SB 548

Version: Filed
Author: Sen. Joyce Krawiec (R-NC)

Created by BCL easyConverter SDK 5 (HTML Version)

4TRANSFORMATION.

5The General Assembly of North Carolina enacts:

8"Medicaid and NC Health Choice Managed Care for Behavioral Health Services.

12" 108D-1. Definitions.

13The following definitions apply in this Chapter, unless the context clearly requires otherwise:

*DRS55053-MR-91C*

17" 108D-2. Scope; applicability of this Chapter.

18This Chapter applies to every LME/MCO and to every managed care entity, applicant,

19enrollee, provider of emergency services, and network provider of an LME/MCO.a managed care

20entity. This Chapter does not apply to Medicaid or NC Health Choice services delivered through

21the fee-for-service program. Nothing in this Chapter shall be construed to grant a NC Health

22Choice beneficiary benefits in excess of what is required by G.S. 108A-70.21.

23" 108D-3. Conflicts; severability.

24(a) To the extent that this Chapter conflicts with the Social Security Act or 42 C.F.R. Part

25438, Parts 438 and 457, federal law prevails.prevails, except when the applicability of federal

26law or rules have been waived by agreement between the State and the U.S. Department of Health

27and Human Services.

28(b) To the extent that this Chapter conflicts with any other provision of State law that is

29contrary to the principles of managed care that will ensure successful containment of costs for

30behavioral health care services, this Chapter prevails and applies.

31(c) If any section, term, or provision of this Chapter is adjudged invalid for any reason,

32these judgments shall not affect, impair, or invalidate any other section, term, or provision of this

33Chapter, but the remaining sections, terms, and provisions shall be and remain in full force and

34effect.

37" 108D-5.1. General provisions.

38(a) Nothing in this Article shall be construed to limit or prevent the Department from

39disenrolling, from a PHP, an enrollee who (i) is no longer eligible to receive services through the

40Medicaid or NC Health Choice programs or (ii) becomes a member of a population of

41beneficiaries that is not required to enroll in a PHP under State law.

42(b) Nothing in this Article shall be construed to exclude a Medicaid or NC Health Choice

43beneficiary who is otherwise required by State law to enroll in a PHP from enrolling in a PHP,

44or to prevent a beneficiary who is otherwise exempted from enrollment in a PHP from

45disenrolling from a PHP and receiving services through the fee-for-service program.

46" 108D-5.2. Enrollee requests for disenrollment.

47(a) In General. – An enrollee, or the enrollee's authorized representative, who is

48requesting disenrollment from a PHP, shall submit an oral or written request for disenrollment to

49the enrollment broker.

1(b) Without Cause Enrollee Requests or Disenrollment. – An enrollee shall be allowed to

2disenroll from the PHP without cause only during the times specified in 42 C.F.R. 438.56(c)(2),

3except that enrollees who are in any of the following groups may disenroll at any time:

14(c) With Cause Enrollee Requests for Disenrollment. – An enrollee, or the enrollee's

15authorized representative, may submit a request to disenroll from a PHP for cause at any time.

16For cause reasons for disenrollment from a PHP include the following:

44(d) Expedited Enrollee Requests for Disenrollment. – An enrollee, or the enrollee's

45authorized representative, may submit an expedited request for disenrollment to the enrollment

46broker when the enrollee has an urgent medical need that requires disenrollment from the PHP.

47For purposes of this subsection, an urgent medical need means that continued enrollment in the

48PHP could jeopardize the enrollee's life, health, or ability to attain, maintain, or regain maximum

49function.

50" 108D-5.3. PHP requests for disenrollment.

1(a) In General. – A PHP requesting disenrollment of an enrollee from the PHP shall

2submit a written request for disenrollment to the enrollment broker.

4disenrollment of an enrollee from the PHP for any reason prohibited by 42 C.F.R. 438.56(b)(2).

5A PHP may request disenrollment of an enrollee only when both of the following criteria are

6met:

11" 108D-5.4. Notices.

