GSNC

ARTICLE 1. County Administration.

Part 1. County Boards of Social Services.

Sec.

Part 2. County Director of Social Services.

Part 2A. Consolidated Human Services.

Part 2B. Regional Social Services Departments.

Part 3. Special County Attorneys for Social Service Matters.

PART 1. COUNTY BOARDS OF SOCIAL SERVICES.

§ 108A-1. Creation.

Every county shall have a governing board for social services, which may be a county board of social services created pursuant to this Part, a consolidated human services board created pursuant to G.S. 153A-77(b), a board of county commissioners that has assumed the powers and duties of a county board of social services or a consolidated human services board, or a regional board of social services created pursuant to G.S. 108A-15.8. The governing board shall establish policies for the programs established by this Chapter in conformity with the rules and regulations of the Social Services Commission and under the supervision of the Department of Health and Human Services. Provided, however, policies for the program of medical assistance shall be established in conformity with the rules and regulations of the Department of Health and Human Services.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5014; 1937, c. 319, s. 3; 1941, c. 270, s. 2; 1945, c. 47; 1953, c. 132; 1955, c. 249; 1957, c. 100, s. 1; 1959, c. 1255, s. 1; 1961, c. 186; 1963, c. 139; c. 247, ss. 1, 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; 1977, 2nd Sess., c. 1219, s. 6; 1981, c. 275, s. 1; 1995 (Reg. Sess., 1996), c. 690, s. 5; 1997-443, s. 11A.118(a); 2017-41, s. 4.2.)

Cross References. - As to certain financial assistance and in-kind goods not being considered in determining assistance paid under Chapter 108A and Chapter 111, see G.S. 108A-26.

As to the Social Services Commission, see G.S. 143B-153 et seq.

Editor's Note. - Session Laws 1981, c. 275 repealed former Chapter 108, Social Services, and enacted present Chapter 108A in its place. Where appropriate, the historical citations to the sections in the former Chapter have been added to corresponding sections in the current Chapter.

Many of the cases and Opinions of the Attorney General cited under the various sections below were decided under corresponding sections of former Chapter 108.

Effect of Amendments. - Session Laws 2017-41, s. 4.2, effective March 1, 2019, in the first sentence, substituted "governing board for social services, which may be a county board" for "or board", and inserted "created pursuant to this Part," substituted "G.S. 153A-77(b), a board of county commissioners pursuant to G.S. 108A-15.3B. The governing board" for "G.S. 153A-77(b) which"; and deleted "county" preceding "policies" in the second and third sentences.

Legal Periodicals. - For survey of 1981 administrative law, see 60 N.C.L. Rev. 1165 (1982).

CASE NOTES

Personal Jurisdiction. - In a case alleging negligent placement of a foster child who sexually assaulted another child, where defendants raised the issues of failure to state a claim and lack of subject matter jurisdiction, but failed to raise the issue of personal jurisdiction, and stipulated in the record before the appellate court that they were properly before the trial court, the defendants could not argue that they were not subject to suit under Chapters 108A and 122C and under G.S. 153A-77. Hobbs v. North Carolina Dep't of Human Resources, 135 N.C. App. 412, 520 S.E.2d 595 (1999).

Employees of Local Departments - Applicability of Eleventh Amendment. - After examining the characterization of the local departments of social service under State law, the relative extent of State control over the departments, the relative extent to which the departments depends on State funding, and the effect of a potential damage award on the State treasury, the departments were found to be an arm of the State and, therefore, the individual defendants, each of whom worked for a department, were State officials for Eleventh Amendment purposes. Shell v. Wall, 808 F. Supp. 481 (W.D.N.C. 1992).

The Commission misapplied the law by concluding that the Davie County Department of Social Services (DSS) was not an agent of the North Carolina Department of Human Resources (DHR) in its delivery of child protective services. Whitaker v. N.C. Dep't of Human Resources, Social Servs. Comm'n, 121 N.C. App. 602, 468 S.E.2d 404 (1996).

Cited in Shell v. Wall, 808 F. Supp. 481 (W.D.N.C. 1992); Rivera v. Guilford County, 286 F. Supp. 2d 635 (M.D.N.C. 2003); Frank v. Savage, 205 N.C. App. 183, 695 S.E.2d 509 (2010).

Opinions of Attorney General

County Commissioner May Serve on Social Services Board. - There is nothing in this Chapter to suggest any impropriety with the "county commissioner member" also serving as chairman of the social services board. See opinion of Attorney General to C. Preston Cornelius, Senior Resident, Superior Court Judge, 60 N.C.A.G. 50 (1990).

§ 108A-2. Size.

The county board of social services of a county shall consist of three members, except that the board of commissioners of any county may increase such number to five members. The decision to increase the size to five members or to reduce a five-member board to three shall be reported immediately in writing by the chairman of the board of commissioners to the Department of Health and Human Services.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5014; 1937, c. 319, s. 3; 1941, c. 270, s. 2; 1945, c. 47; 1953, c. 132; 1955, c. 249; 1957, c. 100, s. 1; 1959, c. 1255, s. 1; 1961, c. 186; 1963, c. 139; c. 247, ss. 1, 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; 1981, c. 275, s. 1; 1995 (Reg. Sess., 1996), c. 690, s. 6; 1997-443, s. 11A.118(a).)

Local Modification. - Mecklenburg: 1981, c. 625.

§ 108A-3. Method of appointment; residential qualifications; fee or compensation for services; consolidated human services board appointments.

Three-Member Board. - The board of commissioners shall appoint one member who may be a county commissioner or a citizen selected by the board; the Social Services Commission shall appoint one member; and the two members so appointed shall select the third member. In the event the two members so appointed are unable to agree upon selection of the third member, the senior regular resident superior court judge of the county shall make the selection.
Five-Member Board. - The procedure set forth in subsection (a) shall be followed, except that both the board of commissioners and the Social Services Commission shall appoint two members each, and the four so appointed shall select the fifth member by majority vote of the membership. If a majority of the four are unable to agree upon the fifth member, the senior regular superior court judge of the county shall make the selection.
Provided further that each member so appointed under subsection (a) and subsection (b) of this section by the Social Services Commission and by the county board of commissioners or the senior regular resident superior court judge of the county, shall be bona fide residents of the county from which they are appointed to serve, and will receive as their fee or compensation for their services rendered from the Department of Health and Human Services directly or indirectly only the fees and compensation as provided by G.S. 108A-8.
Consolidated Human Services Board. - The board of county commissioners shall be the sole appointing authority for members of a consolidated human services board and shall appoint those members in accordance with G.S. 153A-77(c).

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5014; 1937, c. 319, s. 3; 1941, c. 270, s. 2; 1945, c. 47; 1953, c. 132; 1955, c. 249; 1957, c. 100, s. 1; 1959, c. 1255, s. 1; 1961, c. 186; 1963, c. 139; c. 247, ss. 1, 2; 1969, c. 546, s. 1; 1971, c. 369; 1973, c. 476, s. 138; 1981, c. 275, s. 1; 1995 (Reg. Sess., 1996), c. 690, s. 7; 1997-135, s. 1; 1997-443, s. 11A.118(a).)

CASE NOTES

Cited in Shell v. Wall, 808 F. Supp. 481 (W.D.N.C. 1992); Rivera v. Guilford County, 286 F. Supp. 2d 635 (M.D.N.C. 2003).

Opinions of Attorney General

Subsection (b) does not require that all four members of a five member county board of social services be present when the board selects its fifth member. See opinion of Attorney General to Mr. Stephen M. Schoeberle, Burke County Staff Attorney, 58 N.C.A.G. 48 (1988).

Subsection (b) requires that the other four members of a county board of social services be unanimous in their selection of the fifth member. See opinion of the Attorney General to Mr. Stephen M. Schoeberle, Burke County Staff Attorney, 58 N.C.A.G. 48 (1988).

The legislature intended to permit a county commissioner to serve as a member of the county social services board. See opinion of Attorney General to C. Preston Cornelius, Senior Resident, Superior Court Judge, 60 N.C.A.G. 50 (1990).

§ 108A-4. Term of appointment.

Each member of a county board of social services shall serve for a term of three years. No member may serve more than two consecutive terms. Notwithstanding the previous sentence, the limitation on consecutive terms does not apply if the member of the social services board was a member of the board of county commissioners at any time during the first two consecutive terms, and is a member of the board of county commissioners at the time of reappointment.

History

CASE NOTES

Cited in Frank v. Savage, 205 N.C. App. 183, 695 S.E.2d 509 (2010).

§ 108A-5. Order of appointment.

Three-Member Board: The term of the member appointed by the Social Services Commission shall expire on June 30, 1981, and every three years thereafter; the term of the member appointed by the board of commissioners shall expire on June 30, 1983, and every three years thereafter; and the term of the third member shall expire on June 30, 1982, and every three years thereafter.
Five-Member Board: Whenever a board of commissioners of any county decides to expand a three-member board to a five-member board of social services, the Social Services Commission shall appoint an additional member for a term expiring at the same time as the term of the existing member appointed by the board of commissioners, and the board of commissioners shall appoint an additional member for a term expiring at the same time as the term of the existing member appointed by the Social Services Commission. The change to a five-member board shall become effective at the time when the additional members shall have been appointed by both the county board of commissioners and the Social Services Commission. Thereafter all appointments shall be for three-year terms.
Change from Five-Member to Three-Member Board: The change shall become effective on the first day of July following the decision to change by the board of commissioners. On that day, the following two seats on the board of social services shall cease to exist:
1. The seat held by the member appointed by the Social Services Commission whose term would have expired on June 30, 1983, or triennially thereafter; and
2. The seat held by the member appointed by the board of commissioners whose term would have expired June 30, 1981, or triennially thereafter.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5014; 1937, c. 319, s. 3; 1941, c. 270, s. 2; 1945, c. 47; 1953, c. 132; 1955, c. 249; 1957, c. 100, s. 1; 1959, c. 1255, s. 1; 1961, c. 1986; 1963, c. 139; c. 247, ss. 1, 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; c. 724, s. 1; 1981, c. 275, s. 1.)

§ 108A-6. Vacancies.

Appointments to fill vacancies shall be made in the manner set out in G.S. 108A-3. All such appointments shall be for the remainder of the former member's term of office and shall not constitute a term for the purposes of G.S. 108A-4.

History

§ 108A-7. Meetings.

The board of social services of a county shall meet at least once per month, or more often if a meeting is called by the chairman. Such board shall elect a chairman from its members at its July meeting each year, and the chairman shall serve a term of one year or until a new chairman is elected by the board. A consolidated county human services board shall meet in accordance with the provisions of G.S. 153A-77.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 4; C.S., s. 5015; 1937, c. 319, s. 4; 1941, c. 270, s. 3; 1947, c. 92; 1959, c. 320; 1961, c. 186; 1969, c. 546, s. 1; 1981, c. 275, s. 1; 1995 (Reg. Sess., 1996), c. 690, s. 8.)

§ 108A-8. Compensation of members.

Members of the county board of social services may receive a per diem in such amount as shall be established by the county board of commissioners. Reimbursement for subsistence and travel shall be in accordance with a policy set by the county board of commissioners.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 4; C.S., s. 5015; 1937, c. 319, s. 4; 1941, c. 270, s. 3; 1947, c. 92; 1959, c. 320; 1961, c. 186; 1969, c. 546, s. 1; 1971, c. 124; 1981, c. 275, s. 1; 1985, c. 418, s. 3.)

§ 108A-9. Duties and responsibilities.

The county board of social services shall have the following duties and responsibilities:

To select the county director of social services according to the merit system rules of the North Carolina Human Resources Commission;
To advise county and municipal authorities in developing policies and plans to improve the social conditions of the community;
To consult with the director of social services about problems relating to his office, and to assist him in planning budgets for the county department of social services;
To transmit or present the budgets of the county department of social services for public assistance, social services, and administration to the board of county commissioners;
To have such other duties and responsibilities as the General Assembly, the Department of Health and Human Services or the Social Services Commission or the board of county commissioners may assign to it.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5014; 1937, c. 319, s. 3; 1941, c. 270, s. 2; 1945, c. 47; 1953, c. 132; 1955, c. 249; 1957, c. 100, s. 1; 1959, c. 1255, s. 1; 1961, c. 186; 1963, c. 139; c. 247, ss. 1, 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; 1977, 2nd Sess., c. 1219, s. 7; 1981, c. 275, s. 1; 1997-443, s. 11A.118(a); 2013-382, s. 9.1(c).)

