AN ACT AUTHORIZING THE CHILDREN AND FAMILIES SPECIALTY PLAN AS AN ADDITIONAL MEDICAID MANAGED CARE PLAN AND MAKING OTHER CHANGES TO MEDICAID MANAGED CARE STATUTES.
Senate committee substitute replaces the content of the 3rd edition with the following.
Directs the Department of Health and Human Services (DHHS) to issue a request for proposals to procure a single statewide children and families specialty plan (CAF specialty plan) with services to begin no later than December 1, 2023. Limits proposal submissions to entities operating a standard benefit plan or a behavioral health and intellectual/developmental disabilities tailored plan (BH IDD tailored plan) contract with DHHS at the time the request for proposals is issued, and limits those entities one response each. Specifies that eligible entities under common control or ownership with one another are limited to collectively submitting one response. Directs DHHS to define the services available and the Medicaid and NC Health Choice beneficiaries who are eligible to enroll in the children and families specialty plan, except as otherwise specified in the act.
Amends and adds to the defined terms set forth in GS 108D-1, applicable to the Chapter, which governs Medicaid and NC Health Choice Managed Care Programs. Adds and defines children and families specialty plan (CAF specialty plan) as statewide capitated prepaid health plan contract under the Medicaid transformation demonstration waiver that meets all of the requirements of Article 4 of the Chapter, as amended by the act, including the requirements pertaining to the CAF specialty plan, but excluding the requirements only pertaining to BH IDD tailored plans. Makes conforming changes. Amends the definitions provided for prepaid health plans (PHPs) and standard benefit plans to account for PHP contracts to operate CAF specialty plans in addition to BH IDD tailored plans. Eliminates the term closed network.
Sections 3 and 9
Revises and adds to the population categories exempt from capitated PHP contracts coverage for Medicaid and NC Health Choice program aid under GS 108D-40. Regarding the exempt category described in subdivision (a)(12) for recipients with a serious mental illness, a serious emotional disturbance, a severe substance use disorder, an intellectual/developmental disability, or who have survived a traumatic brain injury and who are receiving traumatic brain injury services, who are on the waiting list for the Traumatic Brain Injury waiver, or whose traumatic brain injury otherwise is a knowable fact, until BH IDD tailored plans become operational, at which time this population will be enrolled with a BH IDD tailored plan, revises the option for the described population from voluntarily enrolling with a PHP subject to the specified conditions, to provide for the option to voluntarily enroll with PHP operating a standard benefit plan, with access limited to the plan's covered behavioral health services, except as provided for recipients being served through the Community Alternatives Program for Disabled Adults (CAP/DA) under subdivision (a)(11). Eliminates the exclusion of coverage under subsubdivision (a)(13)c. for 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, for a time determined by DHHS of up to 5 years after the capitated PHP contracts begin. Enacts a new exclusion for recipient who, until the CAF specialty plan becomes operational, are: (1) children enrolled in foster care in this State; (2) receiving adoption assistance, or (3) former foster care youth until they reach the age of 26. Adds that, starting on the date that capitated contracts for BH IDD tailored plans begin, and until the CAF specialty plan becomes operational, recipients described in this new subdivision may voluntarily enroll in a PHP operating a standard benefit plan or, if eligible under GS 108D-40(a)(12), as amended, enroll with a BH IDD tailored plan. Provides that when the CAF specialty plan becomes operational, recipients described in new subdivision (14) will be enrolled in accordance with GS 108D-62, as enacted. Makes conforming changes.
Amends GS 108D-5.3 to allow enrollees within the described groups to request disenrollment from a PHP (was, allowed to disenroll) at any time. Revises the groups to include beneficiaries who are described in new GS 108D-40(a)(14), and amended GS 108D-40(a)(12). Eliminates inclusion of beneficiaries who are in the form foster care Medicaid eligibility category and those who receive Title IV-E adoption assistance.
Amends GS 108D-21, regarding the closed network of providers maintained by LME/MCOs to furnish mental health, intellectual or developmental disabilities, and substance abuse services to its enrollees. Defines the closed network as the network of providers that have contracted with the LME/MCO operating the combined 1915(b) and (c) waivers.
Sections 5 through 7
Amends GS 108D-23, regarding the closed network of providers maintained by BH IDD tailored plans. Defines closed network as the network of providers that have contracted with the entity operating a BH IDD tailored plan to furnish behavioral health, intellectual and developmental disability, and traumatic brain injury services enrollees to enrollees.
Enacts GS 108D-24, requiring the entity operating the CAF specialty plan to develop and maintain a closed network of providers only for the provision of intensive in-home services, multi-systemic therapy, residential treatment services, and services provided in private residential treatment facilities. Adds that the closed network is the network of providers that have contracted with the entity operating the CAF specialty plan to furnish the services specified to enrollees.
Amends GS 108D-22, which requires each PHP to develop and maintain a provider network that meets access to care requirements for its enrollees, to except the CAF specialty plan networks set out in new GS 108D-24 in addition to the existing exception for the BH IDD tailored plan networks set out in GS 108D-23.