12(a) Notices of Resolution. – For each disenrollment request by an enrollee or a PHP, the

13Department shall issue a written notice of resolution approving or denying the request by mail to

14the enrollee before the first day of the second month following the month in which the enrollee

15or PHP requested disenrollment. For expedited enrollee requests for disenrollment made under

16G.S. 108D-5.2(d), the Department shall issue the written notice of resolution approving or

17denying the expedited request within three calendar days of receipt of the request. In the same

18mailing as the notice, the Department shall also provide the enrollee with an appeal request form

19that includes all of the following:

32(b) Notices Pertaining to Expedited Enrollee Request for Disenrollment. – If the

33Department determines that an enrollee's request for disenrollment does not meet the criteria for

34an expedited request, the Department shall do the following:

41" 108D-5.5. Appeals of adverse disenrollment determinations.

42(a) Appeals. – An enrollee, or the enrollee's authorized representative, who is dissatisfied

43with an adverse disenrollment determination may file an appeal for a hearing with the Office of

44Administrative Hearings within 30 calendar days of the date on the notice of resolution. A request

45for a hearing to appeal an adverse disenrollment determination of the Department under this

46section is a contested case subject to the provisions of Article 3 of Chapter 150B of the General

47Statutes. The appeal shall be conducted in accordance with the procedures in Part 6A of Article

482 of Chapter 108A of the General Statutes.

49(b) Parties. – The Department shall be the respondent for purposes of appeals under this

50section.

2" 108D-11. LME/MCO Managed care entity grievance and appeal procedures, generally.

3(a) Each LME/MCO managed care entity shall establish and maintain internal grievance

4and appeal procedures that (i) comply with the Social Security Act and 42 C.F.R. Part 438,

5Subpart F, and (ii) afford enrollees, and network providers authorized in writing to act on behalf

6of enrollees, enrollees and their authorized representatives constitutional rights to due process

7and a fair hearing.

8(b) Enrollees, or network providers authorized in writing to act on behalf of enrollees, An

9enrollee, or the enrollee's authorized representative, may file requests for grievances grievances

10and LME/MCO managed care entity level appeals orally or in writing. However, unless the

11enrollee or network provider enrollee, or the enrollee's authorized representative, requests an

12expedited appeal, the oral filing appeal must be followed by a written, signed grievance or appeal.

13(c) An LME/MCO A managed care entity shall not attempt to influence, limit, or interfere

14with an enrollee's right or decision to file a grievance, request for an LME/MCO managed care

15entity level appeal, or a contested case hearing. However, nothing in this Chapter shall be

16construed to prevent an LME/MCO a managed care entity from doing any of the following:

21(d) An LME/MCO A managed care entity shall not take punitive action against a provider

22for any of the following:

33(e) The appeal procedures set forth in this Article shall not apply to instances in which

34the sole basis for the managed care entity's decision is a provision in the State Plan or in federal

35or State law requiring an automatic change adversely affecting some or all beneficiaries.

36" 108D-12. LME/MCO Managed care entity grievances.

37(a) Filing of Grievance. – An enrollee, or a network provider authorized in writing to act

38on behalf of an enrollee, or the enrollee's authorized representative, has the right to file a

39grievance with an LME/MCO a managed care entity at any time to express dissatisfaction about

40any matter other than a managed care action. an adverse benefit determination. Upon receipt of

41a grievance, an LME/MCO a managed care entity shall cause a written acknowledgment of

42receipt of the grievance to be sent by United States mail.

43(b) Notice of Grievance Disposition. – The LME/MCO managed care entity shall resolve

44the grievance and cause a notice of grievance disposition resolution to be sent by United States

45mail to the enrollee and all other affected parties as expeditiously as the enrollee's health

46condition requires, but no later than 90 30 days after receipt of the grievance.grievance, provided

47that the managed care entity may extend such time frame to the extent permitted under 42 C.F.R.

48 438.408(c).

49(c) Right to LME/MCO Level Appeal. – There is no right to appeal the resolution of a

50grievance to OAH or any other forum.

51" 108D-13. Standard LME/MCO managed care entity level appeals.

1(a) Notice of Managed Care Action. Adverse Benefit Determination.An LME/MCO A

2managed care entity shall provide an enrollee with a written notice of a managed care action an

3adverse benefit determination by United States mail as required under 42 C.F.R. 438.404. The

4notice of action will employ a standardized form included as a provision in the contracts contract

5between the LME/MCOs managed care entity and the Department of Health and Human

6Services.Department.

