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.
House committee substitute makes the following changes to the 2nd edition.
Changes the title of new GS Chapter 108D to Medicaid Managed Care for Behavioral Health Services (was, LME/MCO Enrollee Grievances and Appeals). Makes clarifying changes to the definitions in GS 108D-1, spelling out acronyms and defining a Local Management Entity/Managed Care Organization (LME/MCO) as defined in GS 122C-3(20c). Amends the definition for network provider to delete provision that the term also includes a provider of emergency services. Deletes the definition for provider.
Makes organizational, clarifying, and stylistic changes. Places LME/MCO enrolleegrievances and appeals procedures in new Article 2, Enrollee Grievances and Appeals. Clarifies that there is no right to appeal the resolution of an LME/MCO grievance tothe Office of Administrative Hearings (OAH) or any other forum.
Amends new GS 108D-6 to delete specifications regardingthe content ofawritten notice of a managed care action to an enrollee and of the enrollee's right to appeal the managed care action, insteadrequiring that an LME/MCO provide an enrollee with written notice of a managed care action via United States mail as required under 42 CFR Part 438, Subpart F.
Provides that an enrolleeor a network provider with written authorization to act on behalf of an enrolleehas a right to file a request for an LME/MCO level appeal of a notice of managed care action no later than 30 days after the mailing date of the notice of managed care action or the grievance disposition.
Makes a technical correction to new GS 108D-6 and GS 108D-7 to provide that the enrollee is to be provided with an appeal request form for a contested case hearing that meets the requirements of GS 108D-8(f).
Amends GS 108D-7, adding a new subsection (f) to require an LME/MCO to provide an enrollee with reasonable assistance in completing forms and taking other procedural steps necessary to file an appeal including providing (1) interpreter servicesand (2) toll free numbers with adequate teletypewriter/telecommunications devices for the deaf and interpreter capability. Re-letters subsections as necessary.
Amends GS 108D-8 to provide that in requesting an appeal, the enrollee must file the appeal request form in accordance with OAH rules. Provides that any simplified hearing procedures approved by the chief administrative law judge (ALJ) must comply with all of the specified requirements in GS 108D-8(h). Directs the ALJ assigned to hear the case to consider and rule on all pre-hearing motions before the scheduled date for a hearing on the merits of the case (was, may includesuch a requirement). Provides that the enrollee has the burden of proof on all issues submitted to the OAH for a contested hearing under this section and the enrollee has the burden of going forward (was, provided the enrollee has burden of proof to show entitlement to a requested benefit under specified circumstances and the agency has the burden of proof in an appeal from a managed care action to impose a penaltyor to reduce, terminate, or suspend a previously granted benefit).
Deletes amendment to GS 122C-3, which defined LME/MCO as an LME approved by the Department of Health and Human Services (DHHS) to operate the 1915(b)/(c) Medicaid Waiver.
Amends GS 122C-151.3 and GS 122C-151.4 to clarify that these sections do not apply to specified LME/MCOs, enrollees, applicants, emergency service providers, or network providers subject to GS Chapter 108D. Amends GS 150B-23 to provide that an LME/MCO is considered an agency as defined in GS 150B-2(1a) only for the purposes of contested cases commenced as Medicaid managed care enrollee appeals under GS Chapter 108D.
Directs DHHS to take any action necessary to implement this act by September 30, 2013, including submitting to the Centers for Medicare and Medicaid Services a Medicaid State Plan Amendment with a retroactive effective date of July 1, 2013 (was, required DHHS to submit a plan to implement this act on or before December 1, 2013).DHHS is to report to the Joint Legislative Oversight Committee on Health and Human Services on the status of the implementation of this act on or before September 30, 2013.
Makes this act effective when it becomes law (was, effective June 1, 2014) and applies to grievances and managed care actions filed on or after that date.
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