Editor's Note. - Session Laws 2013-382, s. 9.1(b), provides: "The following entities and positions created by Chapter 126 of the General Statutes are hereby renamed by this act:

"(1) The State Personnel Commission is renamed the 'North Carolina Human Resources Commission.'

"(2) The Office of State Personnel is renamed the 'North Carolina Office of State Human Resources.'

"(3) The State Personnel Director is renamed the 'Director of the North Carolina Office of State Human Resources.'"

Session Laws 2013-382, s. 9.1(c), provides: "Modification of References. - The Revisor of Statutes shall delete any references in the General Statutes to the State Personnel Act, State Personnel Commission, the State Personnel Director, and the Office of State Personnel (or any derivatives thereof) and substitute references to the North Carolina Human Resources Act, the State Human Resources Commission, the Director of the Office of State Human Resources, and the Office of Human Resources (or the appropriate derivative thereof) to effectuate the renaming set forth in this section wherever conforming changes are necessary."

Session Laws 2013-382, s. 9.2, provides: "No action or proceeding pending on the effective date of this section, brought by or against the State Personnel Commission, the Director of the Office of State Personnel, or the Office of State Personnel, shall be affected by any provision of this section, but the same may be prosecuted or defended in the new name of the Commission, Director, and Office. In these actions and proceedings, the renamed Commission, Director, or Office shall be substituted as a party upon proper application to the courts or other public bodies." Session Laws 2013-382 became effective August 21, 2013.

Session Laws 2013-382, s. 9.3, provides: "Any business or other matter undertaken or commanded by the former State Personnel Commission, State Personnel Director, or Office of State Personnel regarding any State program, office, or contract or pertaining to or connected with their respective functions, powers, obligations, and duties that are pending on the date this act becomes effective may be conducted and completed by the Commission, Director, or Office in the same manner and under the same terms and conditions and with the same effect as if conducted and completed by the formerly named commission, director, or office." Session Laws 2013-382 became effective August 21, 2013.

Effect of Amendments. - Session Laws 2013-382, s. 9.1(c), effective August 21, 2013, substituted "North Carolina Human Resources Commission" for "State Personnel Commission" in subdivision (1).

CASE NOTES

The county department of social services is merely an extension of the county. Meares v. Brunswick County, 615 F. Supp. 14 (E.D.N.C. 1985).

And Has No Sovereign Immunity. - Because the Brunswick County Department of Social Services and the Brunswick County Board of Social Services are extensions of Brunswick County which does not enjoy sovereign immunity, neither do they have sovereign immunity. Meares v. Brunswick County, 615 F. Supp. 14 (E.D.N.C. 1985).

District court declined to grant a county department's Fed. R. Civ. P. 12(b)(1) motion to dismiss a former employee's disability discrimination claims on the ground that the department lacked the capacity to be sued where none of the provisions of G.S. 108A-9 nor any other authority supported the contention that the department was not a legal entity due to the North Carolina Board of Social Services's governing authority. Rivera v. Guilford County, 286 F. Supp. 2d 635 (M.D.N.C. 2003).

The sole involvement of the county board of social services in personnel matters is to select the county director of social services. And the director derives his authority to appoint personnel directly from the General Assembly, not from the board. Thus the local board does not become the "local appointing authority" pursuant to G.S. 126-37 (now repealed) in the absence of a permanent full-time director. In re Brunswick County, 81 N.C. App. 391, 344 S.E.2d 584 (1986).

Extent of Authority Exercised by County over Director. - It is apparent that the county is at most only equal to the State in the authority it can exert over the director of social services. Fracaro v. Priddy, 514 F. Supp. 191 (M.D.N.C. 1981), decided under former Chapter 108.

In an action by eligibility supervisor of county department of social services alleging that her constitutional rights had been violated when her employment was terminated by the director of social services, the county could not be held liable to the plaintiff since the director was not acting for the county, but rather for the State, and since the county board of social services did not have the authority to dismiss the eligibility supervisor. Fracaro v. Priddy, 514 F. Supp. 191 (M.D.N.C. 1981), decided under former Chapter 108.

Local Appointing Agency. - Where an employer is a county department of social services, the local appointing agency is the director of the department. Enoch v. Alamance County Dep't of Soc. Servs., 164 N.C. App. 233, 595 S.E.2d 744 (2004).

Cited in Shell v. Wall, 808 F. Supp. 481 (W.D.N.C. 1992).

§ 108A-10. Fees.

The county board of social services is authorized to enter into contracts with any governmental or private agency, or with any person, whereby the board of social services agrees to render services to or for such agency or person in exchange for a fee to cover the cost of rendering such service. This authority is to be limited to services voluntarily rendered and voluntarily received, but shall not apply where the charging of a fee for a particular service is specifically prohibited by statute or regulation. The fees to be charged under the authority of this section are to be based upon a plan recommended by the county director of social services and approved by the local board of social services and the board of county commissioners. In no event is the fee charged to exceed the cost to the board of social services. Fee policies may not conflict with rules and regulations adopted by the Social Services Commission or Department of Health and Human Services regarding fees.

The fees collected under the authority of this section are to be deposited to the account of the social services department so that they may be expended for social services purposes in accordance with the provisions of Article 3 of Chapter 159, the Local Government Budget and Fiscal Control Act. No individual employee is to receive any compensation over and above his regular salary as a result of rendering services for which a fee is charged.

The county board of social services shall annually report to the county commissioners receipts received under this section. Fees collected under this section shall not be used to replace any other funds, either State or local, for the program for which the fees were collected.

History

(1981, c. 275, s. 1; 1997-443, s. 11A.118(a).)

§ 108A-11. Inspection of records by members.

Every member of the county board of social services may inspect and examine any record on file in the office of the director relating in any manner to applications for and provision of public assistance and social services authorized by this Chapter. No member shall disclose or make public any information which he may acquire by examining such records.

History

PART 2. COUNTY DIRECTOR OF SOCIAL SERVICES.

§ 108A-12. Appointment.

The board of social services of every county shall appoint a director of social services in accordance with the merit system rules of the North Carolina Human Resources Commission. Any director dismissed by such board shall have the right of appeal under the same rules.
Two or more boards of social services may jointly employ a director of social services to serve the appointing boards and such boards may also combine any other functions or activities as authorized by Part 1 of Article 20 of Chapter 160A. The boards shall agree on the portion of the director's salary and the portion of expenses for other joint functions and activities that each participating county shall pay.

History

(1917, c. 170, s. 1; 1919, c. 46, ss. 3, 4; C.S., s. 5016; 1921, c. 128; 1929, c. 291, s. 1; 1931, c. 423; 1937, c. 319, s. 5; 1941, c. 270, s. 4; 1957, c. 100, s. 1; 1961, c. 186; 1969, c. 546, s. 1; 1981, c. 275, s. 1; 2013-382, s. 9.1(c).)

Editor's Note. - Session Laws 2013-382, s. 9.1(b), provides: "The following entities and positions created by Chapter 126 of the General Statutes are hereby renamed by this act:

"(1) The State Personnel Commission is renamed the 'North Carolina Human Resources Commission.'

"(2) The Office of State Personnel is renamed the 'North Carolina Office of State Human Resources.'

"(3) The State Personnel Director is renamed the 'Director of the North Carolina Office of State Human Resources.'"

Effect of Amendments. - Session Laws 2013-382, s. 9.1(c), effective August 21, 2013, substituted "North Carolina Human Resources Commission" for "State Personnel Commission" in the first sentence of subsection (a).

CASE NOTES

Department of Human Resources Liable for Acts of County Director Negligently Placing Foster Child. - In an action alleging that a foster child was negligently placed in a home by the Durham County Department of Social Services, the Department of Human Resources would be liable for the negligent acts of its agents, the Durham County Director of Social Services and his subordinates, since the Department of Human Resources, through the Social Services Commission, has the right to control the manner in which the county director is to execute his obligation to place children in foster homes. Vaughn v. North Carolina Dep't of Human Resources, 296 N.C. 683, 252 S.E.2d 792 (1979), decided under former Chapter 108.

The director of the County Department of Social Services is a public officer for purposes of sovereign immunity. Meyer v. Walls, 122 N.C. App. 507, 471 S.E.2d 422 (1996), aff'd in part and rev'd in part, 347 N.C. 97, 489 S.E.2d 880 (1997).

Cited in Hare v. Butler, 99 N.C. App. 693, 394 S.E.2d 231 (1990); Shell v. Wall, 808 F. Supp. 481 (W.D.N.C. 1992).

§ 108A-13. Salary.

The board of social services of every county, with the approval of the board of county commissioners, shall determine the salary of the director in accordance with the classification plan of the North Carolina Human Resources Commission, and such salary shall be paid by the county from the federal, State and county funds available for this purpose.

History

Editor's Note. - Session Laws 2013-382, s. 9.1(b), provides: "The following entities and positions created by Chapter 126 of the General Statutes are hereby renamed by this act:

"(1) The State Personnel Commission is renamed the 'North Carolina Human Resources Commission.'

"(2) The Office of State Personnel is renamed the 'North Carolina Office of State Human Resources.'

"(3) The State Personnel Director is renamed the 'Director of the North Carolina Office of State Human Resources.'"

Effect of Amendments. - Session Laws 2013-382, s. 9.1(c), effective August 21, 2013, substituted "North Carolina Human Resources Commission" for "State Personnel Commission."

§ 108A-14. Duties and responsibilities.

The director of social services shall have the following duties and responsibilities:
1. To serve as executive officer of the board of social services and act as its secretary;
2. To appoint necessary personnel of the county department of social services in accordance with the merit system rules of the North Carolina Human Resources Commission;
3. To administer the programs of public assistance and social services established by this Chapter under pertinent rules and regulations;
4. To administer funds provided by the board of commissioners for the care of indigent persons in the county under policies approved by the county board of social services;
5. To act as agent of the Social Services Commission and Department of Health and Human Services in relation to work required by the Social Services Commission and Department of Health and Human Services in the county;
6. To investigate cases for adoption and to supervise adoptive placements;
7. To issue employment certificates to children under the regulations of the State Department of Labor;
8. To supervise adult care homes under the rules and regulations of the Medical Care Commission;
9. To assist and cooperate with the Division of Adult Correction and Juvenile Justice of the Department of Public Safety and their representatives;
10. Repealed by Session Laws 2003-13, s. 7, effective April 17, 2003, and applicable to all petitions for sterilization pending and orders authorizing sterilization that have not been executed as of April 17, 2003.
11. To assess reports of child abuse and neglect and to take appropriate action to protect such children pursuant to the Child Abuse Reporting Law, Article 3 of Chapter 7B of the General Statutes;
12. To accept children for placement in foster homes and to supervise placements for so long as such children require foster home care;
13. To respond by investigation to notification of a proposed adoptive placement pursuant to G.S. 48-3(b) and (c); and
14. To receive and evaluate reports of abuse, neglect, or exploitation of disabled adults and to take appropriate action as required by the Protection of the Abused, Neglected, or Exploited Disabled Adults Act, Article 6 of this Chapter, to protect these adults.
15. To receive and evaluate reports of financial exploitation of disabled adults, to investigate credible reports of financial exploitation under Article 6A of this Chapter, and to take appropriate action to protect these adults.
The director may delegate to one or more members of his staff the authority to act as his representative. The director may limit the delegated authority of his representative to specific tasks or areas of expertise. The director may designate, subject to the approval of the Commissioner of Labor, additional personnel outside his staff to issue youth employment certificates.