7(b) Request for Appeal. – An enrollee, or a network provider authorized in writing to act

8on behalf of the enrollee, the enrollee's authorized representative, has the right to file a request

9for an LME/MCO a managed care entity level appeal of a notice of managed care action adverse

10benefit determination no later than 30 60 days after the mailing date of the grievance disposition

11or notice of managed care action. adverse benefit determination. Upon receipt of a request for an

12LME/MCO a managed care entity level appeal, an LME/MCO a managed care entity shall

13acknowledge receipt of the request for appeal in writing by United States mail.

14(c) Continuation of Benefits. – An LME/MCO A managed care entity shall continue or

15reinstate the enrollee's benefits of a Medicaid enrollee during the pendency of an LME/MCO a

16managed care entity level appeal to the same extent required under 42 C.F.R. 438.420. 42

17C.F.R. 438.420 and subsection (c1) of this section. In accordance with 42 C.F.R. 457.1260,

18NC Health Choice enrollees shall not be entitled to continuation or reinstatement of benefits.

19(c1) Reinstatement of Benefits for PHP Enrollees. – A PHP shall reinstate the benefits of

20a Medicaid enrollee if all of the following occur:

31(d) Notice of Resolution. – The LME/MCO managed care entity shall resolve the appeal

32as expeditiously as the enrollee's health condition requires, but no later than 45 30 days after

33receiving the request for appeal. appeal, provided that the managed care entity may extend such

34time frame as permitted under 42 C.F.R. 438.408. The LME/MCO managed care entity shall

35provide the enrollee and all other affected parties with a written notice of resolution by United

36States mail within this 45-day 30-day period.

37(e) Right to Request Contested Case Hearing. – An enrollee, or a network provider

38authorized in writing to act on behalf of an enrollee, the enrollee's authorized representative, may

39file a request for a contested case hearing under G.S. 108D-15 as long as (i) the enrollee enrollee,

40or network provider the enrollee's authorized representative, has exhausted the appeal procedures

41described in this section or G.S. 108D-14.G.S. 108D-14 or (ii) the enrollee has been deemed,

42under 42 C.F.R. 438.408(c)(3), to have exhausted the managed care entity level appeals

43process.

44(f) Request Form for Contested Case Hearing. – In the same mailing as the notice of

45resolution, the LME/MCO managed care entity shall also provide the enrollee with an appeal

46request form for a contested case hearing that meets the requirements of G.S. 108D-15(f).

47" 108D-14. Expedited LME/MCO managed care entity level appeals.

48(a) Request for Expedited Appeal. – When the time limits for completing a standard

49appeal could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or

50regain maximum function, an enrollee, or a network provider authorized in writing to act on

51behalf of an enrollee, the enrollee's authorized representative, has the right to file a request for

1an expedited appeal of a managed care action an adverse benefit determination no later than 30

260 days after the mailing date of the notice of managed care action. adverse benefit determination.

3For expedited appeal requests made by enrollees, an enrollee, or the enrollee's authorized

4representative, the LME/MCO managed care entity shall determine if the enrollee qualifies for

5an expedited appeal. For expedited appeal requests made by network providers on behalf of

6enrollees, a network provider as an enrollee's authorized representative, the LME/MCO managed

7care entity shall presume an expedited appeal is necessary.

8(b) Notice of Denial for Expedited Appeal. – If the LME/MCO managed care entity

9denies a request for an expedited LME/MCO managed care entity level appeal, the LME/MCO

10managed care entity shall make reasonable efforts to give the enrollee and all other affected

11parties oral notice of the denial and follow up with a written notice of denial by United States

12mail by no later than two calendar days 72 hours after receiving the request for an expedited

13appeal. In addition, the LME/MCO managed care entity shall resolve the appeal within the time

14limits established for standard LME/MCO managed care entity level appeals in G.S. 108D-13.

15(c) Continuation of Benefits. – An LME/MCO A managed care entity shall continue or

16reinstate the enrollee's benefits of a Medicaid enrollee during the pendency of an expedited

17LME/MCO managed care entity level appeal to the extent required under 42 C.F.R. 438.420.

