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.
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.
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