History

(1917, c. 170, s. 1; 1919, c. 46, s. 3; C.S., s. 5017; 1941, c. 270, s. 5; 1957, c. 100, s. 1; 1961, c. 186; 1969, c. 546, s. 1; 1971, c. 710, s. 5; 1973, c. 476, ss. 133.3, 138; c. 1262, s. 109; c. 1339, s. 2; 1977, 2nd Sess., c. 1219, s. 8; 1981, c. 275, s. 1; 1983, c. 293; 1985, c. 203, ss. 1, 2; 1991, c. 258, s. 1; 1993, c. 553, s. 31; 1995, c. 214, s. 2; c. 535, s. 4; 1997-443, s. 11A.118(a); 1998-202, s. 13(v); 2003-13, s. 7; 2005-55, s. 12; 2005-276, s. 10.42; 2011-145, s. 19.1(h); 2013-337, s. 3; 2013-382, s. 9.1(c); 2017-186, s. 2(vvvv).)

School-Based Child and Family Team Initiative. - Session Laws 2005-276, s. 6.24, provides for the development and implementation of a School-Based Child and Family Team Initiative. See note at G.S. 115C-105.20.

Editor's Note. - Session Laws 2013-382, s. 9.1(b), provides: "The following entities and positions created by Chapter 126 of the General Statutes are hereby renamed by this act:

"(1) The State Personnel Commission is renamed the 'North Carolina Human Resources Commission.'

"(2) The Office of State Personnel is renamed the 'North Carolina Office of State Human Resources.'

"(3) The State Personnel Director is renamed the 'Director of the North Carolina Office of State Human Resources.'"

Effect of Amendments. - Session Laws 2005-55, s. 12, effective October 1, 2005, substituted "assess" for "investigate" in subdivision (a)(11).

Session Laws 2005-276, s. 10.42, effective July 1, 2005, substituted "Medical Care" for "Social Services" in subdivision (a)(8).

Session Laws 2011-145, s. 19.1(h), effective January 1, 2012, substituted "Division of Adult Correction of the Department of Public Safety" for "Department of Correction" in subdivision (a)(9).

Session Laws 2013-337, s. 3, effective December 1, 2013, added subdivision (a)(15).

Session Laws 2013-382, s. 9.1(c), effective August 21, 2013, substituted "North Carolina Human Resources Commission" for "State Personnel Commission" in subdivision (a)(2).

Session Laws 2017-186, s. 2(vvvv), effective December 1, 2017, inserted "and Juvenile Justice" in subdivision (a)(9).

CASE NOTES

Director Has Exclusive Power to Hire and Fire Department Personnel. - Subdivision (a)(2) of this section gives the director of a county department of social services the exclusive power to hire and fire the department's personnel; the statute makes no distinction between "acting" and "permanent" directors. In re Brunswick County, 81 N.C. App. 391, 344 S.E.2d 584 (1986).

Chapter 126 establishes and provides for the administration of the State personnel system. Yow v. Alexander County Dep't of Social Servs., 70 N.C. App. 174, 319 S.E.2d 626, cert. denied, 312 N.C. 625, 323 S.E.2d 927 (1984).

Authority Exercised by County over Director. - It is apparent that the county is at most only equal to the State in the authority it can exert over the director of social services. Fracaro v. Priddy, 514 F. Supp. 191 (M.D.N.C. 1981), decided under former Chapter 108.

Trainee Has No Property Interest in Continued Employment. - An employee who is subject to the State Personnel Act and who holds a "trainee" appointment as defined by the North Carolina Administrative Code does not have a property interest in her continued employment which is protected by the due process clause of the Fourteenth Amendment. Yow v. Alexander County Dep't of Social Servs., 70 N.C. App. 174, 319 S.E.2d 626, cert. denied, 312 N.C. 625, 323 S.E.2d 927 (1984).

Department of Human Resources Liable for Acts of County Director Negligently Placing Foster Child. - In an action alleging that a foster child was negligently placed in a home by the Durham County Department of Social Services, the Department of Human Resources would be liable for the negligent acts of its agents, the Durham County Director of Social Services and his subordinates, since the Department of Human Resources, through the Social Services Commission has the right to control the manner in which the county director is to execute his obligation to place children in foster homes. Vaughn v. North Carolina Dep't of Human Resources, 296 N.C. 683, 252 S.E.2d 792 (1979), decided under former Chapter 108.

Liability of Social Workers Negligently Placing Foster Child. - The language of subsection (b) of this section and the holding of Meyer v. Walls, 347 N.C. at 111, 489 S.E.2d at 888, lead to the conclusion that defendants who were acting for and representing a director of social services were acting as public officials and could therefore not be held individually liable in a case alleging negligent placement of a foster child. Hobbs v. North Carolina Dep't of Human Resources, 135 N.C. App. 412, 520 S.E.2d 595 (1999).

Discretion and Immunity of Social Workers - Pursuant to G.S. 108A-14, a social worker for a county department of human services has the statutory authority to exercise discretion in that capacity, that is, in the capacity of a social worker; thus, where a social worker took various actions in the social worker's capacity as a social worker for a county human services agency that clearly required the exercise of discretion and were not simply ministerial, the social worker was considered a public official for purposes of public official immunity. Dalenko v. Wake County Dep't of Human Servs., 157 N.C. App. 49, 578 S.E.2d 599 (2003), cert. denied, 357 N.C. 458, 585 S.E.2d 386 (2003), cert. denied, 540 U.S. 1178, 124 S. Ct. 1411, 158 L. Ed. 2d 79 (2004).

As a county social worker exercised discretion in the performance of her duties of investigating claims of child neglect and abuse, she qualified as a public official pursuant to G.S. 108A-14(b), such that she was entitled to public official immunity in a wrongful death action arising from an investigation that she was involved in involving a child who later died from shaken baby syndrome. Hunter v. Transylvania County Dep't of Soc. Servs., 207 N.C. App. 735, 701 S.E.2d 344 (2010), review denied 717 S.E.2d 377, 2011 N.C. LEXIS 669 (N.C. 2011).

Investigation of Child Abuse and Neglect. - Under subdivision (a)(11), the General Assembly made clear its intent to include as work required of a county director of social services the investigation of reports of child abuse and neglect. Gammons v. North Carolina Dep't of Human Resources, 344 N.C. 51, 472 S.E.2d 722 (1996).

Juvenile Petition for Termination of Parental Rights. - Trial court had subject matter jurisdiction over the juvenile petition filed by the caseworker even though the caseworker did not sign it and, thus, the trial court could enter its termination of parental rights order regarding the father; while the caseworker did not specifically state in the petition that the caseworker was an authorized representative of the director of the Department of Social Services, the caseworker's verification of the petition was sufficient for the trial court to exercise jurisdiction over the case. In re D.D.F., 187 N.C. App. 388, 654 S.E.2d 1 (2007).

Representative of a local department of social services, which was acting as a state agent, was acquainted with the facts of a termination of parental rights case. Therefore, the representative's verification of the petitions alleging neglect and dependency was effective to grant jurisdiction to the trial court. In re N.X.A., 254 N.C. App. 670, 803 S.E.2d 244 (2017), review denied, 807 S.E.2d 148, 2017 N.C. LEXIS 957 (N.C. 2017).

Cited in Farrell v. Transylvania County Bd. of Educ., 199 N.C. App. 173, 682 S.E.2d 224 (2009).

§ 108A-15. Social services officials and employees as public guardians.

The director and assistant directors of social services of each county may serve as guardians for adults adjudicated incompetent under the provisions of Chapter 35A, and they shall do so if ordered to serve in that capacity by the clerk of superior court having jurisdiction of a guardianship proceeding brought under either Article.

History

(1977, c. 725, s. 6; 1981, c. 275, s. 1; 1985, c. 361, s. 3; 1987, c. 550, s. 23.)

PART 2A. CONSOLIDATED HUMAN SERVICES.

§ 108A-15.1. Consolidated human services board; human services director.

Except as otherwise provided by this section and subject to any limitations that may be imposed by the board of county commissioners under G.S. 153A-77, a consolidated human services board created pursuant to G.S. 153A-77(b) shall have the responsibility and authority to carry out the programs established in this Chapter in conformity with the rules and regulations of the Social Services Commission and under the supervision of the Department of Health and Human Services in the same manner as a county social services board.
In addition to the powers conferred by G.S. 153A-77(d), a consolidated human services board shall have all the powers and duties of a county board of social services as provided by G.S. 108A-9, except that the consolidated human services board may not:
1. Appoint the human services director.
2. Transmit or present the budget for social services programs.
In addition to the powers conferred by G.S. 153A-77(e), a human services director shall have all the powers and duties of a director of social services provided by G.S. 108A-14, except that the human services director may:
1. Serve as the executive officer of the consolidated human services board only to the extent and in the manner authorized by the county manager.
2. Appoint staff of the consolidated human services agency only upon the approval of the county manager.

History

(1995 (Reg. Sess., 1996), c. 690, s. 9; 1997-443, s. 11A.118(a).)

§§ 108A-15.2 through 108A-15.6: Reserved for future codification purposes.

PART 2B. REGIONAL SOCIAL SERVICES DEPARTMENTS.

§ 108A-15.7. Creation of regional social services departments.

A regional social services department, including more than one county, may be formed upon agreement of the county boards of commissioners and, if applicable, either the county board of social services or consolidated human services board having jurisdiction over each of the counties involved.
A regional social services department may incorporate all programs and services offered by the county departments or it may include only selected programs and services.
A county may join an existing regional social services department upon agreement of the boards of commissioners having jurisdiction over each of the counties included in the region as well as the board of county commissioners and, if applicable, either the county board of social services or consolidated human services having jurisdiction over the county department seeking to join the regional department.
The regional social services departments may include more than one judicial district. To promote judicial efficiency, a regional social services department shall make every effort to include complete judicial districts rather than dividing a judicial district across departments.
The regional social services department shall have centralized administrative operations that are geographically located in one county but maintain a physical presence for delivery of social services in every county served by the region.
A county that joins a regional social services department shall be required to contribute financially to the regional department pursuant to rules adopted by the Commission.
A regional social services department shall be a public authority as defined in G.S. 159-7(b)(10).

History

(2017-41, s. 4.1.)

Editor's Note. - Session Laws 2017-41, s. 4.6, as amended by Session Laws 2017-102, s. 40(e), made this section effective March 1, 2019.

Session Laws 2017-41, provides in its preamble: "Whereas the children and families involved in North Carolina's child welfare system are among our most vulnerable children and most fragile families; and

"Whereas, the recent federal Child and Family Services Review (CFSR) and the North Carolina Statewide Child Protective Services Evaluation of the State's Child Protective Services (CPS) program identified troubling gaps and flaws in North Carolina's child welfare system that are allowing too many of those vulnerable children and fragile families to fall through the cracks; and

"Whereas, transforming the child welfare system to better ensure the safety, permanency, and well-being of children and families is the right thing to do; and

"Whereas, county social services agencies are facing significant resource and administration challenges in areas other than child welfare, such as public assistance and adult services; and

"Whereas, a recent audit by the North Carolina State Auditor of Medicaid eligibility determinations by county departments of social services concluded that most of the county departments reviewed in the audit did not consistently meet standards for timeliness and accuracy; and

"Whereas, a recent report by the Program Evaluation Division reached similar conclusions regarding county administration of Medicaid eligibility determinations; and

"Whereas, North Carolina's Aging Services Plan and a recent report on Alzheimer's and related dementias by the North Carolina Institute of Medicine emphasize the tremendous growth of the aging population and anticipate relying heavily on social services agencies to support the needs of this population; and

"Whereas, it has been challenging for the State to effectively supervise administration of complex social services programs in 100 counties and it would be more efficient and effective for the State to supervise fewer local agencies; and

"Whereas, it is our charge to spend public dollars wisely and effectively on administration of public assistance; and

"Whereas, for the aforementioned reasons, North Carolina requires a plan of action to systematically reform the child welfare system and reduce the number of departments of social services to allow for better supervision and administration of social services programs;"

Session Laws 2017-41, s. 1.1, provides: "Regional Supervision of and Collaboration by Local Social Services Programs. - (1) The Department of Health and Human Services (Department) is responsible for supervision of the local administration of social services programs, including child welfare, adult protective services and guardianship, public assistance, child support enforcement, and other programs. In order to enhance State supervision and oversight for these programs, the Department shall develop a plan for establishing regional offices charged with supervision of administration of social services at the local level. The plan shall also identify any necessary legislative and regulatory changes necessary to improve regional collaboration among county or regional social services agencies or programs.

