LME/MCO ENROLLEE GRIEVANCES & APPEALS.

View NCGA Bill Details2013-2014 Session
Senate Bill 553 (Public) Filed Thursday, March 28, 2013
AN ACT TO ESTABLISH GRIEVANCE AND APPEAL PROCEDURES FOR LOCAL MANAGEMENT ENTITY/MANAGED CARE ORGANIZATION (LME/MCO) MEDICAID ENROLLEES; TO REQUIRE THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO ESTABLISH A SUPPORTIVE HOUSING PROGRAM FOR INDIVIDUALS TRANSITIONING FROM INSTITUTIONAL SETTINGS TO INTEGRATED COMMUNITY-BASED SETTINGS, TO CLARIFY HOW FUNDS APPROPRIATED TO THE DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR THE ESTABLISHMENT AND OPERATION OF THIS PROGRAM SHALL BE USED, AND TO CREATE A COMMUNITY LIVING HOUSING FUND WITHIN THE HOUSING FINANCE AGENCY TO INTEGRATE INDIVIDUALS WITH DISABILITIES INTO COMMUNITY-BASED SUPPORTED HOUSING; AND TO MODIFY ALLOCATION OF STATE'S SHARE IN HOSPITAL PROVIDER ASSESSMENT TAX.
Intro. by Hise.

Status: Ch. SL 2013-397 (Senate Action) (Aug 23 2013)

SOG comments (2):

Long title change.

Senate committee substitute changes the long title. The original title is as follows:

A BILL TO BE ENTITLED AN ACT TO ESTABLISH GRIEVANCE AND APPEAL PROCEDURES FOR MEDICAID ENROLLEES OF LOCAL MANAGEMENT ENTITIES THAT HAVE BEEN APPROVED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO OPERATE AS A MANAGED CARE ORGANIZATION UNDER THE 1915(B)/(C) MEDICAID WAIVER.

Title change

The conference report to the 3rd edition amends the act's long title. The previous title was: AN ACT TO ESTABLISH GRIEVANCE AND APPEAL PROCEDURES FOR LOCAL MANAGEMENT ENTITY/MANAGED CARE ORGANIZATION (LME/MCO) MEDICAID ENROLLEES.

Bill History:

S 553/S.L. 2013-397

Bill Summaries:

  • Summary date: Sep 3 2013 - More information

    AN ACT TO ESTABLISH GRIEVANCE AND APPEAL PROCEDURES FOR LOCAL MANAGEMENT ENTITY/MANAGED CARE ORGANIZATION (LME/MCO) MEDICAID ENROLLEES; TO REQUIRE THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO ESTABLISH A SUPPORTIVE HOUSING PROGRAM FOR INDIVIDUALS TRANSITIONING FROM INSTITUTIONAL SETTINGS TO INTEGRATED COMMUNITY-BASED SETTINGS, TO CLARIFY HOW FUNDS APPROPRIATED TO THE DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR THE ESTABLISHMENT AND OPERATION OF THIS PROGRAM SHALL BE USED, AND TO CREATE A COMMUNITY LIVING HOUSING FUND WITHIN THE HOUSING FINANCE AGENCY TO INTEGRATE INDIVIDUALS WITH DISABILITIES INTO COMMUNITY-BASED SUPPORTED HOUSING; AND TO MODIFY ALLOCATION OF STATE'S SHARE IN HOSPITAL PROVIDER ASSESSMENT TAX. Enacted August 23, 2013. Section 7 is effective October 1, 2013. Section 10 is effective July 1, 2013. The remainder is effective August 23, 2013.


  • Summary date: Jul 25 2013 - More information

    Conference report makes the following changes to the 3rd edition.

    Part I.

    Amends GS 108D-8(h) by amending the information that the Office of Administrative Hearings must include in its notice of hearing, to include the circumstances in which a medial assessment may be obtained at the LME/MCO's expense (was, at the Department of Health and Human Service's expense).

    Part II.

    Enacts new Article 1B, Transitions to Community Living, in GS Chapter 122C.

    Includes definitions for terms as they apply in this Article. Directs the Department of Health and Human Services (DHHS), in consultation with the NC Housing Finance Agency (HFA), to establish and administer the NC Supportive Housing Program (SHP), a tenant-based rental assistance program. Provides that the purpose of the SHP is to transition individuals who are diagnosed with serious mental illness and serious and persistent mental illness from institutional settings to more integrated community-based settings appropriate to meet their needs. Directs DHHS, in consultation with the HFA and LME/MCOs, to arrange for program participants to be placed in available housing slots through the program with all of the rights and obligations created by a landlord-tenant relationship.