1842 C.F.R. 438.420 and subsection (c1) of this section. In accordance with 42 C.F.R. 457.1260,

19NC Health Choice enrollees shall not be entitled to continuation or reinstatement of benefits.

20(c1) Reinstatement of Benefits for PHP Enrollees. – A PHP shall reinstate the benefits of

21a Medicaid enrollee who is a Medicaid beneficiary in accordance with G.S. 108D-13(c1).

22(d) Notice of Resolution. – If the LME/MCO managed care entity grants a request for an

23expedited LME/MCO managed care entity level appeal, the LME/MCO managed care entity

24shall resolve the appeal as expeditiously as the enrollee's health condition requires, and no later

25than three working days 72 hours after receiving the request for an expedited appeal. appeal,

26provided that the managed care entity may extend such time frame as permitted under 42 C.F.R.

27 438.408. The LME/MCO managed care entity shall provide the enrollee and all other affected

28parties with a written notice of resolution by United States mail within this three-day 72-hour

29period.

30(e) Right to Request Contested Case Hearing. – An enrollee, or a network provider

31authorized in writing to act on behalf of an enrollee, the enrollee's authorized representative, may

32file a request for a contested case hearing under G.S. 108D-15 as long as (i) the enrollee enrollee,

33or network provider the enrollee's authorized representative, has exhausted the appeal procedures

34described in G.S. 108D-13 or this section. section or (ii) the enrollee has been deemed, under 42

35C.F.R. 438.408(c)(3), to have exhausted the managed care entity level appeals process.

36(f) Reasonable Assistance. – An LME/MCO A managed care entity shall provide the

37enrollee with reasonable assistance in completing forms and taking other procedural steps

38necessary to file an appeal, including providing interpreter services and toll-free numbers that

39 have adequate teletypewriter/telecommunications devices for the deaf (TTY/TDD) and

40interpreter capability.

41(g) Request Form for Contested Case Hearing. – In the same mailing as the notice of

42resolution, the LME/MCO managed care entity shall also provide the enrollee with an appeal

43request form for a contested case hearing that meets the requirements of G.S. 108D-15(f).

44" 108D-15. Contested case hearings on disputed managed care actions.adverse benefit

45determinations.

46(a) Jurisdiction of the Office of Administrative Hearings. – The Office of Administrative

47Hearings does not have jurisdiction over a dispute concerning a managed care action, an adverse

48benefit determination, except as expressly set forth in this Chapter.

49(b) Exclusive Administrative Remedy. – Notwithstanding any provision of State law or

50rules to the contrary, this section is the exclusive method for an enrollee to contest a notice of

51resolution of an adverse benefit determination issued by an LME/MCO. a managed care entity.

1G.S. 108A-70.9A, 108A-70.9B, and 108A-70.9C do not apply to enrollees contesting a managed

2care action.an adverse benefit determination.

3(c) Request for Contested Case Hearing. – A request for an administrative hearing to

4appeal a notice of resolution of an adverse benefit determination issued by an LME/MCO a

5managed care entity is a contested case subject to the provisions of Article 3 of Chapter 150B of

6the General Statutes. An enrollee, or a network provider authorized in writing to act on behalf of

7an enrollee, the enrollee's authorized representative, has the right to file a request for appeal to

8contest a notice of resolution as long as (i) the enrollee enrollee, or network provider the enrollee's

9authorized representative, has exhausted the appeal procedures described in G.S. 108D-13 or

10 G.S. 108D-14.G.S. 108D-14 or (ii) the enrollee has been deemed, under 42 C.F.R.

11438.408(c)(3), to have exhausted the managed care entity level appeals process.

12(d) Filing Procedure. – An enrollee, or a network provider authorized in writing to act on

13behalf of an enrollee, the enrollee's authorized representative, may file a request for an appeal by

14sending an appeal request form that meets the requirements of subsection (e) of this section to

15OAH and the affected LME/MCO managed care entity by no later than 30 120 days after the

16mailing date of the notice of resolution. A request for appeal is deemed filed when a completed

17and signed appeal request form has been both submitted into the care and custody of the chief

18hearings clerk of OAH and accepted by the chief hearings clerk. Upon receipt of a timely filed

19appeal request form, information contained in the notice of resolution is no longer confidential,

20and the LME/MCO managed care entity shall immediately forward a copy of the notice of

21resolution to OAH electronically. OAH may dispose of these records after one year.

