AN ACT TO REQUIRE FURTHER REPORTING FROM THE DEPARTMENT OF HEALTH AND HUMAN SERVICES RELATED TO TRANSFORMATION OF THE MEDICAID AND NC HEALTH CHOICE PROGRAMS AND TO MODIFY CERTAIN PROVISIONS OF THE MEDICAID TRANSFORMATION LEGISLATION. Enacted July 28, 2016. Section 2(j) is effective July 28, 2016. The remainder is effective retroactively to June 1, 2016.
Summary date: Aug 2 2016 - More information
Summary date: Jul 1 2016 - More information
Conference report makes the following changes to the 3rd edition.
Amends Section 4 of SL 2015-245, concerning the structure of the transformed Medicaid and NC Health Choice programs as described in Section 1 of SL 2015-245, by making the following changes to subdivision (2). Defines provider-led entity or PLE to be an entity that (1) a majority of the entity's ownership is held by an individual or entity that has as its primary business purpose the ownership or operation of one or more capitated contracts described in subdivision (3) of the statute (previously, did not specify capitated contracts) or Medicaid and NC Health Choice providers; (2) a majority of the entity's governing body is composed of individuals who are licensed in the State as physicians, physician assistants, nurse practitioners, or psychologists and have experience treating beneficiaries of the North Carolina Medicaid program (previously, did not have experience requirement); and (3) holds a PHP license issued by the Department of Insurance. Additionally, amends subdivision (4), concerning services covered by PHPs, to include behavioral health services for Medicaid recipients currently covered by the local management entities/managed care organizations (LME/MCOs) for four years after the date capitated contracts begin (previously, are to be excluded from the capitated contracts for at least four years after the date capitated contracts begin).
Amends SL 2015-245 (Medicaid Transformation and Reorganization), Section 22A, to authorize DHHS, notwithstanding SL 2015-241 (2015 Appropriations Act), as amended, which requires a reduction within the Division of Medical Assistance (DMA), to establish, maintain, or adjust all Medicaid program components, except for eligibility categories and income thresholds, within the appropriated and allocated budget for the Medicaid program, provided that the total Medicaid expenditures, net of agency receipts, do not exceed the authorized budget for the Medicaid program, in accordance with GS 108A-54(e). Additionally, provides that if DHHS intends to maintain any program components authorized in Section 22A(a) (as enacted by the act), then no later than 60 calendar days after the act becomes law, DHHS is required to request that the Office of State Budget and Management (OSBM) certify that there are sufficient recurring Medicaid funds to maintain the program component. Establishes that, if OSBM does not certify by the end of the 30-day period that there are sufficient recurring Medicaid funds to maintain the program component, then DHHS must implement reduction required by SL 2015-241, as amended.
Provides that new Section 2(j) of the act is effective when the act becomes law, and the remainder is retroactively effective June 1, 2016.
Summary date: May 25 2016 - More information
House committee substitute makes the following changes to the 2nd edition.
Amends Section 4 of SL 2015-245 to provide that the required capitated contracts will not cover: (1) services provided directly by a Children's Developmental Services Agency (CDSA) or by a provider under contract with a CDSA if the service is authorized through the CDSA and is included on the child's Individualized Family Service Plan (was, services provided pursuant to a contract with Children's Developmental Services Agencies only) and (2) services for Medicaid program applicants during the period of time prior to eligibility determination (was, services for Medicaid program applicants during the three-month retroactive eligibility period, with services provided during a prospective 12-month continuous enrollment period covered by the capitated contracts). Amends the categories that do not have to be covered by capitated PHP contracts to also exclude recipients who participate in the North Carolina Health Insurance Premium Payment program. Amends the existing exclusions to remove language that required presumptively eligible recipients who submit a full Medicaid application and are determined eligible for the Medicaid program to be covered by capitated contracts during the prospective 12-month continuous enrollment period after they have been determined eligible.
Amends SL 2015-245 by adding a new section that authorizes the Department of Health and Human Services (DHHS) to seek approval from the Centers for Medicare and Medicaid Services (CMS) through the 1115 waiver to allow parents to retain Medicaid eligibility while their child is being served temporarily by the foster care program. States the General Assembly's intent to expand Medicaid eligibility to cover this population upon implementation of the 1115 waiver, if CMS approves this coverage in the waiver.
Amends the powers of the Secretary of the Department of Health and Human Services in GS 108A-54 to clarify that in administering and operating the Medicaid and NC Health Choice programs, the total expenditures must not exceed the authorized budget for the Medicaid program and NC Health Choice program.
