider repayment.
Amends proposed GS 108C-4 to remove the definition provisions. Removes several provisions related to criminal history checks, except that DHHS must conduct criminal history record checks of provider applicants and enrolled providers in accordance with federal law and regulation. Provides that DHHS must honor civil and criminal settlement agreements entered into with a provider or any person with a 5% or greater direct or indirect ownership interest in the provider within 10 years of the effective date of the act.
Amends GS 108C-5 to detail reasons DHHS may suspend payment to providers, suspension procedures, and audit procedures. Effective when the act becomes law, and applies to audits instituted on or after that date and to final overpayments, assessments, or fines due on or after that date.
Deletes all provisions of proposed GS 108C-6 and replaces them with a new GS 108C-6 providing that DHHS may establish a registry of billing agents, clearinghouses, and/or alternate payees that submit claims on behalf of providers and to charge a fee to recover the costs of maintaining the registry in accordance with federal law and implementing regulations. Provides procedure for registration. Effective January 1, 2012.
Enacts new GS 108C-7 providing a provider may be required to undergo prepayment claims review by DHHS. Details the procedure for prepayment claims review.
Enacts new GS 108C-8 providing that, absent specified circumstances, DHHS is not to pursue recovery of Medicaid or Health Choice overpayments owed to the state for any total amount less than $150.
Enacts new GS 108C-9 detailing the application procedure for provider enrollment in North Carolina Medicaid or North Carolina Health Choice.
Enacts new GS 108C-10 providing that a provider must notify DHHS at least 30 calendar days prior to the effective date of any change of ownership. Details the instances that constitute a change of ownership under the act. Provides that assigned Medicaid administrative participation or enrollment agreements are subject to all applicable statutes, regulations, and the terms and conditions under which they were originally issued. Prohibits DHHS from requiring a provider to accept an assigned Medicaid administrative participation or enrollment agreement upon change in ownership as a condition of enrollment.
Enacts new GS 108C-11 to require a provider cooperate with all activities, announced or unannounced, conducted by DHHS. Directs DHHS to make attempts to examine documentation without interfering with the clinical activities of the provider while conducting activities on the provider’s premises.
Enacts new GS 108C-12 detailing the appeals process for a Medicaid provider or applicant to appeal an adverse determination made by DHHS.
Rewrites GS 150B-1(d)(9) to provide that DHHS is exempt from the rule making procedures under the Article when adopting new or amending existing medical coverage policies under the State Medicaid Program pursuant to GS 108A-54.2. Rewrites GS 150B-(1)(e) to remove the exemption from the contested case provisions of the following: (1) Medicaid providers appealing a denial or reduction in reimbursement for community support services and (2) community support services providers appealing decisions by the LME to deny or withdraw the provider’s endorsement.
Makes other clarifying and organizational changes. Deletes provisions authorizing the Division of Medical Assistance and other entities to study the criminal history record and other employment background checks among all providers and health care licensing boards. Unless otherwise noted, act is effective when it becomes law. Changes title to AN ACT RELATING TO REQUIREMENTS OF MEDICAID AND HEALTH CHOICE PROVIDERS.
Summary date: Mar 31 2011 - View summary
Adds a new GS Chapter 108C, Medicaid and Health Choice Provider Requirements. Requires the Department of Health and Human Services (department) to conduct screening of Medicaid and Health Choice providers and applicants in accordance with the federal Affordable Care Act, related regulations, and the act. Designates types of providers as being in Limited, Moderate, or High Risk Provider Categories, and sets out screening requirements for Limited, Moderate, and High Screening Levels. If a provider could fit in more than one category, the highest must be used. If the provider is also enrolled in Medicare, the department may rely on screening performed by Medicare contractors, and for out-of-state providers, may rely on screening performed by comparable agencies of other states. Enrollment must be revalidated at least every five years. Enrolled providers must permit unannounced on-site inspections of all provider locations. Sets out criminal history record check requirements for certain providers. Authorizes the Division of Medical Assistance, in consultation with stakeholder groups and the state Department of Justice, to study the status of criminal history record and employment background checks among all providers and health care licensing boards and make recommendations to the General Assembly when it reconvenes in 2012 concerning the use of background checks in connection with participation in the Medicaid and Health Choice programs.