22(e) Parties. – The LME/MCO managed care entity shall be the respondent for purposes

23of this appeal. The LME/MCO or enrollee managed care entity, the enrollee, or the enrollee's

24authorized representative may move for the permissive joinder of the Department under Rule 20

25of the North Carolina Rules of Civil Procedure. The Department may move to intervene as a

26necessary party under Rules 19 and 24 of the North Carolina Rules of Civil Procedure.

27(f) Appeal Request Form. – In the same mailing as the notice of resolution, the

28LME/MCO managed care entity shall also provide the enrollee with an appeal request form for

29a contested case hearing which shall be no more than one side of one page. The form shall include

30at least all of the following:

43(g) Continuation of Benefits. – An LME/MCO A managed care entity shall continue or

44reinstate the enrollee's benefits of a Medicaid enrollee during the pendency of an appeal to the

45same extent required under 42 C.F.R. 438.420.42 C.F.R. 438.420, G.S. 108D-13, and

46G.S. 108D-14. In accordance with 42 C.F.R. 457.1260, NC Health Choice enrollees shall not

47be entitled to continuation or reinstatement of benefits. Notwithstanding any other provision of

48State law, the administrative law judge does not have the power to order and shall not order an

49LME/MCO a managed care entity to continue benefits in excess of what is required by 42 C.F.R.

50 438.420. 42 C.F.R. 438.420, except to the extent required by G.S. 108D-13(c1) and

51G.S. 108D-14(c1).

1(h) Simple Procedures. – Notwithstanding any other provision of Article 3 of Chapter

2150B of the General Statutes, the chief administrative law judge of OAH may limit and simplify

3the administrative hearing procedures that apply to contested case hearings conducted under this

4section in order to complete these cases as expeditiously as possible. Any simplified hearing

5procedures approved by the chief administrative law judge under this subsection must comply

6with all of the following requirements:

43(i) Mediation. – Upon receipt of an appeal request form as provided by G.S. 108D-15(f)

44or other clear request for a hearing by an enrollee, OAH shall immediately notify the Mediation

45Network of North Carolina, which shall contact the enrollee within five days to offer mediation

46in an attempt to resolve the dispute. If mediation is accepted, the mediation must be completed

47within 25 days of submission of the request for appeal. Upon completion of the mediation, the

48mediator shall inform OAH and the LME/MCO managed care entity within 24 hours of the

49resolution by facsimile or electronic messaging. If the parties have resolved matters in the

50mediation, OAH shall dismiss the case. OAH shall not conduct a hearing of any contested case

51involving a dispute of a managed care action an adverse benefit determination until it has

1received notice from the mediator assigned that either (i) the mediation was unsuccessful, (ii) the

2petitioner has rejected the offer of mediation, or (iii) the petitioner has failed to appear at a

3scheduled mediation. If the enrollee accepts an offer of mediation and then fails to attend

4mediation without good cause, OAH shall dismiss the contested case.

5(j) Burden of Proof. – The enrollee has the burden of proof on all issues submitted to

6OAH for a contested case hearing under this section and has the burden of going forward. The

7administrative law judge shall not make any ruling on the preponderance of evidence until the

8close of all evidence in the case.

9(k) New Evidence. – The enrollee shall be permitted to submit evidence regardless of

10whether it was obtained before or after the LME/MCO's managed care action managed care

11entity's adverse benefit determination and regardless of whether the LME/MCO the managed

12care entity had an opportunity to consider the evidence in resolving the LME/MCO managed

13care entity level appeal. Upon the receipt of new evidence and at the request of the LME/MCO,

14managed care entity, the administrative law judge shall continue the hearing for a minimum of

1515 days and a maximum of 30 days in order to allow the LME/MCO managed care entity to

16review the evidence. Upon reviewing the evidence, if the LME/MCO managed care entity

20administrative law judge shall determine whether the LME/MCO managed care entity

21substantially prejudiced the rights of the enrollee and whether the LME/MCO, managed care

22entity, based upon evidence at the hearing: hearing, did any of the following:

28(m) To the extent that anything in this Part, Chapter, Chapter 150B of the General Statutes,

29or any rules or policies adopted under these Chapters is inconsistent with the Social Security Act

30or 42 C.F.R. Part 438, Subpart F, federal law prevails and applies to the extent of the conflict.