Summary date: May 17 2016 - More information
Senate committee substitute makes the following changes to the 1st edition.
Amends the act's short and long titles.
Amends Section 3 of SL 2015-245 to require DHHS (Department of Health and Human Services), instead of its Division of Health Benefits, to meet several Medicaid transformation reporting and development requirements. This replacement was made necessary due to the changes made to Section 4 of the same session law, which now provides that DHHS alone (previously, DHHS through the Division of Health Benefits) is responsible for the planning and implementation of the Medicaid transformation pursuant to SL 2015-245. Further amends Section 4 of SL 2015-245 concerning services not covered by capitated prepaid health plans (PHPs) contracts, adding four new services not covered, including services provided through the Program of All-Inclusive Care for the Elderly program and services provided pursuant to a contract with Children's Developmental Services Agencies. Makes clarifying and organizational changes. Also amends the provisions concerning the populations covered by PHPs, adding five new classes of individuals that are not covered, including medically needy Medicaid recipients, members of federally recognized tribes, or undocumented aliens that qualify for emergency services under 8 USC 1611. Further provides that there can be up to 12 contracts (previously, allowed up to only 10 contracts) between the Division of Health Benefits and a Provider-led entity (PLE).
Amends Section 5 of SL 2015-245, updating and replacing references to the phrase "DHHS through the Division of Health Benefits" with "DHHS." Also amends provisions concerning the designation of Medicaid and NC Health Choice providers as essential providers, adding State Veterans Homes to the list of providers that at a minimum are designated essential providers. Further amends Section 8 and 9 of the session law, updating and correcting references to "DHHS through the Division of Health Benefits" to just "DHHS." Also amends Section 10 of SL 2015-245 by making DHHS responsible for implementing the Medicaid transformation and operating all functions, powers, duties, obligations, and services related to the transformed Medicaid and NC Health Choice programs (previously these were responsibilities of the Division of Health Benefits). Also adds language that allows the Secretary of DHHS to appoint a Director of the Division of Health Benefits prior to GS 143B-216.85 (Appointment; term of office; and removal of the Director of the Division of Health Benefits) becoming effective.
Amends GS 143B-216.80, creation of the Division of Health Benefits, providing that the Division of Health Benefits will be vested with all functions, powers, duties, obligations, and services that were previously vested in the Division of Medical Assistance once the Division of Medical Assistance has been eliminated. Makes organizational and clarifying changes and also adds a new subsection (b), which substantively was previously found in GS 108A-54 (g), which sets out certain exemptions, limitations, and modifications for the Division of Health Benefits, including that employees of the Division are not subject to the NC Human Resources Act, except as provided, and that the Secretary can retain private legal counsel as provided.
Amends GS 108A-54, concerning the authorization of the Medical Assistance Program, providing that DHHS will continue to administer and operate the Medicaid and NC Health Choice program through the Division of Medical Assistance until the Division of Medical Assistance is eliminated, at which time all such powers and duties will be vested in the Division of Health Benefits. Makes clarifying and conforming changes. Deletes provisions from (g) which are now substantively found in GS 143B-216.80.
Amends GS 143B-139.6C(d), the definitions section concerning the cooling-off period for certain DHHS employees, making organizational and clarifying changes, as well as providing that if an employee or contract employee of DHHS within the previous six months personally participated in (in addition to regulatory or licensing decision that applied to the vendor): (1) an audit, decision, investigation, or other action that affected the vendor, or (2) the award (was, award or management) of a contract to the vendor, then that employee is considered a former employee of DHHS for the purposes of the cooling off period and prohibition on contracting with former employees of DHHS.
Summary date: May 10 2016 - More information
Identical to H 968 filed on 4/26/26.
Directs the Department of Health and Human Services to submit a report to the Joint Legislative Oversight Committee for Medicaid and NC Health Choice and the Fiscal Research Division no later than October 1, 2016, containing the following: (1) the status of the 1115 waiver submission to the Centers for Medicare and Medicaid Services (CMS) and any other submissions relating to the transition of Medicaid and Health Choice from fee for service to capitation, with responses from CMS and strategies to ensure approval of a waiver for Medicaid transformation, (2) a detailed Work Plan for the implementation of the transformation of Medicaid and Health Choice programs, (3) a detailed description of any developments or changes during the planning process to enable the General Assembly to address any barriers to successful implementation of the Medicaid and NC Health Choice transformation.
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