Bill Summaries: S 594 MEDICAID ADMIN. CHANGES & TECH. CORRECTIONS.-AB

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  • Summary date: Jun 29 2021 - More information

    AN ACT MODIFYING CERTAIN MEDICAID-RELATED PROVISIONS OF THE 2020 COVID-19 RECOVERY ACT, UPDATING THE MEDICAID PROGRAM BENEFICIARY APPEALS PROCESSES, INCREASING THE AMOUNT OF ALLOWABLE THERAPEUTIC LEAVE UNDER THE MEDICAID PROGRAM, CLARIFYING THE CODIFICATION OF BEHAVIORAL HEALTH SERVICES COVERED BY STANDARD BENEFIT PLANS, AUTHORIZING COVERAGE OPTIONS FOR BEHAVIORAL HEALTH SERVICES FOR POPULATIONS NOT COVERED BY PREPAID HEALTH PLAN CONTRACTS, REVISING THE TRANSFER OF AREA AUTHORITY FUND BALANCES, REMOVING THE RATE FLOOR FOR DURABLE MEDICAL EQUIPMENT, AND MAKING VARIOUS TECHNICAL CORRECTIONS TO THE STATUTES GOVERNING THE NORTH CAROLINA MEDICAID PROGRAM. SL 2021-62. Enacted June 29, 2021. Effective June 29, 2021, except as otherwise provided.


  • Summary date: Jun 24 2021 - More information

    House amendments to the 3rd edition make the following changes.

    Amendment #1 further amends GS 108D-35 by adding peer support services to those services that must be covered by all capitated PHP contracts.

    Amendment #2 amends the requirement that the Department of Health and Human Services (DHHS) post on its website any formula developed for determining the amount of risk reserve and other funds to be transferred when a county disengages from one area authority and realigns with another area authority, by requiring that the formula be posted before it is finalized. Requires that the final version of the formula be posted to the website by August 1, 2021.


  • Summary date: Jun 23 2021 - More information

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

    Part I.

    Changes the effective date of the proposed additions to Section 4.5, SL 2020-4, specifying that uninsured individuals receiving Medicaid coverage for COVID-19 testing are not covered by capitated prepaid health plan contracts under Article 4 of GS Chapter 130D. Makes the changes effective July 1, 2021 (was, the date the act becomes law).

    Part II.

    Makes a technical change to eliminate the section caption for new GS 108D-15.1, which provides for expedited contested case hearings on disputed adverse benefit determinations by a managed care entity. 

    Part III.

    Eliminates the proposed addition of peer support services, substance abuse comprehensive outpatient treatment program services, and substance abuse intensive outpatient program services to the services that all capitated PHP contracts governed by Article 4 must cover under GS 108D-35(1). Also eliminates the proposed addition of social setting detoxification services or clinically managed residential withdrawal services to the mandated coverage under GS 108D-35(1), effective upon the approval by the Centers for Medicare and Medicaid Services (CMS) of NC Medicaid coverage for such services, on the effective date of the allowed coverage. Makes conforming deletions.

    Eliminates the proposed changes to GS 108D-35, authorizing DHHS to determine whether services for Medicaid program applicants can be covered by a capitated contract during any period of time prior to eligibility determination.

    Adds the following content.

    Amends GS 108D-60 to authorize DHHS to contract with entities operating Behavioral Health and Intellectual/Developmental Disability (BH IDD) tailored plans under a capitated or other arrangement for the management of behavioral health, intellectual and developmental disability, and traumatic brain injury services for any recipients excluded from prepaid health plan (PHP) contracts under specified subdivisions of GS 108D-40(a), with population categories identified including medically needy Medicaid recipients, members of federally recognized tribes, participants in the North Carolina Health Insurance Premium Payment (NC HIPP) program, and those being served through the Community Alternatives Program for Children (CAP/C) or the Community Alternatives Program for Disabled Adults (CAP/DA), among others. Amends GS 122C-115, granting authority for such entities to continue to manage the named services for these described recipients under any contract with DHHS in accordance with GS 108D-60. 