31conflict, except when the applicability of federal law or rules have been waived by agreement

32between the State and the U.S. Department of Health and Human Services. All rules, rights, and

33procedures for contested case hearings concerning managed care actions adverse benefit

34determinations shall be construed so as to be consistent with applicable federal law and shall

35provide the enrollee with no lesser and no greater rights that are no less than those provided under

36federal law.

37" 108D-16. Notice of final decision and right to seek judicial review.

38 The administrative law judge assigned to conduct a contested case hearing under

39G.S. 108D-15 shall hear and decide the case without unnecessary delay. The judge shall prepare

40a written decision that includes findings of fact and conclusions of law and send it to the parties

41in accordance with G.S. 150B-37. The written decision shall notify the parties of the final

42decision and of the right of the enrollee and the LME/MCO managed care entity to seek judicial

43review of the decision under Article 4 of Chapter 150B of the General Statutes.

46" 108D-21. LME/MCO provider networks.

47Each LME/MCO operating the combined 1915(b) and (c) waivers shall maintain and utilize

48a closed network of providers to furnish mental health, intellectual or developmental disabilities,

49and substance abuse services to its enrollees.

50" 108D-22. PHP provider networks.

1(a) Except as provided in G.S. 108D-23, each PHP shall develop and maintain a provider

2network that meets access to care requirements for its enrollees. A PHP may not exclude

3providers from their networks except for failure to meet objective quality standards or refusal to

4accept network rates. Notwithstanding the previous sentence, a PHP must include all providers

5in its geographical coverage area that are designated essential providers by the Department in

6accordance with subdivision (b) of this section, unless the Department approves an alternative

7arrangement for securing the types of services offered by the essential providers.

8(b) The Department shall designate Medicaid and NC Health Choice providers as

9essential providers if, within a region defined by a reasonable access standard, the provider either

10(i) offers services that are not available from any other provider in the region or (ii) provides a

11substantial share of the total units of a particular service utilized by Medicaid and NC Health

12Choice beneficiaries within the region during the last three years and the combined capacity of

13other service providers in the region is insufficient to meet the total needs of the Medicaid and

14NC Health Choice enrollees. The Department shall not classify physicians and other practitioners

15as essential providers. At a minimum, providers in the following categories shall be designated

16essential providers:

22" 108D-23. BH IDD Tailored Plan networks.

23Entities operating BH IDD Tailored Plans shall utilize closed provider networks only for the

24provision of behavioral health, intellectual and developmental disability, and traumatic brain

25injury services."

27arising from local management entity/managed care organization (LME/MCO) notices of

28adverse benefit determination mailed on or after that date and (ii) grievances received by an

29LME/MCO on or after that date.

41" 108A-24. Definitions.

42As used in Chapter 108A:

21" 108A-56. Acceptance of federal grants.

22All of the provisions of the federal Social Security Act providing grants to the states for

23medical assistance are accepted and adopted, and the provisions of this Part shall be liberally

24construed in relation to such act so that the intent to comply with it shall be made effectual. to

25effectuate compliance with the act, except to the extent the applicability of federal law or rules

26have been waived by agreement between the State and the U.S. Department of Health and Human

27Services. Nothing in this Part or the regulations made under its authority shall be construed to

28deprive a recipient of assistance of the right to choose the licensed provider of the care or service

29made available under this Part within the provisions of the federal Social Security Act.Act, or

30valid waiver agreement. This section shall not be construed to prohibit a PHP from (i) requiring

31its enrollees to obtain services from providers that are under contract with the PHP or (ii)

32imposing utilization management criteria to a request for services, to the extent these actions are

33not otherwise prohibited by State or federal law or regulation, or by the Department."

