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  • Summary date: Apr 10 2023 - View Summary

    Requires every local management entity/managed care organization (LME/MCO) to submit the following to the Department of Health and Human Services (DHHS) quarterly beginning October 1, 2023, and for four years thereafter: (1) number of individuals served by the LME/MCO who had an emergency department stay of more than 24 hours and the length of stay for each individual; (2) number, and percentage of, individuals served by the LME/MCO who were unable to access a healthcare provider both willing and able to initiate services within 30 days of the approval of those services; (3) amount of funds retained by the LME/MCO for services approved for an individual served by the LME/MCO but not used due to limited access to appropriate or available providers; (4) number of healthcare providers in the LME/MCO's network by provider type and any subsequent change; and (5) number of individuals deemed eligible for mental, behavioral, or substance use services pursuant to contract between DHHS and the LME/MCO who are not receiving any or all of those services through the LME/MCO, except when the needed service is made available by another payor.

    Requires the Secretary of DHHS to adopt rules incorporating the following to be met no later than December 31, 2023, and quarterly thereafter: (1) LME/MCOs must have fewer than two beneficiaries per county in the LME/MCO's catchment area boarded in a hospital emergency department at any one time; and (2) individuals served by the LME/MCO must have access to a willing and available healthcare provider and begin receiving all approved services within 45 days of the approval of the services at least 85% of the time (excluding specialized medical services for which there are extended wait times for individuals who are not Medicaid beneficiaries). Allows the Secretary to incorporate these items into any future managed care contracts. Also allows the Secretary to develop additional measures of LME/MCO compliance with requirements for timely access to services for individuals they serve. Failure of an LME/MCO to meet the benchmarks for two consecutive quarters constitutes a failure to provide for minimally adequate services and the Secretary must take corrective action and initiate the procedure in GS 122C-124.1 (actions by the Secretary when area authority or county program is not providing minimally adequate services).