"(2) In developing the plan, the Department shall take into consideration the recommendations of the Social Services Regional Supervision and Collaboration Working Group created under Section 1.2.(a) of this act.

"(3) The Department shall submit the plan to the Joint Legislative Oversight Committee on Health and Human Services by November 15, 2018. The plan shall provide for the system of regional supervision to be operational no later than March 1, 2020. The Department shall not implement the plan without an act by the General Assembly."

Session Laws 2017-41, s. 1.2(a)-(f), provides: "(a) Social Services Regional Supervision and Collaboration Working Group. - The School of Government at the University of North Carolina at Chapel Hill (SOG) shall convene a Social Services Regional Supervision and Collaboration Working Group (Working Group) to make recommendations to the Department regarding the regional supervision and collaboration plan.

"(b) Composition. - The Working Group shall consist of the following members:

"(1) Three members of the Senate appointed by the President Pro Tempore of the Senate, one of whom shall be designated as a cochair.

"(2) Three members of the House of Representatives appointed by the Speaker of the House of Representatives, one of whom shall be designated as a cochair.

"(3) Three representatives from the Department appointed by the Secretary of Health and Human Services or the Secretary's designee.

"(4) One designee of the Chief Justice of the North Carolina Supreme Court, appointed by the Chief Justice.

"(5) Four county commissioners representing the North Carolina Association of County Commissioners (NCACC), each of whom shall represent different regions of the State, appointed by the Director of the NCACC.

"(6) Two county social services directors, one of whom shall be appointed by the President Pro Tempore of the Senate and one of whom shall be appointed by the Speaker of the House of Representatives.

"(7) One representative from the North Carolina Association of Social Services Attorneys (NCASSA), appointed by the President of the NCASSA.

"(8) One representative from the Association of North Carolina County Social Services Directors, appointed by the President of the Association.

"(c) Ad Hoc Subcommittees. - The cochairs may, at their discretion, establish ad hoc subcommittees involving experts and representatives of stakeholder organizations to provide information and offer recommendations related to their areas of expertise and interest. Experts and organizations may include:

"(1) Social Services Commission.

"(2) North Carolina Association of County Boards of Social Services.

"(3) Guardian ad Litem Program.

"(4) Office of Indigent Defense Services.

"(5) North Carolina Partnership for Children, Inc.

"(6) Disability Rights of North Carolina.

"(7) Benchmarks NC.

"(8) North Carolina Association of Local Health Directors.

"(9) North Carolina Council of Community Programs.

"(10) North Carolina Emergency Management Association.

"(11) North Carolina Child Support Council.

"(12) North Carolina Pediatric Society.

"(13) AARP North Carolina.

"(14) County commissioners representing jurisdictions that have diverse geographic, socioeconomic, and demographic characteristics.

"(15) Directors and administrators of consolidated human services agencies.

"(16) Other experts or stakeholders identified by the cochairs.

"(d) Duties. - The Working Group shall develop recommendations for the regional supervision and collaboration plan required by Section 1.1 of this act. The Working Group shall divide its work into two stages, the first to address regional supervision and the second to address interagency collaboration and regionalization.

"(1) Stage One. - The Working Group shall convene its first meeting no later than October 6, 2017. During the first stage, the Working Group shall develop recommendations regarding:

"a. The size, number, and location of the regions. Recommendations shall take into consideration (i) the need for regions to maintain direct, local connections with the jurisdictions they serve; (ii) alignment with other regional organizations that intersect with the work of social services, as appropriate; and (iii) awareness of the cultural differences and similarities between regions.

"b. The allocation of responsibility between the central, regional, and local officials in supervising and administering the social services programs and services.

"c. Methods for holding the regional offices accountable for performance and responsiveness.

"d. Requirements for the regional offices to share information about local departmental performance with the relevant board or boards of county commissioners, county or regional board of social services, or consolidated human services board.

"e. Options for authorizing the board of county commissioners to intervene in urgent situations to assume direct control of the department of social services at the local level prior to the State assuming control of service delivery pursuant to G.S. 108A-74.

"f. Any other issues related to regional supervision identified by the cochairs.

"(2) Stage Two. - During the second stage, the Working Group shall:

"a. Develop recommendations regarding legislative and regulatory changes necessary to improve collaboration between counties in the administration of social services programs and services. Recommendations shall address, at a minimum, information sharing, conflicts of interest, and intercounty movement of people enrolled in programs or receiving social services.

"b. Develop a vision for transitioning the State from a county-administered system to a regionally administered system. The vision shall identify general benefits and challenges associated with making such a transition.

"(e) Reports. -

"(1) Stage One. - The Working Group shall submit a report to the Joint Legislative Oversight Committee on Health and Human Services (Committee) and the Department at the conclusion of Stage One, which shall be no later than April 15, 2018. After receiving the Stage One report, the Committee may terminate the Working Group if it concludes that the Working Group is not making sufficient progress.

"(2) Stage Two. - The Working Group shall submit a report to the Committee and the Department at the conclusion of Stage Two, which shall be no later than February 1, 2019.

"(f) Role of the School of Government. - The School of Government at the University of North Carolina at Chapel Hill shall assist the Working Group as follows:

"(1) Convene and facilitate meetings.

"(2) Provide necessary clerical and administrative support.

"(3) Prepare the Working Group reports.

"(4) Provide technical assistance, as appropriate."

Session Laws 2017-41, s. 2.1(a)-(e), provides: "(a) Contract for Social Services Reform. - The Office of State Budget and Management, in consultation with the Department of Health and Human Services, shall develop and issue a request for proposal (RFP) no later than September 30, 2017, to contract with a third-party organization to develop a plan to reform the State supervision and accountability for the social services system, including child welfare, adult protective services and guardianship, public assistance, and child support enforcement ("system reform"). In developing the system reform plan, the organization shall:

"(1) Evaluate the role of the State in the social services system.

"(2) Develop a new vision and strategic direction for the social services system, including leadership and governance at the State and regional levels.

"(3) Develop a plan for reforming the social services system in order to improve outcomes for children and families, enhance State supervision of local social services administration, improve accountability for outcomes in social services at the local, regional, and State levels.

"(4) Develop a plan for collection, analysis, and effective use of data by the social services system.

"(5) Create a Social Services System Transparency and Wellness Dashboard (Dashboard) as provided in subsection (c) of this section.

"(6) Develop a plan for consistent, standardized continuous quality improvement (CQI) for social services at the State, regional, and county levels.

"(7) Review policies and procedures to support and accelerate system reform, focusing on sustainable change that will improve outcomes for children and families.

"(8) Provide ongoing evaluation and oversight of the Department's implementation of social services system reform.

"(9) Develop a child welfare reform plan as specified in subsection (b) of this section.

"(10) Comply with all applicable reporting and implementation requirements specified in subsection (d) of this section.

"In developing and implementing the social services system reform plan, the organization shall engage the services of national technical advisors with broad expertise and experience in implementing large-scale, systemic social services reform. The national technical advisors may have specialized expertise in certain areas of social services, such as child welfare, adult services, public assistance, or child support enforcement.

"(b) Child Welfare Reform. - The contract with the third-party organization required by subsection (a) of this section shall also require the organization to develop a child welfare reform plan that, at a minimum, makes recommendations regarding:

"(1) Child Protective Services (CPS), including the system for receiving reports and investigating allegations of child abuse, neglect, or dependency.

"(2) Preventive and in-home services that provide struggling families with needed supports and treatment to prevent removal of the children from the home.

"(3) Child fatality oversight, including a review of the existing structure, communication, and effectiveness of the Community Child Protection Teams, the Child Fatality Prevention Team, and use of Citizen Review Panels. Oversight shall also include identification of systemic problems in the child welfare system that may increase risk of harm or death to a child and implementation of timely and appropriate systemic reforms following a child fatality.

"(4) Placement of children in foster care and other out-of-home settings.

"(5) Services provided to children, youth, and parents involved with child welfare to achieve reunification of families.

"(6) Efforts to achieve permanency for children either through reunification with family, legal guardianship or custody, or adoption.

"(7) Provision of health care, mental health, and educational services to children and families involved with the child welfare system.

"(8) Services provided to older youth in foster care and to those who have aged out of foster care.

"(9) Strategies to ensure well-trained and adequately compensated staff to improve performance and reduce turnover.

"(10) Practice and implementation, including:

"a. Ensuring a statewide, trauma-informed, culturally competent, family-centered practice framework.

"b. Incorporating more evidence-based practices, including evidence-informed prevention services designed to reduce the number of children entering foster care.

"c. Specifying expectations regarding professional development, training, and performance standards.

"d. Eliminating unnecessary barriers to licensing foster care and therapeutic foster care families to ensure an adequate supply of qualified families.

"e. Improving provider and foster parent feedback loops. For purposes of this sub-subdivision, 'feedback loops' refers to a situation in which a portion of the output of a situation is used for new input.

"f. Performing time use and salary surveys for Division of Social Services staff.

"g. Promoting relationship building across agencies and providers.

"h. Implementing family supports for adoptions, which includes (i) collecting data on the incidence of disrupted adoptions and unlawful transference of children in North Carolina, (ii) the outcomes for children and families associated with disrupted adoptions, and (iii) the provision of supports needed to assist families at risk of disruption in order to keep those families together.

"i. Maintaining sibling groups, in accordance with the 'Fostering Connections to Success and Increasing Adoptions Act of 2008."'

"j. Developing a statewide, standardized functional protocol to be used for case planning, service referrals, and enhancing executive-level decision making around resource allocation and other system reform efforts.

"(c) In developing the child welfare components of the reform plan pursuant to this section, the organization shall do each of the following:

"(1) Ensure the plan complies with the requirements of the federal Child and Family Services Review Program Improvement Plan effective January 1, 2017.

"(2) Consult regularly with the Social Service Regional Supervision and Collaboration Working Group and offer recommendations appropriate to align the goals and direction for both efforts.

"(3) Review the program for corrective action under G.S. 108A-74, as amended by Part III of this act, and offer any recommendations necessary to align the corrective action program with the child welfare reform plan.

"(d) The social services reform effort described in this section shall also include the creation of a Social Services System Transparency and Wellness Dashboard (Dashboard) that will collect data from the North Carolina Families Accessing Services through Technology (NC FAST) system. The Dashboard shall serve as a report card and include regular reports of the components of social services including, at a minimum, child welfare, adult services, public assistance, and child support enforcement. The Dashboard shall be continuously updated to allow for monitoring by State leadership, staff and families involved in the social services system, and the general public to ensure maximum accountability and transparency and the effective and efficient use of social services and funds. The Department of Health and Human Services shall work closely with the organization to identify available data sources to include in the Dashboard for the relevant programs. With respect to child welfare specifically, the Dashboard shall address the data issues highlighted in the Child and Family Services Review (CFSR) and the North Carolina Statewide Child Protective Services Evaluation of the State's Child Protective Services system dated March 1, 2016, to ensure the provision of accurate federal reporting and improved case management, continuous quality improvement (CQI), and overall improved outcomes for children and families. The data from the Dashboard shall be readily available on the Department's Web site. For purposes of this subsection, the term 'Dashboard' means a standard set of performance and outcome metrics that indicate how effectively the components of the social services system are working.

"(e) The following reporting and implementation requirements shall occur:

"(1) The Office of State Budget and Management (OSBM) shall report to the Joint Legislative Oversight Committee on Health and Human Services (Committee) upon hiring an organization as required by subsection (a) of this section to develop the social services reform plan pursuant to this section.

"(2) OSBM shall include in the contract clear direction that time is of the essence and failure to perform within the required time line constitutes breach of contract. OSBM shall also include a provision in the contract authorizing it to terminate the contract without financial penalty to the State if OSBM, in consultation with the Committee, determines that progress on development of the child welfare reform plan is unsatisfactory.

