AN ACT TO MODIFY THE LAWS PERTAINING TO MEDICAID AND NC HEALTH CHOICE AS NEEDED FOR THE IMPLEMENTATION OF MEDICAID TRANSFORMATION.
Makes the following changes to GS Chapter 108D. Retitles the Chapter as Medicaid and NC Health Choice Managed Care Programs (was, Medicaid Managed Care for Behavioral Health Services).
Adds to the defined terms: adverse benefit determination, adverse disenrollment determination, beneficiary, Behavioral Health and Individuals with Developmental Disabilities Tailored Plan (BH IDD Tailored Plan), enrollment broker, fee-for-service program, mail, managed care entity, Medicaid transformation demonstration waiver, prepaid health plan (PHP), provider, and standard plan. Modifies existing defined terms: applicant, contested case hearing, enrollee, Local Management Entity (LME), mental health, intellectual or developmental disabilities, and substance abuse services (MH/IDD/SA services), network provider, and notice of manager care action (now notice of adverse determination). Now defines enrollee to mean a Medicaid or NC Health Choice beneficiary who is currently enrolled with a local management entity/managed care organization or a prepaid health plan (previously more narrowly defined as a Medicaid beneficiary who is currently enrolled with a local management entity/managed care organization). Deletes the defined terms: managed care action, Managed Care Organization, notice of resolution, and Prepaid Inpatient Health Plan. Makes conforming changes throughout the Chapter.
Modifies the scope of the Chapter set out in GS 108D-2 to provide that the Chapter applies to every managed care entity, applicant, enrollee, providers of emergency services, and network provider of a managed care entity. Exempts from the Chapter's provisions Medicaid or NC Health Choice services delivered through the fee-for-service program. Clarifies that the Chapter does not grant a NC Health Choice beneficiary benefits in excess of what is required by GS 108A-70.21.
Amends GS 108D-3 to provide that federal law prevails if there is conflict between the Chapter and the Social Security Act or 42 CFR Parts 438 (Managed Care) and 457 (Allotments and Grants to States for Child Health Insurance Programs). Adds an exception for state law to prevail when the applicability of federal law or rules has been waived by agreement between the State and the US Department of Health and Human Services. Provides that the Chapter prevails over conflicting State law contrary to the principles of managed care that will ensure successful containment of costs for health care services (previously, specified behavioral health care services).
Enacts Article 1A, Disenrollment and Prepaid Health Plans (PHP). Sets forth general provisions regarding construction of the Article. Allows for enrollees or their authorized representative to submit an oral or written request for disenrollment from a PHP. Details distinct parameters for disenrollment requests by an enrollee without cause or with cause, as specified. Provides for expedited requests for disenrollment for urgent medical needs that require disenrollment from the PHP. Permits a PHP to request disenrollment of an enrollee from a PHP only if the enrollee's behavior seriously hinders the PHP's ability to care for the enrollee or other enrollees of the PHP, and the PHP has documented efforts to resolve the issues that form the basis of the request for disenrollment of the enrollee. Requires PHPs to comply with federal law in requesting disenrollment. Provides for written resolution of approval or denial of a request by the Department of Health and Human Services (DHHS) within the first day of the second month following the month of request or within three calandar days of receipt of an expedited request. Requires DHHS to include an appeal request form which meets specified criteria, including informing the enrollee that the appeal form must be filed within 30 days of the mailing date of the notice. Provides for situations where DHHS determines a request does not meet the criteria for an expedited request.
Provides for the appeal process for an adverse disenrollment determination to the Office of Administrative Hearings, to be conducted in accordance with Part 6A, Medicaid Recipient Appeals Process, Article 2 of GS Chapter 108A.
Makes changes throughout Article 2, Enrollee Grievances and Appeals, to refer to managed care entities rather than LME/MCOs. Now requires managed care entities to establish and maintain internal grievance and appeal procedures that comply with specified federal law and afford enrollees and their authorized representatives (was, and network providers authorized in writing to act on behalf of enrollees) constitutional rights to due process and a fair hearing. Makes conforming changes throughout the Article to refer to an enrollee's authorized representative. Authorizes an enrollee or the enrollee's authorized representative to file grievances and managed care entity level appeals orally or in writing (was, file request for grievances). Establishes that the Article 2 appeals process does not apply to instances in which the sole basis for the managed care entity's decision is a provision in the State Plan or in federal or state law requiring an automatic change adversely affecting some or all beneficiaries. Makes changes to refer to an adverse benefit determination rather than a managed care action, and a notice of grievance resolution rather than a notice of grievance disposition. Now requires the notice of grievance resolution to be mailed no later than 30 days (was, 90 days) after receipt of the grievance. Allows the managed care entity to extend the time frame to the extent permitted by the specified federal law, 42 CFR 438.408(c).