    Directs that, when a county disengages and realigns area authorities, a portion of the risk reserve and other funds of an area authority must be transferred to the area authority with which a county is realigning, with the transferred amount determined by DHHS pursuant to a formula developed pursuant to the requirements and limitations specified. Exempts the development and application of the formula from statutory rulemaking requirements; however, requires DHHS to accept public comment on the proposed formula. Requires area authorities to provide DHHS with necessary financial information for determination of the transfer amount. Requires DHHS to post the formula on its website and provide notice to all area authorities and the specified NCGA committees and division. Directs DHHS to report to the specified NCGA committees and division by October 15, 2021, on any formulas developed and any funds transferred during the previous quarter. Requires quarterly reporting beginning January 15, 2022, through April 15, 2026, on any funds transferred as a result of disengagements during the previous quarter. Requires a final quarterly report on June 30, 2026. Effective when the act becomes law and applies to disengagements approved by DHHS with an effective date on or after September 1, 2021; expires June 30, 2026.

    Changes the proposed revisions to Section 11 of SL 2020-88, regarding the rate floor for durable medical equipment and supplies and orthotics and prosthetics under managed care, by setting the reimbursement rate at 100% of the lesser of the supplier's usual and customary rate or the maximum allowable Medicaid fee-for-service rates, for the first five years (was, the lesser of the supplier's usual and customary rate or the maximum allowable Medicaid fee-for-service rates, for the first three years). Makes the changes effective July 1, 2021 (was, effective on the date the act becomes law).

    Part IV.

    Changes the effective date for the proposed changes to GS 108D-5.3(b)(1) and GS 108D-40(a)(5) (providing for the enrollment and disenrollment of beneficiaries who meet the federal definition of Indian), and the proposed repeal of GS 108D-40(a)(5a) and conforming proposed changes to GS 122C-115(e) (eliminating the exclusion of eligible recipients who are enrolled in a DHHS-contracted Indian managed care entity from the populations capitated PHP contracted are automatically required to cover). Makes the changes effective July 1, 2021 (was, effective on the date the act becomes law).

    Changes the effective date of the proposed changes to GS 108D-35, specifying that capitated PHP contracts do not cover services documented in an individualized family service plan under the federal Individuals with Disabilities Education Act that are provided and billed by a Children's Development Services Agency or by such Agency's contracted provider of those services. Makes the changes effective July 1, 2021 (was, effective on the date the act becomes law).

    Changes the act's long title. 


  • Summary date: May 6 2021 - More information

    Senate committee substitute adds the following content to the 1st edition.

    Part III.

    Adds peer support services, substance abuse comprehensive outpatient treatment program services, and substance abuse intensive outpatient program services to the services that all capitated PHP contracts governed by Article 4 must cover under GS 108D-35(1). Makes organizational changes to organize the subdivision's provisions into sub-subdivisions. 

    Additionally adds social setting detoxification services or clinically managed residential withdrawal services to the mandated coverage under GS 108D-35(1), effective upon the approval by the Centers for Medicare and Medicaid Services (CMS) of NC Medicaid coverage for such services, on the effective date of the allowed coverage. Requires the Secretary of the Department of Health and Human Services to notify the Revisor of Statutes of the effective date allowed by CMS upon receipt of approval. Repeals this provision if CMS approval is not granted by June 30, 2023.

    Further amends GS 108D-35, organizing its provisions into subsections (a) and (b). Adds a new subsection (c) to authorize DHHS to determine whether services for Medicaid program applicants can be covered by a capitated contract during any period of time prior to eligibility determination (currently prohibited by subdivision (6) of the statute). Makes conforming changes.  

    Makes a technical change to the heading given to Section 3.5 of the act. 