35" 108A-70. Recoupment of amounts spent on medical care.

36(a) The To the extent necessary to reimburse the Department or a PHP for expenditures

37for costs under this Part, and provided that claims for current and past due child support shall

38take priority over claims for those expenditures, the Department may garnish the wages, salary,

39or other employment income of, and the Secretary of Revenue shall withhold amounts from State

40tax refunds to, any person who:who meets all of the following criteria:

48to the extent necessary to reimburse the Department for expenditures for such costs under this

49Part; provided, however, claims for current and past due child support shall take priority over

50any such claims for the costs of such services.

51…."

2rewritten:

3"Part 6A. Medicaid Recipient Appeals Process.Appeals Process for Certain Medicaid and NC

5" 108A-70.9A. Appeals by Medicaid recipients.Definitions; Medicaid recipient appeals.

6(a) Definitions. – The following definitions apply in this Part, unless the context clearly

7requires otherwise.

21(b) General Rule. Medicaid recipient appeals. – Notwithstanding any provision of State

22law or rules to the contrary, this section shall govern the process used by a Medicaid recipient to

23appeal an adverse determination made by the Department.Department and the process used by a

24Medicaid or NC Health Choice recipient to appeal an adverse disenrollment determination by the

25Department.

26…

27" 108A-70.9B. Contested Medicaid cases.

28(a) Application. – This section applies only to contested Medicaid cases commenced by

29Medicaid recipients under G.S. 108A-70.9A. as defined in this Part. Except as otherwise

32Medicaid case commenced by a Medicaid or NC Health Choice recipient is subject to the

33provisions of Article 3 of Chapter 150B of the General Statutes. To the extent any provision in

34this section section, Article 1A of Chapter 108D of the General Statutes, or G.S. 108A-70.9A

35conflicts with another provision in Article 3 of Chapter 150B of the General Statutes, this section

36section, Article 1A of Chapter 108D of the General Statutes, and G.S. 108A-70.9A control.

37(b) Simple Procedures. – Notwithstanding any other provision of Article 3 of Chapter

38150B of the General Statutes, the chief administrative law judge may limit and simplify the

39procedures that apply to a contested Medicaid case involving a Medicaid or NC Health Choice

40recipient in order to complete the case as quickly as possible.

50G.S. 108A-70.9A(e) or other clear request for a hearing by a Medicaid or NC Health Choice

51recipient, OAH shall immediately notify the Mediation Network of North Carolina, which shall

1contact the recipient within five days to offer mediation in an attempt to resolve the dispute. If

2mediation is accepted, the mediation must be completed within 25 days of submission of the

3request for appeal. Upon completion of the mediation, the mediator shall inform OAH and the

4Department within 24 hours of the resolution by facsimile or electronic messaging. If the parties

5have resolved matters in the mediation, OAH shall dismiss the case. OAH shall not conduct a

6hearing of any contested Medicaid case until it has received notice from the mediator assigned

7that either: (i) the mediation was unsuccessful, or (ii) the petitioner has rejected the offer of

8mediation, or (iii) the petitioner has failed to appear at a scheduled mediation. If the recipient

9accepts an offer of mediation and then fails to attend mediation without good cause, OAH shall

10dismiss the contested case.

11(d) Burden of Proof. – The recipient has the burden of proof on all issues submitted in a

12contested Medicaid case to OAH for a Medicaid contested case hearing and has the burden of

13going forward. The administrative law judge shall not make any ruling on the preponderance of

14evidence until the close of all evidence.

15…

16(f) Issue for Hearing. – For each adverse determination and each adverse disenrollment

17determination, the hearing shall determine whether the Department substantially prejudiced the

18rights of the recipient and if the Department, based upon evidence at the hearing:hearing, did any

19of the following:

25…

26" 108A-70.9C. Informal review permitted.

27Nothing in this Part shall prevent the Department from engaging in an informal review of a

28contested Medicaid case with a recipient prior to issuing a notice of adverse determination as

29provided by G.S. 108A-70.9A(c).under G.S. 108A-70.9A(c) or a notice of resolution under

30G.S. 108D-5.4."