Concerning standard managed care entity level appeals, grants an enrollee or the enrollee's authorized representative the right to file a request for a managed care entity level appeal of a notice of adverse benefit determination within 60 days (was within 30 days) after the mailing date of the notice. Requires a managed care facility to continue or reinstate (was just continue) the benefits of a Medicaid enrollee during the pendency of a managed care entity level appeal to the same extent required under 42 CFR 438.420 and new subsection (c1) of GS 108D-13.
Specifies that NC Health Choice enrollees are not entitled to continuation or reinstatement of benefits. Requires the PHP to reinstate the benefits of a Medicaid enrollee if four requirements are satisfied, including timely filing of the appeal, timely filing for continuation of benefits, the appeal being one that involves termination, suspension, or reduction of a previously authorized service, and the service was ordered by an authorized provider. Now requires the managed care entity to resolve an appeal and notify the enrollee and all other affected parties within 30 days (was, 45 days) after receiving the request for appeal. Allows the managed care entity to extend the timeframe as permitted under federal law, 42 CFR 438.408. Now additionally permits an enrollee or the enrollee’s authorized representative to file a request for a contested hearing case hearing under GS 108D-15 if the enrollee has been deemed under 42 CFR 438.408(c)(3) to have exhausted the managed care entity level appeals process (previously, only after extinguishing the appeals procedures under GS 108D-14 concerning expedited appeals.
Concerning expedited managed care entity level appeals, specifies that for expedited appeal requests made by a network provider as an enrollee’s authorized representative, the managed care entity is to presume an expedited appeal is necessary. Now requires a managed care entity that denies a request for expedited appeal to make reasonable efforts to give the enrollee and all other affected parties oral notice of the denial and follow up with a written notice of denial by mail no later than 72 hours (was, two calendar days) after receiving the request. Requires a managed care facility to continue or reinstate (was, just continue) the benefits of a Medicaid enrollee during the pendency of an expedited managed care entity level appeal to the same extent required under 42 CFR 438.420 and new subsection (c1) of GS 108D-14, which requires PHP reinstatement in the same manner as during the pendency of standard appeal requests, in accordance with new GS 108D-13(c1). If granting the request for an expedited appeal, now requires the managed care entity to resolve the appeal and provide written notice to the enrollee and all other affected parties within 72 hours (was, three working days) after receiving the request. Allows the managed care entity to extend the timeframe for resolution as permitted under federal law, 42 CFR 438.408. Now additionally permits an enrollee or the enrollee’s authorized representative to file a request for a contested hearing case hearing under GS 108D-15 if the enrollee has been deemed under 42 CFR 438.408(c)(3) to have exhausted the managed care entity level appeals process (previously, only after exhausting the appeals procedures under GS 108D-13 concerning standard appeals).
Makes conforming changes to GS 108D-15 concerning contested case hearings on disputed adverse benefit determinations. Now requires the appeals request form required to be included with the managed care entity’s notice of resolution to inform the enrollee that the form must be mailed or faxed no later than 120 days (was, 30 days) after the mailing date of the notice, and for NC Health Choice enrollee’s the NC Health Choice identification number (Medicaid enrollees are already required to include the enrollee’s identification number). Requires the continuation or reinstate of a Medicaid enrollee’s benefits during the pendency of an appeal in the same manner as appeals at the managed care entity level. Specifies that an administrative law judge cannot order a managed care entity to continue benefits in excess of what is required under federal law, except to the extent required by GS 108D-13(c1) and GS 108D-14(c1), as enacted. Makes conforming changes regarding conflict of Chapter provisions and federal law. Specifies that the rules, rights, and procedures for contested hearings concerning adverse benefit determinations cannot provide an enrollee with rights less than those provided under federal law (was, no lesser or greater rights than under federal law).
Enacts Article 3, Managed Care Entity Provider Networks.