"(3) The organization shall submit a preliminary report to the Committee no later than 180 days after the contract is finalized. The preliminary report shall set forth the progress made on developing the reform plan and the objectives for the subsequent 180 days. After that preliminary report is submitted, the organization shall submit bimonthly reports to Committee on the progress of development and implementation of the child welfare reform plan.

"(4) The Department shall submit preliminary recommendations to the Committee no later than October 1, 2018, regarding legislative changes necessary to implement the reform plan developed by the organization. After the preliminary report is submitted, the Department may submit additional reports to the Committee identifying additional legislative changes that are necessary to implement the reform plan as it is further developed and implemented."

§ 108A-15.8. Regional board of social services.

A regional social services department shall be governed by a regional board of social services. A regional board of social services shall have the same powers and duties as a county social services board, including the appointment of the regional director of social services, with respect to those services or programs that have been assigned to the regional social services department.
A regional board of social services shall be composed of 12 members. However, a regional board of social services may be increased up to a maximum number of 18 members by agreement of the boards of county commissioners in all counties that comprise the region. The agreement shall be evidenced by concurrent resolutions adopted by the affected boards of county commissioners.
The county board of commissioners of each county in the region shall appoint two members to the regional board of social services, one of whom may be a county commissioner. If more than eight counties join the regional social services department, the board of county commissioners of each county in the region shall appoint one member to the regional board of social services who may be a county commissioner. The Social Services Commission shall appoint two members. The members of the regional social services board shall appoint members to fill any remaining vacancies. The composition of the board shall reasonably reflect the population makeup of the entire region and provide equitable region-wide representation. All members shall be residents of the region.
Except as provided in this subsection, members of a regional board of social services shall serve terms of three years. Two of the original members shall serve terms of one year, and two of the original members shall serve terms of two years. No member shall serve more than three consecutive three-year terms. County commissioner members shall serve only as long as the member is a county commissioner.
Whenever a county shall join or withdraw from an existing regional social services department, the regional board of social services shall be dissolved and a new board shall be appointed as provided in subsection (c) of this section.
Vacancies shall be filled by the appointing authority for any unexpired portion of a term.
A chairperson shall be elected annually by a regional board of social services. The regional social services director shall serve as secretary to the board.
A majority of the actual membership, excluding vacancies, shall constitute a quorum.
Upon being given written notice and an opportunity to respond, a member may be removed from office by the regional board of social services for any of the following:
1. Commission of a felony or other crime involving moral turpitude.
2. Violation of a State law governing conflict of interest.
3. Violation of a written policy adopted by the county board of commissioners of each county in the region.
4. Habitual failure to attend meetings.
5. Conduct that tends to bring the office into disrepute.
A member may receive a per diem in an amount established by the county commissioner members of the regional board of social services. Reimbursement for subsistence and travel shall be in accordance with a policy set by the county commissioner members of the regional board of social services.
The board shall meet at least quarterly. The chairperson or three of the members may call a special meeting.
A regional board of social services is authorized to provide liability insurance for the members of the board and the employees of the regional social services department. A regional board of social services is also authorized to contract for the services of an attorney to represent the board, the regional social services department, and its employees, as appropriate. The purchase of liability insurance pursuant to this subsection waives both the regional board of social services' and the regional social services department's governmental immunity, to the extent of insurance coverage, for any act or omission occurring in the exercise of a governmental function. By entering into a liability insurance contract with the regional board of social services, an insurer waives any defense based upon the governmental immunity of the regional board of social services or the regional social services department.

History

(2017-41, s. 4.1.)

Editor's Note. - Session Laws 2017-41, s. 4.6, as amended by Session Laws 2017-102, s. 40(e), made this section effective March 1, 2019.

§ 108A-15.9. Dissolution of a regional social services department.

Whenever the board of commissioners of each county constituting a regional social services department determines that the department is not operating in the best interests of the respective counties, they may direct that the regional social services department be dissolved.
Whenever a board of commissioners of a county which is a member of a regional social services department determines that the department is not operating in the best interests of that county, it may withdraw from the regional social services department.
Dissolution of a regional social services department or withdrawal from the regional social services department by a county shall be effective only at the end of the fiscal year in which the action of dissolution or withdrawal transpired.
Notwithstanding the provisions of subsection (a) of the section, no regional social services department shall be dissolved without prior written notification to the Department.
Any budgetary surplus available to a regional social services department at the time of its dissolution shall be distributed to those counties comprising the region on the same pro rata basis that the counties appropriated and contributed funds to the regional social services department budget during the current fiscal year. Distribution to the counties shall be determined on the basis of an audit of the financial record of the regional social services department. The regional board of social services shall select a certified public accountant or an accountant who is subsequently certified by the Local Government Commission to conduct the audit. The audit shall be performed in accordance with G.S. 159-34. The same method of distribution of funds described above shall apply when one or more counties of a regional social services department withdraw from a region.

History

(2017-41, s. 4.1.)

Editor's Note. - Session Laws 2017-41, s. 4.6, as amended by Session Laws 2017-102, s. 40(e), made this section effective March 1, 2019.

§ 108A-15.10. Regional social services director.

A regional social services director appointed by a regional social services board shall have all the powers and duties of a director of social services provided by G.S. 108A-14 and other applicable laws. The director shall also have the authority to enter contracts, in accordance with the Local Government Finance Act, Chapter 159 of the General Statutes, on behalf of the regional social services department.

History

(2017-41, s. 4.1; 2017-102, s. 40(d).)

Editor's Note. - Session Laws 2017-41, s. 4.6, as amended by Session Laws 2017-102, s. 40(e), made this section effective March 1, 2019.

Effect of Amendments. - Session Laws 2017-102, s. 40(d), effective March 1, 2019, added the second sentence.

§§ 108A-15.11 through 108A-15.15: Reserved for future codification purposes.

PART 3. SPECIAL COUNTY ATTORNEYS FOR SOCIAL SERVICE MATTERS.

§ 108A-16. Appointment.

With the approval of the board of social services, the board of commissioners of any county may appoint a licensed attorney to serve as a special county attorney for social service matters, or designate the county attorney as special county attorney for social service matters.

History

(1959, c. 1124, s. 1; 1961, c. 186; 1969, c. 546, s. 1; 1981, c. 275, s. 1.)

§ 108A-17. Compensation.

The special county attorney for social service matters shall receive compensation for the performance of his duties and for his expenses in such amount as the board of commissioners may provide. His compensation shall be a proper item in the annual budget of the county department of social services.

History

(1959, c. 1124, s. 1; 1961, c. 186; 1969, c. 546, s. 1; 1981, c. 275, s. 1.)

§ 108A-18. Duties and responsibilities.

The special county attorney shall have the following duties and responsibilities:
1. To serve as legal advisor to the county director, the county board of social services, and the board of county commissioners on social service matters;
2. To represent the county, the plaintiff, or the obligee in all proceedings brought under Chapter 52A, the Uniform Reciprocal Enforcement of Support Act and to exercise continuous supervision of compliance with any order entered in any proceeding under that act;
3. To represent the county board of social services in appeal proceedings and in any litigation relating to appeals;
4. To assist the district attorney with the preparation and prosecution of criminal cases under Article 40 of Chapter 14, entitled "Protection of the Family";
5. To assist the district attorney with the preparation and prosecution of proceedings authorized by Chapter 49, entitled "Bastardy" [Children Born Out of Wedlock];
6. To perform such other duties as may be assigned to him by the board of county commissioners, the board of social services, or the director of social services.
In performing any of the duties and responsibilities set out in this section, the special county attorney is authorized to call upon any director of social services or the Department of Health and Human Services for any information as he may require to perform his duties, and such director and Department are directed to assist him in performing such duties.

History

(1959, c. 1124, ss. 2, 3; 1969, c. 546, s. 1; 1973, c. 47, s. 2; c. 476, s. 138; 1981, c. 275, s. 1; 1997-443, s. 11A.118(a).)

Editor's Note. - The bracketed language in subdivision (a)(5) has been inserted to reflect the current chapter title at the direction of the Revisor of Statutes.

§§ 108A-19 through 108A-23: Reserved for future codification purposes.

ARTICLE 2. Programs of Public Assistance.

Part 1. In General.

Sec.

Part 2. Work First Program.

Part 3. State-County Special Assistance.

Part 4. Foster Care and Adoption Assistance Payments.

Part 5. Food and Nutrition Services.

Part 6. Medical Assistance Program.

Part 6A. Appeals Process for Certain Medicaid and NC Health Choice Determinations.

Part 7. Medical Assistance Provider False Claims Act.

Part 8. Health Insurance Program for Children.

Part 9. Weatherization Assistance Program and Heating/Air Repair and Replacement Program.

Part 10. Medicaid Eligibility Decision Processing Timeliness.

Part 11. Medicaid Eligibility Determinations Accuracy and Quality Assurance.

PART 1. IN GENERAL.

§ 108A-24. Definitions.

As used in Chapter 108A:

"Applicant" is any person who requests assistance or on whose behalf assistance is requested.
Repealed by Session Laws 2001-424, s. 21.52.
"Community service" means work exchanged for temporary public assistance.
"County block grant" means federal and State money appropriated to implement and maintain a county's Work First Program.
"County department of social services" means a county department of social services, consolidated human services agency, or other local agency designated to administer services pursuant to this Article.
"County Plan" is the biennial Work First Program plan prepared by each Electing County pursuant to this Article and submitted to the Department for incorporation into the State Plan that also includes the Standard Work First Program.
"Department" is the Department of Health and Human Services, unless the context clearly indicates otherwise.
"Dependent child" is a person 17 years of age or younger or, in the medical assistance program, a person under 19 years of age. A child 18 years of age, if in high school and expected to graduate by his or her 19th birthday, may receive Work First benefits through the month he or she turns 19 years of age or graduates from high school, whichever comes first.
"Electing County" means a county that elects to develop and is approved to administer a local Work First Program.
"Employment" means work that requires either a contribution to FICA or the filing of a State N.C. Form D-400, or the equivalent.
"Family" means a unit consisting of a minor child or children and one or more of their biological parents, adoptive parents, stepparents, or grandparents living together. For purposes of the Work First Program, family also includes a blood or half-blood relative or adoptive relative limited to brother, sister, great-grandparent, great-great-grandparent, uncle, aunt, great-uncle, great-aunt, great-great-uncle, great-great-aunt, nephew, niece, first cousin, stepbrother, and stepsister.
"Federal TANF funds" means the Temporary Assistance for Needy Families block grant funds provided for in Title IV-A of the Social Security Act.
"Fee-for-service program" means a payment model for the Medicaid and NC Health Choice programs operated by the Department of Health and Human Services pursuant to its authority under Part 6 and Part 8 of Article 2 of Chapter 108A of the General Statutes in which the Department pays enrolled providers for services provided to Medicaid and NC Health Choice recipients rather than contracting for the coverage of services through a capitated payment arrangement.
Repealed by Session Laws 2009-489, s. 1, effective August 26, 2009.
"FICA" means the taxes imposed by the Federal Insurance Contribution Act, 26 U.S.C. § 3101, et seq.
"Full-time employment" means employment which requires the employee to work a regular schedule of hours per day and days per week established as the standard full-time workweek by the employer, but not less than an average of 30 hours per week.
Repealed by Session Laws 1983, c. 14, s. 3.
"Mutual Responsibility Agreement" ("MRA") is an agreement between a county and a recipient of Work First Program assistance which describes the conditions for eligibility for the assistance and what the county will provide to assist the recipient in moving from assistance to self-sufficiency. A MRA may provide for recipient parental responsibilities and child development goals and what a county or the State will provide to assist the recipient in achieving those child development goals. Improvement in literacy shall be a part of any MRA, but a recipient shall not be penalized if unable to achieve improvement. A MRA is a prerequisite for any Work First Program assistance under this Article.
"Parent" means biological parent or adoptive parent, and for Work First purposes, includes a stepparent.
"Prepaid health plan" or "PHP" has the same meaning as in G.S. 108D-1.
"Recipient" is a person to whom, or on whose behalf, assistance is granted under this Article.
"Resident," unless otherwise defined by federal regulation, is a person who is living in North Carolina at the time of application with the intent to remain permanently or for an indefinite period; or who is a person who enters North Carolina seeking employment or with a job commitment.
"Secretary" is the Secretary of Health and Human Services, unless the context clearly indicates otherwise.
"Standard Program County" means a county that participates in the Standard Work First Program.
"Standard Work First Program" means the Work First Program developed by the Department.
"State Plan" is the biennial Work First Program plan, based upon the aggregate of the Electing County Plans and the Standard Work First Program, prepared by the Department for the State's Work First Program pursuant to this Article, and submitted sequentially to the Budget Director, to the General Assembly, to the Governor, and to the appropriate federal officials for approval.
"Temporary" is a time period, not to exceed 60 cumulative months, which meets the federal requirement of Title IV-A.
"Title IV-A" means the Social Security Act, 42 U.S.C. § 601, et seq., as amended by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193, as further amended by the Deficit Reduction Act of 2005, P.L. 109-171 and to other provisions of federal law as may apply to assistance provided in this Article.
"Work" is lawful activity exchanged for cash, goods, uses, or services.
"Work First Diversion Assistance" is a short-term cash payment that is intended to substantially reduce the likelihood of a family requiring Work First Family Assistance. Work First Diversion Assistance must be used to address a specific family crisis or episode of need and may not be used for ongoing or recurrent needs. Work First Diversion Assistance is limited to once in a 12-month period.
"Work First Family Assistance" is a program of time-limited periodic payments to assist in maintaining the children of eligible families while the adult family members engage in activities to prepare for entering and to enter the workplace.
"Work First Program" is the Temporary Assistance for Needy Families program established in this Article.
"Work First Program assistance" means the goods or services provided under the Work First Program.
"Work First Services" are services funded from appropriations made pursuant to this Article and designed to facilitate the purposes of the Work First Program.