    Amends Section 11 of SL 2020-88, which establishes a rate floor for durable medical equipment under managed care at 100% of the Medicare fee-for-service rates for durable medical equipment for the first three years of the initial standard benefit plan prepaid health plan (PHP) capitated contracts under Article 4, GS Chapter 108D. Revises the provision to instead set the reimbursement for durable medical equipment and supplies and orthotics and prosthetics under managed care to be the lesser of the supplier's usual and customary rate or the maximum allowable Medicaid fee-for-service rates for durable medical equipment and supplies and orthotics and prosthetics, applicable to the first three years of the initial standard benefit plan PHP capitated contracts.

    Part IV.

    Amends GS 108D-23, now requiring entities operating Behavioral Health and Intellectual/Developmental Disability (BH IDD) tailored plans to develop and maintain a closed network of providers (was, closed provider networks) only for the provision of behavioral health, intellectual and developmental disability, and traumatic brain injury services.

    Changes the act's long title. 


  • Summary date: Apr 8 2021 - More information

    Part I.

    Amends Section 4.5 of SL 2020-4 (2020 COVID-19 Recovery Act), which authorizes the Department of Health and Human Services (DHHS), Division of Health Benefits (DHB) to provide Medicaid coverage for COVID-19 testing for certain uninsured individuals during the declared nationwide public health emergency for which federal medical assistance is 100%. Adds a provision to specify that individuals receiving this Medicaid coverage are not covered by capitated prepaid health plans contracts under Article 4 of GS Chapter 130D, which governs such contracts.

    Effective 30 days after the act becomes laws, repeals Section 4.7 of SL 2020-4, which identifies four statutory provisions of GS Chapter 108C setting forth provider applicant requirements which are not to apply to the NC Medicaid program and the NC Health Choice program from March 1, 2020, through the duration of the declared nationwide public health emergency as a result of COVID-19.

    Part II.

    Enacts GS 108A-70.9A(c1), directing the DHHS to make available to the Office of Administrative Hearing (OAH) a copy of the notice of an adverse Medicaid benefit determination required by subsection (c). Deems information contained in the notice confidential unless the Medicaid recipient appeals the adverse determination under subsection (d). Allows OAH to dispose of these records after one year. Amends the procedures for appeal in subsection (d), now requiring the recipient to request a hearing within 30 days of the mailing of the notice of adverse determination by filing an appeal request with OAH (was by sending an appeal request form to OAH and DHHS). No longer requires DHHS to immediately forward a copy of the notice to OAH electronically. Makes conforming changes, repealing language now moved to new subsection (c1). Amends the required content of the appeal request form set forth in subsection (e)(1) to include a statement that the recipient can alternatively call the number on the form and provide the information requested on the form, rather than sending the form by mail or fax, within the 30 day time period. Makes conforming changes. 

    Makes similar changes to appeal request forms following receipt of notice of a disenrollment request by an enrollee or a prepaid health plan (PHP) under GS 108D-5.7 to allow an enrollee to file an appeal by calling the number on the form and providing the information requested on the form. Amends GS 108D-5.9 to require an enrollee or a representative to request a hearing to appeal an adverse enrollment determination by filing the appeal request form provided under GS 108D-5.7, as amended, by sending the form by mail or fax, or by calling the number on the form and providing the information requested on the form (previously generally required filing an appeal for a hearing). 

    Amends GS 108D-11 to no longer require an enrollee or representative's managed care entity level appeals made orally to be followed by a written, signed appeal, except when requesting an expedited appeal.

    Amends GS 108D-15(d) to require an enrollee or representative to file a request for appeal of a managed care entity's adverse determination by filing an appeal request form with OAH within 120 days after the mailing date notice of resolution of the entity level appeal (was by sending an appeal request form to OAH and the affected managed care entity). Allows for filing by sending the form by mail or fax, or calling the number on the form and providing the information requested on the form. Makes conforming changes to the appeal request form requirements set forth in GS 108D-15(f)(1).