    Provides guidelines for the administration of housing subsidies for supportive housing and directs the Division of Aging and Adult Services to establish eligibility requirements the Supportive Housing Program. Designates DHHS as having ongoing responsibilities for developing and distributing a list of potentially eligible program participants for each LME/MCO by catchment area. Shifts responsibility for prioritizing this information upon receipt to each LME/MCO. Directs DHHS to annually determine the number of housing slots to be allocated to each LME/MCO as specified in this act. Directs the LME/MCO to develop a written transition plan that identifies certain needs of the individual and the available housing slots that meet the individual's needs.

    Provides guidelines regarding transition services and tenancy support services. Directs DHHS to develop an application process for owners of housing units to participate in the program as landlords.

    Requires DHHS to report annually on October 1 to the Joint Legislative Oversight Committee on Health and Human Services on the number of individuals within the catchment area who transitioned into housing slots available through SHP during the preceding calendar year. Specifies that the report is to contain a breakdown of all the funds used by the LME/MCO to transition these individuals into the housing slots. Provides that DHHS is not required to provide housing slots to individuals beyond the number that can be supported by funds appropriated for this purpose.

    Requires that each LME/MCO transition at minimum 15 eligible individuals to community-based supported housing slots available through SHP no later than October 1, 2013.

    Requires funds appropriated to DHHS for the 2013-15 biennium to develop and implement housing, support, and other services for people with mental illness under the Department of Justice settlement agreement be used in specified ways. Effective October 1, 2013.

    Enacts new GS 122E-3A creating the Community Living Housing Fund (Fund) in the Housing Finance Agency (Agency) to pay for the transition of individuals diagnosed with severe mental illness or severe and persistent mental illness from institutional settings to community-based supported hosing and to increase the percentage of targeted housing units available to individuals with disabilities for use in the NC Supportive Housing Program. Make the Agency, in consultation with DHHS, responsible for administering the Fund. Fund monies are available only upon an act of appropriation by the General Assembly and may only be used for the specified purposes. Terminates the Transitions to Community Living Fund on June 30, 2020, and reverts any remaining balance to the General Fund.

    Part III.

    Amends GS 108A-123(d), if Senate Bill 402 becomes law, to provide that the first $43 million of the state's annual Medicaid payment must be allocated between the equity assessment and the UPL assessment with the remaining portion of the payment allocated to the UPL assessment. Effective July 1, 2013.


  • Summary date: Jul 24 2013 - More information

    Conference report to the 3rd edition is to be summarized.


  • Summary date: Jul 10 2013 - More information

    House committee substitute makes the following changes to the 2nd edition.

    Changes the title of new GS Chapter 108D to Medicaid Managed Care for Behavioral Health Services (was, LME/MCO Enrollee Grievances and Appeals). Makes clarifying changes to the definitions in GS 108D-1, spelling out acronyms and defining a Local Management Entity/Managed Care Organization (LME/MCO) as defined in GS 122C-3(20c). Amends the definition for network provider to delete provision that the term also includes a provider of emergency services. Deletes the definition for provider.

    Makes organizational, clarifying, and stylistic changes. Places LME/MCO enrolleegrievances and appeals procedures in new Article 2, Enrollee Grievances and Appeals. Clarifies that there is no right to appeal the resolution of an LME/MCO grievance tothe Office of Administrative Hearings (OAH) or any other forum.

    Amends new GS 108D-6 to delete specifications regardingthe content ofawritten notice of a managed care action to an enrollee and of the enrollee's right to appeal the managed care action, insteadrequiring that an LME/MCO provide an enrollee with written notice of a managed care action via United States mail as required under 42 CFR Part 438, Subpart F.

    Provides that an enrolleeor a network provider with written authorization to act on behalf of an enrolleehas a right to file a request for an LME/MCO level appeal of a notice of managed care action no later than 30 days after the mailing date of the notice of managed care action or the grievance disposition.

    Makes a technical correction to new GS 108D-6 and GS 108D-7 to provide that the enrollee is to be provided with an appeal request form for a contested case hearing that meets the requirements of GS 108D-8(f).

    Amends GS 108D-7, adding a new subsection (f) to require an LME/MCO to provide an enrollee with reasonable assistance in completing forms and taking other procedural steps necessary to file an appeal including providing (1) interpreter servicesand (2) toll free numbers with adequate teletypewriter/telecommunications devices for the deaf and interpreter capability. Re-letters subsections as necessary.