History

(1981, c. 275, s. 1; 1983, c. 14, s. 3; 1997-443, ss. 11A.118(a), 12.2; 2001-424, s. 21.52; 2009-489, s. 1; 2019-81, s. 3.)

Cross References. - As to who is a permanently and totally disabled person, see G.S. 108A-42.

As to suspension of public assistance benefits for probation violations, see G.S. 15A-1345(a1).

Effect of Amendments. - Session Laws 2009-489, s. 1, effective August 26, 2009, in subdivision (1e), substituted "Electing County" for "county" and added "that also includes the Standard Work First Program" at the end of the subdivision; in subdivision (3), substituted "17 years of age or younger" for "under 18 years of age" in the first sentence and added the second sentence; added the second sentence in subdivision (3c); deleted former subdivision (3f), which read: "'First Stop Employment Assistance' in the program established to assist recipients of Work First Program assistance with employment through job registration, job search, job preparedness, and community service"; added "and for Work First purposes, includes a stepparent" at the end of subdivision (4b); substituted "developed" for "development" in subdivision (9); inserted "as further amended by the Deficit Reduction Act of 2005, P.L. 109-171" in subdivision (12); and added the second and third sentences in subdivision (14).

Session Laws 2019-81, s. 3, effective October 1, 2019, added subdivision (3e), and redesignated former subdivision (3e) as (3g); redesignated former subdivision (3g) as (3h); and added subdivision (4c).

Legal Periodicals. - For survey of 1981 administrative law, see 60 N.C.L. Rev. 1165 (1982).

CASE NOTES

Standing to Appeal Eligibility Decision. - Daughter of deceased Medicaid recipient had no right to appeal from Department of Human Resources decision regarding her father's eligibility, as she was neither an "applicant" nor a "recipient," nor the legal representative of her father's estate. Yates v. North Carolina Dep't of Human Resources, 98 N.C. App. 402, 390 S.E.2d 761 (1990).

"Parent." - Defendant had to register on the Sexual Offender and Public Protection Registry upon defendant's conviction of abducting a child (defendant's stepchild); because defendant was not the biological or adoptive father of the child, defendant was not a "parent" and was required to register pursuant to G.S. 14-208.6(1m). State v. Stanley, 205 N.C. App. 707, 697 S.E.2d 389 (2010).

Injured Party Was a Recipient Despite Being a Minor. - Where the North Carolina Department of Human Resources, Division of Medical Assistance, expended Medicaid funds to pay certain medical care providers for services that they had rendered to an injured party, the injured party qualified as a "recipient" of medical assistance benefits within the meaning of G.S. 108A-24(5) and G.S. 108A-59 even though the injured party was a minor at the time that the benefits were paid; there was no requirement that a "recipient" had to be one who had received a direct cash payment or relief from debt, or one who had the legal right to sue for medical benefits. Campbell v. N.C. Dep't of Human Res., 153 N.C. App. 305, 569 S.E.2d 670 (2002).

Opinions of Attorney General

Residency Requirement for Receipt of Welfare Benefits Unenforceable. - See opinion of Attorney General to Mr. Robert H. Ward, Assistant Commissioner, Department of Social Services, 40 N.C.A.G. 712 (1970), issued under former Chapter 108.

§ 108A-25. Creation of programs; assumption by federally recognized tribe of programs.

The following programs of public assistance are established, and shall be administered by the county department of social services or the Department of Health and Human Services under federal regulations or under rules adopted by the Social Services Commission and under the supervision of the Department of Human Resources:
1. Repealed by S.L. 1997-443, s. 12.3, effective August 28, 1997.
2. State-county special assistance.
3. Food and Nutrition Services.
4. Foster care and adoption assistance payments.
5. Low income energy assistance program.
The program of medical assistance is established as a program of public assistance and shall be administered by the Department of Health and Human Services in accordance with G.S. 108A-54. Medicaid eligibility administration may be delegated to the county departments of social services under rules adopted by the Department of Health and Human Services.
The Work First Program is established as a program of public assistance and shall be supervised and administered as provided in Part 2 of this Article.
The Department of Health and Human Services may accept all grants-in-aid for programs of public assistance which may be available to the State by the federal government. The provisions of this Article shall be liberally construed in order that the State and its citizens may benefit fully from the federal grants-in-aid.
Each Community Care network organization designated by the Department of Health and Human Services as responsible for coordinating the health care of individuals eligible for medical assistance in a county is hereby deemed to be a public agency that is a local unit of government for the sole and limited purpose of all grants-in-aid, public assistance grant programs, and other funding programs.
When any federally recognized Native American tribe within the State assumes responsibility for any social services, Medicaid and NC Health Choice healthcare benefit programs, and ancillary services, including Medicaid administrative and service functions, that are otherwise the responsibility of a county under State law, then, notwithstanding any other provision of law, the county shall be relieved of the legal responsibility related to the tribe's assumption of those services. With respect to a tribe's assumption of any responsibilities for administration of any aspects of the NC Medicaid program, NC Health Choice, and the Supplemental Nutrition Assistance Program (SNAP), the State and the tribe shall execute an agreement to set forth the general terms, definitions, and conditions by which the parties shall operate. The agreement shall also include requirements and procedures regarding the allocation of all federal and other funds for all programs to be administered by the tribe. Upon the execution of the agreement, to allow the tribe to assume certain duties and responsibilities for the administration of the NC Medicaid program, NC Health Choice, and SNAP, the agreement between the State and the tribe shall require the tribe to accept the oversight authority of the State and the Department of Health and Human Services (Department) in the administration and supervision of these programs. In addition to the other necessary terms and conditions, the agreement shall include the following conditions:
1. All requirements as prescribed by federal law, as well as the tribe and State's responsibilities in complying with federal law, including, but not limited to, any specific provisions pertaining to accounting and auditing compliance, maintenance of liability insurance, confidentiality, reporting requirements, indemnity, waiver of immunity, or due process.
2. As the Department is the federally recognized single State agency for the NC Medicaid program, NC Health Choice, and SNAP, provisions stating the Department retains ultimate administrative discretion in the administration interpretation of all applicable policies, rules, and regulations regarding application processing, eligibility determinations and redeterminations, and other functions related to the eligibility process.
3. Provisions by the tribe to ensure that individuals who will be responsible for the tribe's duties and responsibilities under this agreement shall be employed under standards equivalent to current standards for a Merit System of Personnel Administration or any standards later prescribed by the Office of Personnel Management under section 208 of the Intergovernmental Personnel Act of 1970, unless an exemption is obtained from the federal government. The tribe shall also provide the Department with information to verify the unemployment standards included under this condition.
4. Requirements and procedures for allocating to the tribe in a timely manner all federal funds, nonfederal matching funds, and State funds for State programs previously borne by the State. However, requirements and procedures for allocating funds pursuant to this subdivision shall not include any funding the tribe receives directly from federal agencies.
5. The Department shall, when possible and as allowed by the federal government, adopt funding flexibility for Indian Health Services when such flexibility furthers goals addressing health disparities among American Indians.

History

(1937, c. 135, s. 1; c. 288, ss. 3, 31; 1949, c. 1038, s. 2; 1955, c. 1044, s. 1; 1957, c. 100, s. 1; 1965, c. 1173, s. 1; 1969, c. 546, s. 1; 1973, c. 476, s. 138; 1975, c. 92, s. 4; 1977, 2nd Sess., c. 1219, s. 9; 1979, c. 702, s. 1; 1981, c. 275, s. 1; 1997-443, ss. 11A.118(a), 11A.122, 12.3; 2004-203, s. 41; 2007-97, s. 3; 2010-31, s. 10.19A(b); 2014-100, s. 12C.3(c); 2015-241, s. 12C.10(a); 2017-57, s. 11H.22(a).)

Editor's Note. - Session Laws 2011-375, s. 2, provides: "Notwithstanding 10A NCAC 22F.0402, a provider shall submit to the Division of Medical Assistance a written request for a Reconsideration Review within 30 working days from the date of the receipt of notice of tentative decision. Failure to request a Reconsideration Review in the specified time shall result in the implementation of the tentative decision as the Division's final decision. Any provider who had received notice of a tentative decision under 10A NCAC 22F.0402 on or after March 1, 2011, shall be eligible to resubmit a written request for Reconsideration Review within 30 working days of this act becoming law. The Department of Health and Human Services shall amend any rule in conflict with this provision."

Session Laws 2014-100, s. 12C.1(e) provides: "No later than October 1, 2014, the Department of Health and Human Services, Division of Medical Assistance, shall submit to the Centers for Medicare and Medicaid Services (CMS) Medicaid and NC Health Choice state plan amendments and Medicaid waivers necessary to achieve the following:

"(1) To effectuate the changes required by this section.

"(2) To address the healthcare needs identified in community health assessments and plans conducted by the Eastern Band of Cherokee Indians, provided that changes to Medicaid and NC Health Choice services made by the state plan amendments or waivers will be one hundred percent (100%) federally funded. If any state plan amendments or waivers authorized by this subdivision will increase the state share of administrative or other costs, the Department shall report the anticipated increased costs to the Joint Legislative Oversight Committee on Health and Human Services.

"The state plan amendments and waivers authorized by this section shall have an effective date no later than October 1, 2015."

Session Laws 2014-100, s. 12C.3(a) provides: "The purpose of this section is to enable the Eastern Band of Cherokee Indians to assume responsibility for certain social services, healthcare benefit programs, ancillary services, including Medicaid administrative and service related functions, and related reimbursements."

Session Laws 2014-100, s. 12C.3(b), as amended by Session Laws 2015-241, s. 12C.10(e1), and as amended by Session Laws, 2016-94, s. 12C-2(b), provides: "Beginning October 1, 2014, or upon federal approval, the Eastern Band of Cherokee Indians may begin assuming the responsibility for the Supplemental Nutrition Assistance Program (SNAP). When the Eastern Band of Cherokee Indians assumes responsibility for SNAP, then any State statutes, portions of statutes, or rules relating to the provision of social services regarding SNAP services by a county department of social services for members of the Eastern Band of Cherokee Indians shall no longer apply to the Tribe, and the functions, administration, and funding requirements relating to those social services are thereby delegated to the Eastern Band of Cherokee Indians.

