Bill Summary for S 553 (2013-2014)

Summary date: 

May 2 2013

Bill Information:

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.

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Bill summary

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.

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