    Further amends GS 108A-70.9A, enacting new subsection (e1) to allow a Medicaid recipient to request an expedited appeal of an adverse benefit determination if the time otherwise permitted would jeopardize the recipient's life, health, or ability to attain, maintain, or regain maximum function. Lists parameters for expedited appeals, including (1) requiring documentation from a licensed health care professional demonstrating the need for an expedited appeal, (2) DHHS determining expedited appeal criteria are not met and giving the recipient oral notice of denial expeditiously as possible, followed by a written notice of denial, which cannot be appealed, and (3) DHHS determining expediated appeal criteria are met and requiring the administrative law judge to make a decision on the contested case, as required under GS 108A-70.9B, as expeditiously as possible with no mediation procedure required. Amends the appeals request form requirements under subsection (e) to include the recipient's option to request an expedited appeal.

    Similarly enacts GS 108A-79(j1) to allow a Medicaid or NC Health Choice applicant or recipient to request an appeal from the director of social services' decision at the local appeal hearing, or an appeal involving disability, be expedited if time otherwise permitted for a hearing could jeopardize the recipient's life, health, or ability to attain, maintain, or regain maximum function. Lists parameters for expedited appeals, including (1) requiring documentation from a licensed health care professional, or for disability appeals excerpts from medical records, demonstrating the need for an expedited appeal, (2) DHHS determining expedited appeal criteria are not met and giving the appellant oral notice of denial expeditiously as possible, followed by a written notice of denial, which cannot be appealed, and (3) DHHS determining expediated appeal criteria are met and requiring the hearing officer to prepare a proposal and the designate DHHS official to make a final decision on the proposal, as required under subsection (j), as expeditiously as possible. Clarifies that the option for an expedited appeal does not grant an appellant any greater assistance than otherwise entitled. Amends subsection (c) to require the notice of action regarding Medicaid and NC Health Choice programs to include that the public assistance applicant or recipient can request an expedited appeal under the existing procedures of subsection (j1).

    Further amends GS 108D-5.7 regarding an enrollee's request for expedited disenrollment from a PHP, deeming DHHS's oral notification of its determination that the enrollee does not meet the criteria for expedited disenrollment is not required to be followed up by written notice by mail (however, maintains the requirement to follow up with written notice of the denial), and adds that the denial is not appealable. 

    Clarifies that the option for an enrollee to request an expedited appeal under GS 108D-14 applies to standard managed care entity level appeals under GS 108D-13. Further amends the statute to deem managed care entity's denial for an expedited managed care entity level appeal is not appealable. 

    Enacts GS 108D-15.1 to allow an enrollee to request an appeal from an adverse determination by a managed care entity be expedited if the time otherwise permitted for a hearing could jeopardize the enrollee's life, health, or ability to attain, maintain, or regain maximum function. Lists parameters for expedited appeals, including (1) requiring documentation from a licensed health care professional demonstrating the need for an expedited appeal, (2) DHHS determining expedited appeal criteria are not met and giving the enrollee oral notice of denial expeditiously as possible, followed by a written notice of denial, which cannot be appealed, and (3) DHHS determining expediated appeal criteria are met and the administrative law judge is required to make a decision on the contested case, as required under GS 108D-16, as expeditiously as possible with no mediation procedure required. Amends the appeals request form requirements under subsection (f) of GS 108D-15 to include the enrollee's option to request an expedited appeal.

    Part III.

    Revises GS 108A-62 to now provide the following. Permits a medical assistance beneficiary at an intermediate care facility or skilled nursing facility to take therapeutic leave without the facility losing reimbursement under the medical assistance program, so long as the leave taken in a calendar year does not exceed 90 days for a beneficiary in an intermediate care facility, or 60 days for a beneficiary in a skilled nursing facility (previously provided for 60 days in a calendar year for both facilities, with no coverage beyond 60 days). Requires prior approval by either DHB, the respective LME/MCO, or the respective PHP before taking 15 or more consecutive days of therapeutic leave (previously provided for approval by DHB only). Entitles individuals who had exhausted the amount of therapeutic leave prior to the date the act becomes law to any additional leave for the calendar year now allowed under the statute, as amended.