"No later than April 1, 2017, and with the exception of services related to special assistance, childcare, and adult care homes, the Eastern Band of Cherokee Indians may assume responsibility for other programs as described under G.S. 108A-25(e), enacted in subsection (c) of this section. When the Eastern Band of Cherokee Indians assumes responsibility for any of those other programs, then any State statutes, portions of statutes, or rules relating to the provision of services for those programs by a county department of social services for members of the Eastern Band of Cherokee Indians shall no longer apply to the Tribe, and the functions, administration, and funding requirements relating to those programs are thereby delegated to the Eastern Band of Cherokee Indians."

Session Laws 2014-100, s. 12C.3(e) provides: "No later than October 1, 2014, the Department of Health and Human Services, Division of Medical Assistance, shall submit to the Centers for Medicare and Medicaid Services (CMS) Medicaid and NC Health Choice state plan amendments and Medicaid waivers necessary to achieve the following:

"(1) To effectuate the changes required by this section.

"The state plan amendments and waivers authorized by this section shall have an effective date no later than October 1, 2015."

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2014-2015 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2014-2015 fiscal year."

Session Laws 2014-100, s. 38.7, is a severability clause.

Session Laws 2015-241, s. 12C.10(d), (e), as amended by Section 4.2 of S.L. 2015-268, and as amended by Session Laws, 2016-94, s. 12C.2(a), provides: "(d) Approval for the Eastern Band of Cherokee Indians to administer the eligibility process for Medicaid and NC Health Choice is contingent upon federal approval of State Plan amendments and Medicaid waivers by the Centers for Medicare & Medicaid Services (CMS). The Department of Health and Human Services, Division of Medical Assistance (DMA), shall submit any State Plan amendments and Medicaid waivers necessary for the delegation of authority and administrative transfer of function to the Eastern Band of Cherokee Indians or to effectuate the changes required by this section and Section 12C.3 of S.L. 2014-100. All State Plan amendments and Medicaid waivers submitted as allowed under this subsection shall have an effective date of April 1, 2017. DMA shall submit the State Plan amendments and waivers allowed under this subsection and any related responses to CMS requests for additional information to the Eastern Band of Cherokee Indians for review prior to submission to CMS. If CMS does not approve the State Plan amendments and Medicaid waivers allowed by this subsection, the counties shall continue serving individuals living on the federal lands held in trust by the United States.

"(e) When an Advanced Planning Document Update (APDU) is required, the Department of Health and Human Services shall submit an APDU within 30 days after CMS approval of the State Plan amendments allowed under subsection (d) of this section. The Department shall submit the APDU to CMS, the United States Department of Agriculture (USDA), and the Administration for Children and Families (ACF). If CMS, USDA, and ACF do not approve the APDU, the counties shall continue serving individuals living on the federal lands held in trust by the United States."

Session Laws 2015-241, s. 12C.10(f)-(h), as amended by Session Laws 2017-57, s. 11C.10(b), provides: "(f) As soon as practicable, but no later than approval by CMS, USDA, and ACF of the APDU, the Department of Health and Human Services (Department) shall begin functional and detailed design, development, testing, and training of NC FAST, NCTracks, and legacy systems to allow the Eastern Band of Cherokee Indians to assume certain administrative duties consistent with approval given by federal funding partners and any agreements between the Eastern Band of Cherokee Indians and the Department. Failure to approve the APDU shall not hinder the transfer of any social services that do not require approval of federal agencies.

"(f1) The Department, in collaboration with the Eastern Band of Cherokee Indians, shall draft a project plan to meet the April 1, 2017, effective date required by subsection (d) of this section. The Department shall report on the project plan to the Joint Legislative Oversight Committee on Health and Human Services on or before January 1, 2016.

"(g) If federal law allows the Eastern Band of Cherokee Indians to assume responsibility for the NC Medicaid program, NC Health Choice, or SNAP, the Eastern Band of Cherokee Indians shall be allowed to assume responsibility for those programs if they choose to assume such responsibility.

"(h) Repealed by Session Laws 2017-57, s. 11C.10(b), effective July 1, 2017."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2015-2017 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2015-2017 fiscal biennium."

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2016-94, s. 12B.5(a)-(f), provides: "(a) The Department of Health and Human Services, in consultation with the Department of Public Instruction and any other agencies or organizations that administer, support, or study early education in this State, and within resources currently available, shall collaborate on an ongoing basis to develop and implement a statewide vision for early childhood education. In collaborating in this effort, the agencies shall develop a comprehensive approach to early childhood education, birth through third grade, including creating cross agency accountability with a comprehensive set of data indicators, including consideration of the NC Pathways to Grade-Level Reading, to monitor and measure success of the early childhood education systems.

"(b) The Department of Health and Human Services, the Department of Public Instruction, and any other agencies or organizations that administer, support, or study early education programs in this State shall report their findings and recommendations, including any legislative proposals, resulting from the initiative to develop and implement a statewide vision for early childhood education pursuant to subsection (a) of this section. The agencies shall make an initial report to Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Education Oversight Committee on or before January 1, 2017, submit a follow up report to those same committees on or before January 1, 2018, and may make any subsequent reports, annually, on or before January 1, as needed to those same committees.

"(c) The Department of Health and Human Services, in consultation with the Department of Public Instruction, shall promote the successful transition of children who receive assistance from NC Pre-K program and the Child Care Subsidy Assistance program for four- and five-star rated facility classrooms to kindergarten. In its promotion of a successful transition from preschool to kindergarten, the Department of Health and Human Services shall recommend that both NC Pre-K teachers and preschool teachers prepare a preschool to kindergarten transition plan for each child transitioning to kindergarten that documents the child's strengths and needs based on the five Goals and Developmental Indicator domains for children's developmental and learning progress that are based on the NC Foundations for Early Learning and Development. The preparation of the transition plan shall only apply to children who receive assistance through the NC Pre-K program or the Child Care Subsidy Assistance program. It is the intent of the General Assembly that the Departments utilize this transition plan until such time as the standardized program to transition children from preschool to kindergarten, required pursuant to subsection (e) of this section, is developed and implemented.

"(d) The Department of Health and Human Services shall report on the implementation of the transition plan required pursuant to subsection (c) of this section, including any findings and recommendations and any legislative proposals, to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Education Oversight Committee on or before December 15, 2016.

"(e) The Department of Health and Human Services, in consultation with the Department of Public Instruction, shall develop and implement a standardized program to transition children from preschool to kindergarten. In developing this standardized transition program, the Department of Health and Human Services shall identify, at a minimum:

"(1) Methods to standardize student transition information such that it is quantifiable.

"(2) Recommendations for sharing data contained in a student's transition plan between preschool teachers and either kindergarten teachers or the schools that receive the incoming kindergarten students.

"(3) Recommendations for sharing data contained in a student's transition plan between preschool teachers and the parents or guardians of the child who is transitioning to kindergarten.

"(4) Recommendations for preschool teacher training and continuing education to support their role in completing transition plans for preschool children.

"(5) Recommendations for baseline information that should be compiled in transition plans for students transitioning to kindergarten.

"(6) Procedures for the management of transition plan documents, including recommendations for the length of records retention, provisions for confidentiality, and proper disposal.

"(7) Any other components the Department deems appropriate in the provision of information between preschools, students' families, and kindergartens.

"(f) The Department of Health and Human Services shall report on the development of the standardized transition program required pursuant to subsection (e) of this section, including any findings and recommendations and any legislative proposals, to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Education Oversight Committee on or before January 1, 2018."

Session Laws 2016-94, s. 12C.1(a), (b), provides: "(a) Federal Improvement Plan Implementation. - The Department of Health and Human Services, Division of Social Services, shall implement the requirements of the federal Program Improvement Plan to bring our State into compliance with national standards for child welfare policy and practices. The Division shall collaborate with county departments of social services to develop a model of oversight that supports program outcomes and a county's ability to meet performance standards as outlined in the Program Improvement Plan. Oversight may include support for continuous quality improvement, staff training, and data analysis. During the first two years of implementing the Program Improvement Plan, the Division shall ensure the three new Human Services/Planner Evaluator positions funded by this act are used to carry out the activities detailed in the Plan. Upon complete implementation of the Plan, these positions shall be used in child welfare services to continually improve outcomes for children and families.

"The Division shall report on the implementation and outcomes of the Program Improvement Plan to the Joint Legislative Oversight Committee on Health and Human Services. The report shall be submitted semiannually on February 1 and August 1 of each year, with the first report submitted on August 1, 2016, and the final report on February 1, 2019.

"(b) Statewide Strategic Plan. - The Division of Social Services shall develop a statewide strategic plan for child welfare services that complements the required federal Program Improvement Plan. The statewide strategic plan shall, at a minimum, address the findings of the North Carolina Statewide Child Protective Services Evaluation, which was conducted as required by Section 12C.1(f) of S.L. 2014-100, in the areas of county performance, caseload sizes, administrative structure, adequacy of funding, social worker turnover, and monitoring and oversight. The plan shall also address measures for ensuring that Native American children in this State are served in a culturally appropriate manner, including in placements for adoption and foster care. The Division shall submit the plan to the Joint Legislative Oversight Committee on Health and Human Services by December 1, 2016, for consideration by the 2017 General Assembly."

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2016-2017 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2016-2017 fiscal year."

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2017-57, s. 11B.2(a)-(d), provides: "(a) The Department of Health and Human Services, in consultation with the Department of Public Instruction and any other agencies or organizations that administer, support, or study early education in this State, and within resources currently available, shall continue to collaborate on an ongoing basis in the development and implementation of a statewide vision for early childhood education. In collaborating in this effort, the agencies shall continue developing a comprehensive approach to early childhood education, birth through third grade, including creating cross agency accountability with a comprehensive set of data indicators, including consideration of the NC Pathways to Grade-Level Reading, to monitor and measure success of the early childhood education systems.

"(b) The Department of Health and Human Services, the Department of Public Instruction, and any other agencies or organizations that administer, support, or study early education programs in this State shall submit a follow-up report of their findings and recommendations, including any legislative proposals, on the statewide vision for early childhood education pursuant to subsection (a) of this section to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Education Oversight Committee on or before January 1, 2018, and may make any subsequent reports, annually, on or before January 1, as needed to those same committees.

"(c) The Department of Health and Human Services, in consultation with the Department of Public Instruction, shall continue developing a standardized program to transition children from preschool to kindergarten. In developing this standardized transition program, the Department of Health and Human Services shall identify, at a minimum:

"(1) Methods to standardize student transition information such that it is quantifiable.

"(3) Recommendations for sharing data contained in a student's transition plan between preschool teachers and the parents or guardians of the child who is transitioning to kindergarten.

"(4) Recommendations for preschool teacher training and continuing education to support their role in completing transition plans for preschool children.

"(5) Recommendations for baseline information that should be compiled in transition plans for students transitioning to kindergarten.

"(6) Procedures for the management of transition plan documents, including recommendations for the length of records retention, provisions for confidentiality, and proper disposal.

"(7) Any other components the Department deems appropriate in the provision of information between preschools, students' families, and kindergartens.

"(d) The Department of Health and Human Services shall report on the development of the standardized transition program required pursuant to subsection (c) of this section, including any findings and recommendations and any legislative proposals, to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Education Oversight Committee on or before January 1, 2018."

Session Laws 2017-57, s. 11C.7(a), (b), as amended by Session Laws 2018-5, s. 11C.1, provides: "(a) Federal Improvement Plan Implementation. - The Department of Health and Human Services, Division of Social Services, shall continue implementing the requirements of the federal Program Improvement Plan to bring our State into compliance with national standards for child welfare policy and practices. The Division shall collaborate with county departments of social services to develop a model of oversight that supports program outcomes and a county's ability to meet performance standards as outlined in the Program Improvement Plan. Oversight may include support for continuous quality improvement, staff training, and data analysis.

"Of the funds appropriated to the Division in each year of the 2017-2019 fiscal biennium for the child welfare program improvement plan, the sum of sixty thousand dollars ($60,000) recurring in each year of the 2017-2019 fiscal biennium shall be used by the Division, in collaboration with the North Carolina State Commission on Indian Affairs within the Department of Administration, for North Carolina State-recognized tribes to assist in (i) recruiting foster parents, (ii) increasing the number of foster homes for children who are members of a North Carolina State-recognized tribe, and (iii) providing training for staff of county departments of social services to ensure culturally appropriate services for children who are members of a North Carolina State-recognized tribe.