    Amends GS 108D-8 to provide that in requesting an appeal, the enrollee must file the appeal request form in accordance with OAH rules. Provides that any simplified hearing procedures approved by the chief administrative law judge (ALJ) must comply with all of the specified requirements in GS 108D-8(h). Directs the ALJ assigned to hear the case to consider and rule on all pre-hearing motions before the scheduled date for a hearing on the merits of the case (was, may includesuch a requirement). Provides that the enrollee has the burden of proof on all issues submitted to the OAH for a contested hearing under this section and the enrollee has the burden of going forward (was, provided the enrollee has burden of proof to show entitlement to a requested benefit under specified circumstances and the agency has the burden of proof in an appeal from a managed care action to impose a penaltyor to reduce, terminate, or suspend a previously granted benefit).

    Deletes amendment to GS 122C-3, which defined LME/MCO as an LME approved by the Department of Health and Human Services (DHHS) to operate the 1915(b)/(c) Medicaid Waiver.

    Amends GS 122C-151.3 and GS 122C-151.4 to clarify that these sections do not apply to specified LME/MCOs, enrollees, applicants, emergency service providers, or network providers subject to GS Chapter 108D. Amends GS 150B-23 to provide that an LME/MCO is considered an agency as defined in GS 150B-2(1a) only for the purposes of contested cases commenced as Medicaid managed care enrollee appeals under GS Chapter 108D.

    Directs DHHS to take any action necessary to implement this act by September 30, 2013, including submitting to the Centers for Medicare and Medicaid Services a Medicaid State Plan Amendment with a retroactive effective date of July 1, 2013 (was, required DHHS to submit a plan to implement this act on or before December 1, 2013).DHHS is to report to the Joint Legislative Oversight Committee on Health and Human Services on the status of the implementation of this act on or before September 30, 2013.

    Makes this act effective when it becomes law (was, effective June 1, 2014) and applies to grievances and managed care actions filed on or after that date.


  • Summary date: May 2 2013 - More information

    Senate committee substitute makes the following changes to the 1st edition. Amends GS 108D-5 to provide that an enrollee, or a network provider authorized in writing to act on behalf of an enrollee, receiving a grievance disposition has no right to the administrative appeal procedures described in GS 108D-6, GS 108D-7, and GS 108D-8 (previous edition allowed filing a request for an LME/MCO level appeal of a grievance disposition). Makes conforming changes throughout the act.

    Amends GS 108D-6 to require an LME/MCO to provide an enrollee, at least 10 days before the effective date of the manage care action, with written notice of a managed care action and of the enrollee's right to appeal the managed care action (previous edition did not specify time frame for notice). Notice is not required for an enrollee's parent, guardian, or legal representative unless it has been requested in writing. Specifies 12 items that are to be included in the notice.

    Amends GS 108D-8 to provide that the Office of Administrative Hearings (OAH) does not have jurisdiction over a dispute involving a managed care action except as expressly set forth in the chapter. Requires the LME/MCO be the respondent for purposes of the appeal. Allows the LME/MCO or enrollee to move for the permissive joinder of the Department of Health and Human Services (DHHS) under Rule 20; allows DHHS to move to intervene as a necessary party. Requires, in regards to contested case hearings, that an in-person hearing be conducted in the county that contains the headquarters of the LME/MCO, but allows the hearing to be conducted in the enrollee's county of residence, or a nearby county, for good cause. Good cause includes the enrollee's impairments limiting travel or the unavailability of the enrollee's treating professional witnesses. Provides that the simplified procedure may include requiring that all prehearing motions be considered and ruled on by the administrative law judge in the course of the hearing of the case on the merits (was, the judge must consider and rule on all prehearing motions before the scheduled date for a hearing on the merits). Adds that upon receiving an appeal request or a request for a hearing, OAH must immediately notify the Mediation Network of NC, which must contact the recipient within five days to offer mediation in an attempt to resolve the dispute. Sets out requirements if mediation is accepted. If the parties have resolved matters in the mediation, OAH must dismiss the case. Amends the burden of proof provision to provide that the enrollee has the burden of proof to show entitlement to a requested benefit or the propriety of requested action when the LME/MCO has denied the benefit or refused to take the particular action; the agency has the burden of proof when the appeal is from a managed care action to impose a penalty or to reduce, terminate, or suspend a previously granted benefit.

    Amends proposed language in GS 122C-3(20c) to provide that local management entity/managed care organization means an LME that has been approved by DHHS to operate the 1915(b)/(c) Medicaid Waiver (was, approved by DHHS to operate a managed care organization or prepaid inpatient health plan in accordance with 42 CFR Part 438).

    Deletes proposed language in GS 122C-3 and instead provides that the statute does not apply to enrollee grievances or appeals subject to GS Chapter 108D.