Requires each LME/MCO operating the combined 1915(b) and (c) waivers to maintain and utilize a closed network of providers to furnish MH/IDD/SA services to its enrollees. Requires each PHP to develop and maintain a provider network that meets access to care requirements for its enrollees. Mandates PHPs to include providers designated as essential providers by DHHS, unless DHHS approves an alternate arrangement for securing the types of served offered by the essential providers. Details essential provider designation, minimally requiring providers that are federally qualified health centers, rural health centers, free clinics, local health departments, and State Veterans Homes to be identified as essential providers. Requires entities operating BH IDD Tailored Plans to utilize closed provider networks only for the provision of behavioral health, intellectual and developmental disability, and traumatic brain injury services.
Effective October 1, 2019, and applies to appeals arising from LME/MCO notices of adverse determination mailed on or after that date and grievances received by an LME/MCO on or after that date
Amends GS 90-414.4 to require PHPs to submit encounter and claims data by the commencement date of a capitated contract with the Division of Health Benefits for the delivery of Medicaid and NC Health Choice services as specified in Article 4 of GS Chapter 108D (previously referenced SL 2015-245 to define PHP and set the timeline for their submission).
Sections 3 through 7
Makes changes to GS Chapter 108A, Social Services. Adds to the defined terms set forth in GS 108A-24: fee-for-service program and Prepaid Health Plan (PHP). Makes technical and organizational changes.
Amends GS 108A-56 to provide for waiver agreements between the State and the US Department of Health and Human Services concerning statutory construction. Adds further provisions to clarify construction pertaining to PHPs.
Amends GS 108A-70 regarding DHHS garnishing employment income and the Secretary of Revenue withholding tax refunds to recoup certain amount spent on medical care. Makes organizational and clarifying changes. Adds that such actions can be taken to the extent necessary to reimburse a PHP for expenditures for costs under Part 6, Medical Assistance Program. Also adds that only claims for current or past due child support take priority over those claims, or similar reimbursement claims by DHHS under the same provisions.
Expands Part 6A, Article 2 of GS Chapter 108A to also govern the process used by a Medicaid or NC Health Choice recipient to appeal an adverse disenrollment determination by DHHS. Defines adverse enrollment decision and contested Medicaid case, and modifies the definition of adverse determination. Makes conforming, clarifying and technical changes to the Part. Regarding the review of eligibility and Program enrollment decisions under GS 108A-70.29, specifies that the provisions do not apply to requests for disenrollment under Article 1A, GS Chapter 108D. Specifies that the provisions regarding the review of health services decisions applies only to health service decisions for services being provided to NC Health Choice recipient through the fee-for-service program, and excludes adverse benefit determinations.
Amends GS 122C-3, which sets forth the definitions related to the Mental Health, Developmental Disabilities, and Substance Abuse Act. Adds BH IDD Tailored Plan to the defined terms, and references the definition set out in GS 108D-1, as amended. Modifies LME/MCO to include entities under contract with DHHS to operate a BH IDD Tailored Plan.
Section 9 and 10
Amends GS 150B-1 to exempt from the contested case provisions DHHS with respect to disputes involving the performance, terms, or conditions of a contract between DHHS and a PHP. Makes conforming changes to reference NC Health Choice determinations under GS 108A-70.29(b), as amended.
Amends GS 150B-23 to incorporate NC Health Choice enrollee appeals. Specifies when PHPs are to be considered an agency under the provisions.
Modifies Section 4 of SL 2015-245, as amended, concerning services covered by PHPs, to exclude Medicaid services covered by the LME/MCO under combined 1915(b) and (c) waivers unless covered under a BH IDD Tailored Plan. Excludes from PHP coverage for a time determined by DHHS, recipients who are enrolled in the foster care system, receiving Title IV-E adoption assistance, under the age of 26 and formerly were in the foster care system, or under the age of 26 and formerly received adoption assistance. Makes changes to statutory references regarding LME/MCO management upon the commencement of capitated contracts.
Makes clarifying change to Section 5(6) of SL 2015-245, as amended.
Section 13 directs the Revisor of Statutes to codify specified portions of SL 2015-245 into a new Article 4, Prepaid Health Plans, GS Chapter 108D. Details the new Article’s structure. Provides specified authorizations in codifying the specified portions.
Section 14 authorizes the Revisor to replace references to the Division of Medical Assistance with the Division of Health Benefits, except in GS 108A-54; GS 126-5(c)(34), GS 143B-138.1; and GS 143B-216.80. Provides for the changes to be effective July 1, 2019.
Provides that the act is effective October 1, 2019, except as otherwise provided.
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