Amends GS 108D-35 to require all capitated PHP contracts to cover substance abuse comprehensive outpatient treatment program services, substance abuse intensive outpatient program services, and social setting detoxification services. Adds to Medicaid services capitated contracts are prohibited from covering to include those covered by LME/MCOs under an approved 1915(i) waiver. Makes organizational changes and authorizes the Revisor to make necessary technical changes to statutory references to reflect organizational changes made by the act to Article 4 of the Chapter.
Corrects a statutory cross-reference in GS 108D-45, to refer to the nature of contracts for standard benefit plans required under GS 108D-65(6) (was, GS 108D-65(3)). Eliminates the exemption for the statute's limitation on the number of contracts for BH IDD tailored plans described in GS 108D-60.
Amends GS 108D-60, governing BH IDD tailored plans, to revise subdivision (a)(10), which requires automatic enrollment with an entity operating a BH IDD tailored plan for recipients described in GS 108D-40(a)(12), to now exclude recipients also described in new GS 108D-40(a)(14) who are to be enrolled under GS 108D-62, as enacted. Enacts a new subdivision, (a)(11), to exclude recipients described in GS 108D-40(a)(12) from having an option to voluntarily enroll with a PHP operating a standard benefit plan or the CAF specialty plan while receiving services offered to: recipients enrolled in the Innovations waiver; recipients enrolled in the Traumatic Brain Injury waiver; recipients residing in or receiving respite services at an intermediate care facility for individuals with intellectual/developmental disabilities; recipients enrolled in and being served under Transitions to Community Living; and recipients receiving State-funded residential services, including group living, family living, supported living, and residential supports. Makes a conforming change to subdivision (a)(10).
Enacts GS 108D-62, defining CAF specialty plan and setting forth nine defined terms for the statute. Establishes the following requirements of a CAF specialty plan: requiring plans to result from RFPs issued by DHHS submitted by eligible PHPs under contract with DHHS; requiring operating entities to authorize, pay for, and manage all Medicaid and NC Health Choice services covered under the plan; requiring operating entities to operate care coordination functions and provide whole-person, integrated care across healthcare and treatment settings and foster care placements for enrollees; requiring operating entities to be the single point of care management accountability; and requiring DHHS to establish requirements for CAF specialty plan operations that address four considerations, including continuity of care and support across health care settings, changes in placement, and when the child transitions into the former foster youth Medicaid eligibility category. Requires the CAF specialty plans to cover the behavioral health, intellectual and developmental disability, and traumatic brain injury services excluded from standard benefit plan coverage under GS 108D-35(1), excluding five listed services, including innovation waiver services and Traumatic Brain Injury waiver services.
Describes six categories of Medicaid and NC Health Choice recipients for eligible for CAF specialty plan enrollment, including recipients described in new GS 108D-40(a)(14) and their children, for as long as the parent remains enrolled unless the elects otherwise; adults identified on an open child protective services in-home family services agreement case and any minor children living in the same home; adults identified in an open Eastern Band of Cherokee Indians Department of Public Health and Human Services Family Safety program case and any children living in the same home; the minor siblings of a child in foster care who lived in the same home as that child at the time of the child's removal and with whom household reunification efforts are ongoing; recipients who have a child temporarily in foster care who meet three specified criteria; and any other recipients who have had involvement with the child welfare system and whom DHHS has determined would benefit from enrollment in the CAF specialty plan. Establishes three categories of recipients excluded from the CAF specialty plan, including recipients who are excluded from PHP coverage under GS 108D-40(a).
Establishes CAF specialty plan enrollment is voluntary except as follows. Provides for automatic enrollment in the CAF specialty plan of Recipients described in GS 108D-40(a)(14) and their children unless they are also recipients who have a child temporarily in foster care and meet the three described criteria, whereby enrollment is voluntary. Requires recipients eligible to enroll in the CAF specialty plan have the option to enroll with a PHP operating a standard benefit plan or, if eligible under GS 108D-40(a)(12), a BH IDD tailored plan, and specifies the effects of such enrollment. Allows for recipients enrolled in foster care, as described in GS 108D-40(a)(14)(i), who exit the custody of the county department of social services to elect to remain enrolled in the CAF specialty plan for 12 months after the date the recipient exits custody. Allows, in the case of recipients who achieve reunification, a parent, a caretaker relative, a custodian, a guardian, or a minor sibling with whom the recipient reunifies to elect to remain enrolled in the CAF specialty plan as long as the recipient remains enrolled.
Amends GS 122C-3, which sets forth defined terms for the Mental Health, Developmental Disabilities, and Substance Abuse Act, adding CAF specialty plan to the Chapter's defined terms. Amends LME/MCO to provide for capitated PHP contracts under Article 4, GS Chapter 108D, as amended (rather than only specifying BH IDD tailored programs under the Article).
Amends GS 122C-115 to include recipients described in new GS 108D-40(a)(14) in the directives relating to LME/MCO responsibilities to manage Medicaid services before PHP plans under Article 4, GS Chapter 108A are operational.
Enacts GS 122C-115.5, authorizing an area authority to operate a CAF specialty plan under contract with DHHS so long as the area authority has a statewide catchment. Prohibits counties from withdrawing from or declining to participate in the statewide catchment area of the CAF specialty plan.
Changes the act's titles.