    Deletes proposed changes to GS 84-2.1 (practice law defined).

    Amends GS 150B-23 to allow a Medicaid enrollee, or network provider authorized in writing to act on behalf of the enrollee, who appeals a notice of resolution to commence a contested case under the Article in the same manner as any other petitioner.

    Requires DHHS, on or before December 1, 2013, to submit to the Centers for Medicare and Medicaid Services a Medicaid State Plan Amendment necessary to implement the act.

    Makes the act effective June 1, 2014 (was, July 1, 2013), and makes it effective contingent on approval by the Centers for Medicare and Medicaid Services. Requires DHHS to report to the Revisor of Statutes when approval is obtained and the date of the approval.

    Amends the act's long title.


  • Summary date: Apr 1 2013 - More information

    Enacts new GS Chapter 108D, Enrollee Grievances and Appeals of LME/MCO Managed Care Actions. Defines Local Management Entity/Managed Care Organization (LME/MCO) as an LME that has been approved by the Department of Health and Human Services to operate an MCO or PIHP in accordance with 42 CFR Part 438. Requires each LME/MCO to establish and maintain internal grievance and appeal procedures that (1) comply with the Social Security Act and 42 CFR Part 438, Subpart F, and (2) afford enrollees, and network providers authorized to act on behalf of enrollees, constitutional rights to due process and a fair hearing. Provides for the format of the grievance requests. Prohibits attempting to influence, limit, or interfere with an enrollee's right or decision to file a grievance, request for an LME/MCO level appeal, or a contested case hearing; also sets out activities that an LME/MCO is not prevented from doing. Prohibits an LME/MCO from taking punitive actions against a network provider for specified acts, including filing a grievance on behalf of an enrollee or supporting an enrollee's grievance.

    Provides in new GS 108D-5 for the filing of a grievance and requires that an LME/MCO resolve the grievance as expeditiously as the enrollee's health condition requires, but no later than 90 days after receiving the grievance; affected parties must be given written notice of the grievance disposition within the 90 day period. Allows an enrollee, or a network provider acting on behalf of an enrollee, to request for an LME/MCO level appeal of a grievance disposition under GS 108D-6 as long as the described grievance procedure has already been exhausted. Provides further guidelines for a standard LME/MCO level appeal and for expedited LME/MCO level appeals. Allows an expedited appeal when the time limits for completing a standard appeal could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function.

    Specifies that the Office of Administrative Hearings (OAH) does not have jurisdiction over a dispute concerning a grievance or managed care action, except as set forth in the Chapter. Provides that GS 108D-8 (contested case hearings on disputed managed care actions) is the exclusive method for an enrollee to contest a notice of resolution issued by an LME/MCO. Provides that an enrollee, or a network provider acting on behalf of an enrollee, has the right to file a request for appeal to contest a notice of resolution as long as the entity has exhausted the grievance procedure in GS 108D-5, and if applicable, the appeal procedures in GS 108D-6 (standard LME/MCO level appeals) or GS 108D-7 (expedited LME/MCO level appeals). Sets out the procedure for appealing a notice of resolution. Requires an LME/MCO to continue the enrollee's benefits during the pendency of an appeal to the same extent as required under 42 CFR 438.420. Allows the chief administrative law judge of OAH to limit and simplify the administrative hearing procedures that apply to contested case hearings under the statute to complete the cases as expeditiously as possible. Sets out requirements to be met by any simplified hearing procedures. Provides that the enrollee has the burden of proof on all issues submitted to OAH for a contested case hearing and has the burden of going forward. Sets out requirements for the use of new evidence. Requires the administrative law judge, for each managed care action, to determine whether the LME/MCO substantially prejudiced the rights of the enrollee and whether the LME/MCO (1) exceeded its authority or jurisdiction; (2) acted erroneously; (3) failed to use proper procedure; (4) acted arbitrarily or capriciously; or (5) failed to act as required by law or rule. Requires that the written decision notify parties of the decision and the right to seek judicial review of the decision under GS Chapter 150B, Article 4.

    Amends GS 112C-3 to define LME/MCO just as it is defined in new GS Chapter 108D.

    Makes conforming changes to GS GS 122-151.3 (Dispute with area authorities or county programs), and GS 122C-151.4 (Appeal to State MH/DD/SA Appeals Panel). Amends GS 84-2.1 (Practice law defined) to provide that the practice of law does not include representation of an LME/MCO by an employee or a contractor of the LME/MCO in a contested case hearing under GS 108D-8.

    Effective July 1, 2013.

     


  • Summary date: Mar 28 2013 - More information

    To be summarized at a later date.


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