32" 108A-70.29. Program review process.

33(a) Review of Eligibility and Program Enrollment Decisions. – Eligibility and Program

34enrollment decisions for Program applicants or recipients shall be reviewable pursuant to

35G.S. 108A-79. Program recipients shall remain enrolled in the NC Health Choice Program during

36the review of a decision to terminate or suspend enrollment. This subsection does not apply to

37requests for disenrollment from a PHP under Article 1A of Chapter 108D of the General Statutes.

38(b) Review of Fee-for-Service Program Health Services Decisions. – This subsection

39applies only to health services decisions for services being provided to NC Health Choice

40recipients through the fee-for-service program as defined in G.S. 108A-24. This subsection does

41not apply to adverse benefit determinations as defined in G.S. 108D-1. In accordance with 42

42C.F.R. 457.1130 and 42 C.F.R. 457.1150, a Program recipient may seek review of any delay,

43denial, reduction, suspension, or termination of health services, in whole or in part, including a

44determination about the type or level of services, through a two-level review process.

47" 122C-3. Definitions.

48The following definitions apply in this Chapter:

13" 150B-1. Policy and scope.

14…

15(e) Exemptions From Contested Case Provisions. – The contested case provisions of this

16Chapter apply to all agencies and all proceedings not expressly exempted from the Chapter. The

17contested case provisions of this Chapter do not apply to the following:

28…."

30" 150B-23. Commencement; assignment of administrative law judge; hearing required;

32…

33(a3) A Medicaid or NC Health Choice enrollee, or network provider authorized in writing

34to act on behalf of the enrollee, the enrollee's authorized representative, who appeals a notice of

35resolution issued by an LME/MCO a managed care entity under Chapter 108D of the General

36Statutes may commence a contested case under this Article in the same manner as any other

37petitioner. The case shall be conducted in the same manner as other contested cases initiated by

38Medicaid or NC Health Choice enrollees under this Article. Solely and only for the purposes of

39contested cases commenced as Medicaid managed care enrollee appeals under Chapter 108D of

40the General Statutes, pursuant to G.S. 108D-15 by enrollees of LME/MCOs to appeal a notice of

41resolution issued by the LME/MCO, an LME/MCO is considered an agency as defined in

42G.S. 150B-2(1a). The LME/MCO shall not be considered an agency for any other purpose. When

43a prepaid health plan, as defined in G.S. 108D-1, other than an LME/MCO, is under contract

44with the Department of Health and Human Services to issue notices of resolution under Article

452 of Chapter 108D of the General Statutes, then solely and only for the purposes of contested

46cases commenced pursuant to G.S. 108D-15 to appeal a notice of resolution issued by the prepaid

47health plan, the prepaid health plan shall be considered an agency as defined in G.S. 150B-2(1a).

48The prepaid health plan shall not be considered an agency for any other purpose.

49…."

22016-121, Section 11H.17(a) of S.L. 2017-57, Section 4 of S.L. 2017-186, Section 11H.10(d) of

3S.L. 2018-5, and Sections 5 and 6 of S.L. 2018-48, reads as rewritten:

4"SECTION 4. Structure of Delivery System. – The transformed Medicaid and NC Health

5Choice programs described in Section 1 of this act shall be organized according to the following

6principles and parameters:

292016-121 and Section 6(b) of S.L. 2018-49, reads as rewritten:

30"SECTION 5. Role of DHHS. – The role and responsibility of DHHS during Medicaid

31transformation shall include the following activities and functions:

47as amended, specified in this section. These specified portions of S.L. 2015-245, as amended,

48shall be codified into a new Article 4 of Chapter 108D of the General Statutes to be entitled

49"Prepaid Health Plans." The new Article 4 of Chapter 108D of the General Statutes shall have

50the following structure:

36specified in subsection (a) of this Section, the Revisor of Statutes is authorized to do all of the

37following:

1references to the Division of Health Benefits, except that references to the Division of Medical

2Assistance shall not be changed in G.S. 108A-54, 126-5(c)(34), 143B-138.1, and 143B-216.80.

SB 548

Version: Filed
Author: Sen. Joyce Krawiec (R-NC)

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