    Revises and adds to GS 122C-115.3 governing area authorities. Requires the DHHS Secretary to direct the dissolution of any authority that does not receive an initial contract to operate a Behavioral Health and Intellectual/Developmental Disability (BH IDD) tailored plan, prior to the date that BH IDD tailored plans begin operating. Requires the Secretary to deliver a notice of dissolution to the board of county commissioners of each of the counties in the dissolved LME/MCO. Now requires any fund balance or risk reserve (was fund balance only) available to an area authority at the time of its dissolution that is not used to pay liabilities to be transferred to one or more area authorities contracted to operate the 1915(b)/(c) Medicaid waiver or a BH IDD tailored plan in all or a portion of the catchment area of the dissolved authority, as directed by DHHS (previously provided for transfer to the area authority contracted to operate the Medicaid waiver in the catchment area of the dissolved area authority only, and did not specify for the transfer to be at the direction of DHHS). Makes organizational changes to the provisions regarding the directive for the Secretary to guarantee operation reserves for the area authority assuming the Medicate waiver responsibilities if the fund balance transferred doe not meet a specified threshold for anticipated operational expenses, and makes the provisions effective until the date that BH IDD tailored plans begin operating. 

    Part IV.

    Identifies sections in GS Chapter 108A to which the Revisor is directed to replace "the mentally retarded" with "individuals with intellectual disabilities."

    Amends GS 90-21.50, which sets forth definitions applicable to Article 1G governing health care liability, to no longer except the Health Insurance Program for Children established under Part 8, Article 2, GS Chapter 108A, from the State or federal plans exempt from the term health benefit plan. Additionally amends managed care entity to no longer exclude the Health Insurance Program for Children from employers who purchase coverage on behalf of its employees or health care providers, who are excluded from the term. 

    Amends GS 108A-54.3A to increase the age limitations for Medicaid coverage for children receiving foster care or adoption assistance under Title VI-E of the Social Security Act from 19 to 21.

    Amends GS 108A-68.2 to define PHP by statutory cross-reference to GS 108D-1, which defines the term as a prepaid health plan, as defined in GS 58-93-5, that is under a capitated contract with the Department for the delivery of Medicaid and NC Health Choice services, or a local management entity/managed care organization that is under a capitated contract with DHHS to operate a BH IDD tailored plan (previously defined the term to mean an entity holding a PHP license under Article 93 of GS Chapter 58). Makes organizational and technical changes. 

    Amends GS 108C-2.1 to refer Medicaid program providers' "revalidation" rather than "recredentialing."

    Adds CMS (Centers for Medicare and Medicaid Service) to the defined terms in GS 108D-1.

    Further amends GS 108D-1 to revise closed network, now defining the term to mean the network of providers that have contracted with either a LME/MCO operating the combined 1915(b)/(c) waivers, or an entity operating a BH IDD tailored plan, to furnish mental health, intellectual disabilities, and substance abuse services to enrollees (was limited to LME/MCOs).

    Amends GS 108D-5.3(b) to allow beneficiaries who meet the federal definition of Indian to request disenrollment from a PHP at any time (was members of federally recognized tribes). Makes similar changes to GS 108D-40(a), regarding populations not automatically covered by capitated PHP contracts; maintains that such recipient can enroll voluntarily in PHPs. 

    Repeals GS 108D-40(a)(5a), which excludes eligible recipients who are enrolled in a DHHS-contracted Indian managed care entity from the populations capitated PHP contracted are automatically required to cover. Makes conforming changes to GS 122C-115.

    Amends GS 108D-35, specifying that capitated PHP contracts do not cover services documented in an individualized family service plan under the federal Individuals with Disabilities Education Act that are provided and billed by a Children's Development Services Agency or by such Agency's contracted provider of those services (previously excluded services provided and billed by a Children's Development Services Agency that are included on the child's Individualized Family Service Plan). 

    Repeals Article 17 of GS Chapter 131E, which governs provider sponsored organization licensing. 


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