"The Division shall notify the Joint Legislative Oversight Committee on Health and Human Services (Committee) and the Fiscal Research Division within 30 days of complete implementation of the Program Improvement Plan. The Division shall submit a final report to the Committee on the implementation and outcomes of the Program Improvement Plan no later than 90 days after implementation is complete.

"(b) Child Welfare/NC FAST. - The Department of Health and Human Services, Division of Social Services, shall continue toward completion of the child welfare component of the North Carolina Families Accessing Services Through Technology (NC FAST) system to (i) bring the State into compliance with the Statewide Information System systematic factor of the Child and Family Services Review (CFSR) and (ii) ensure that data quality meets federal standards and adequate information is collected and available to counties to assist in tracking children and outcomes across counties.

"It is the intent of the General Assembly that the child welfare component of the NC FAST system be operational by December 31, 2017. To that end, the Department of Health and Human Services, Division of Social Services, shall notify the Joint Legislative Oversight Committee on Health and Human Services (Committee) and the Fiscal Research Division within 30 days of complete implementation of the child welfare component of NC FAST. The Division of Social Services shall then submit a final report to the Committee on the implementation and outcomes of the child welfare component of the NC FAST system no later than 90 days after implementation is complete."

Session Laws 2017-57, s. 11C.10(a), provides: "(a) The Department of Health and Human Services, Division of Social Services, shall submit a final report to the Joint Legislative Oversight Committee on Health and Human Services on the assumption of certain services by the Eastern Band of Cherokee Indians as implemented pursuant to Section 12C.10 of S.L. 2015-241, as amended by Section 12C.2 of S.L. 2016-94, when implementation is complete."

Session Laws 2017-57, s. 11H.22(j), provides "The Department of Health and Human Services may adopt and amend rules to implement this section."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2017-2019 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2017-2019 fiscal biennium."

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2018-2019 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2018-2019 fiscal year."

Session Laws 2018-5, s. 39.7, is a severability clause.

Session Laws 2019-240, s. 24(a)-(e), provides: "(a) The Department of Health and Human Services, Division of Social Services, shall postpone deployment of the North Carolina Families Accessing Services through Technology (NC FAST) system as it relates to case-management functionality for the child welfare system and aging and adult services' programs. The Division shall not deploy the child welfare case-management component of the NC FAST system statewide prior to July 1, 2020, but shall instead continue to develop and improve case-management functionality for the child welfare component of NC FAST only in those counties that participated in the initial pilot program prior to January 1, 2019.

"(b) Counties that were phased-in the NC FAST Child Welfare System after January 1, 2019, may elect to opt out of the utilization of the Intake and Assessment functionality of the NC FAST system.

"(c) The Division shall move forward with developing and issuing requests for information (RFIs) to consider a vehicle for improving or replacing the child welfare case-management component of NC FAST, but shall not issue any contracts without prior approval from the General Assembly. To ensure the request for information includes areas of greatest concerns to the pilot counties, the Division shall consult with the Executive Committee of the North Carolina Association of County Directors of Social Services. The Department shall report to the chairs of the Senate Committee on Health Care, the chairs of the Senate Appropriations Committee on Health and Human Services, the chairs of the House of Representatives Committee on Health, and the chairs of the House of Representatives Appropriations Committee on Health and Human Services no later than May 1, 2020.

"(d) The Joint Legislative Program Evaluation Oversight Committee shall revise the biennial 2019-2020 work plan for the Program Evaluation Division to include a study of the case-management functionality of the child welfare component of NC FAST. The Program Evaluation Division shall submit its evaluation to the Joint Legislative Program Evaluation Oversight Committee and to the Joint Legislative Oversight Committee on Health and Human Services no later than May 1, 2020.

"(e) This section is effective when it becomes law."

Session Laws 2020-88, s. 6(a)-(e), provides: "(a) County departments of social services shall do all of the following:

"(1) Resume Medicaid eligibility redeterminations for beneficiaries whose annual or other periodic renewal of Medicaid eligibility is due on or after September 1, 2020.

"(2) Resume requesting post-eligibility verification information for Medicaid applications received on or after September 1, 2020.

"(3) Make a good-faith effort to redetermine Medicaid eligibility for Medicaid beneficiaries who were due for an annual or other periodic renewal of Medicaid eligibility prior to September 1, 2020, but for whom recertification did not occur.

"(4) Make a good-faith effort to request post-eligibility verification information for Medicaid applications received prior to September 1, 2020, for which post-eligibility verifications have not been requested.

"(b) In complying with the requirements of this section, county departments of social services shall not terminate benefits for a Medicaid beneficiary if doing so would result in the State being ineligible for the increased Medicaid funding under Section 6008 of P.L. 116-127. When a county department of social services identifies a case that would be subject to termination of Medicaid eligibility in the absence of the preceding requirement, the case shall be identified in the NC FAST system utilizing a uniform identifier to be established by the Department of Health and Human Services no later than July 31, 2020. Notices of termination for cases with the identifier shall be sent in accordance with G.S. 108A-79 within 90 days after the expiration of the declared nationwide public health emergency as a result of the 2019 novel coronavirus.

"(c) A county department of social services shall not be financially responsible for the issuance of Medicaid benefits or Medicaid claims payments under G.S. 108A-25.1A for any beneficiary whose Medicaid eligibility was continued as a result of Section 6008(b)(3) of P.L. 116-127.

"(d) This section shall not be construed to prevent a county department of social services or the Department of Health and Human Services from complying with the requirements of any court order or any settlement agreement entered into as a result of litigation or potential litigation.

"(e) If a federally recognized Native American tribe within the State has assumed responsibility for the Medicaid program pursuant to G.S. 108A-25(e), then this section applies to the tribe in the same manner as it applies to county departments of social services.”

Effect of Amendments. - Session Laws 2004-203, s. 41, effective August 17, 2004, added subsection (d).

Session Laws 2007-97, s. 3, effective June 20, 2007, substituted "and Nutrition Services" for "stamp program" in subdivision (a)(3), and made minor punctuation changes throughout subsection (a).

Session Laws 2010-31, s. 10.19A(b), effective July 1, 2010, deleted "for adults" from the end of subdivision (a)(2).

Session Laws 2014-100, s. 12C.3(c), effective July 1, 2014, added "assumption by federally recognized tribe of programs" in the section heading; and added subsection (e).

Session Laws 2015-241, s. 12C.10(a), effective July 1, 2015, rewrote subsection (e).

Session Laws 2017-57, s. 11H.22(a), effective June 28, 2017, added "the Department of Health and Human Services in accordance with G.S. 108A-54. Medicaid eligibility administration may be delegated to" in subsection (b).

Legal Periodicals. - For article reviewing the development of protective services for children in this State, see 54 N.C.L. Rev. 743 (1976).

CASE NOTES

State Participation Is Voluntary. - Participation by the State in aid to families with dependent children is not required, but is voluntary; implementation is left to the states. Gilliard v. Craig, 331 F. Supp. 587 (W.D.N.C. 1971), aff'd, 409 U.S. 807, 93 S. Ct. 39, 34 L. Ed. 2d 66 (1972), rehearing denied, 409 U.S. 1119, 93 S. Ct. 892, 34 L. Ed. 2d 704 (1973), decided under former Chapter 108.

Medicaid Has No Resource Spend-Down Provision. - The North Carolina Medicaid statute, like the federal statute, does not have a specific resource spend-down provision in its plan. Elliot ex rel. Casstevens v. Department of Human Resources, 115 N.C. App. 613, 446 S.E.2d 809, aff'd, 341 N.C. 191, 459 S.E.2d 273 (1995).

Use of Resource Spend-Down Not Required. - The North Carolina Medicaid plan, established in subsection (b), does not require the use of resource spend-down when evaluating Medicaid eligibility. Elliot ex rel. Casstevens v. Department of Human Resources, 115 N.C. App. 613, 446 S.E.2d 809, aff'd, 341 N.C. 191, 459 S.E.2d 273 (1995).

Recoupment of Overpayments - Where North Carolina Department of Health and Human Services, Division of Medical Assistance (DMA) sought to recoup Medicaid overpayments made to a debtor hospital, in order to qualify for recoupment, the DMA's recoupment claim was required to have arisen from the "same transaction" as the overpayment; the bankruptcy court found that the ongoing stream of services, advances, and reconciliations that was unique to the Medicaid system constituted a single transaction for recoupment purposes, and although the relationship between the hospital and the DMA involved several transactions for the provision of services to several patients, this relationship was not analogous to multiple, separate equipment purchases from a single supplier, which would not have been part of the same transaction. In re Dist. Mem'l Hosp. of Southwestern N.C. Inc., 297 B.R. 451 (Bankr. W.D.N.C. 2002).

Decision Rationally Related to Goal of Statute. - There was no substantive due process right violated in the trial court's decision to affirm the decision of the North Carolina Department of Health and Human Services, Division of Public Health, (DHHS) to decertify a corporation as a provider of HIV case management services because the trial court perceived that the corporation's lack of proper progress notes prevented DHHS from being able to accurately account for funds allotted by the Division of Medical Services for the program of public assistance, and given that the problem was evident in all four case managers at the corporation, decertification would ensure that funds provided for public assistance would be protected; the trial court's decision was rationally related to the G.S. 108A-25(b) goal of providing a program of public assistance, as supported by the trial court's findings of fact, conclusions of law and substantial record evidence. Bradley-Reid Corp. v. N.C. HHS, 201 N.C. App. 305, 689 S.E.2d 494 (2009).

Cited in Luna v. Div. of Soc. Servs., 162 N.C. App. 1, 589 S.E.2d 917 (2004); Cloninger v. N.C. HHS, 203 N.C. App. 345, 691 S.E.2d 127 (2010), review denied 364 N.C. 324, 2010 N.C. LEXIS 1083 (2010).

§ 108A-25.1: Repealed by Session Laws 2001-424, s. 21.52, effective July 1, 2001.

§ 108A-25.1A. Responsibility for errors.

A county department of social services shall be financially responsible for the erroneous issuance of Medicaid benefits and Medicaid claims payments resulting when the county department of social services takes any action that requires payment of Medicaid claims for an ineligible individual, for ineligible dates, or in an amount that includes a recipient's liability and for which the State cannot claim federal participation.
Notwithstanding subsection (a) of this section, a county department of social services shall not be financially responsible for the erroneous issuance of Medicaid benefits and Medicaid claims payments resulting from a failure or error attributable solely to the State.
The amounts to be charged back to a county department of social services for erroneous payments of claims shall be the State and federal shares of all erroneous payments, not to exceed the lesser of the amount of actual error or claims payment.

History

(2017-57, s. 11H.22(f).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(h)-(j), as amended by Session Laws 2018-5, s. 11H.5(d), provides: "(h) Beginning 18 months after the Department has implemented the training and certification program under subsection (g) of this section, the Department shall include in its audits required under G.S. 108A-70.46 a verification that all county departments of social services are in compliance with the certification program requirements for individuals involved in the Medicaid eligibility determination process.

"(i) No later than March 1, 2018, the Department shall submit to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, and the Fiscal Research Division a report on the implementation of the training and certification program required under this section. The report shall include the following:

"(1) A detailed outline of what the training and certification program will entail, including how many hours of training will be required for certification, how frequently recertification will be required, and how often training will be provided by the Department to the county departments of social services.

"(2) A plan of implementation of the training and certification program, including a specific time line of implementation.

"(3) Anticipated costs to the Department, as well as any costs to the county department of social services, of implementing the training and certification program. This should include an identification of any additional resources required by the Department or a county department of social services in order to implement the training and certification program.

"(4) Any other information the Department is able to provide regarding the training and certification program development.

"(j) The Department of Health and Human Services may adopt and amend rules to implement this section."

Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017, and applicable to errors identified on or after that date.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Session Laws 2020-88, s. 6(a)-(e), provides: "(a) County departments of social services shall do all of the following:

"(1) Resume Medicaid eligibility redeterminations for beneficiaries whose annual or other periodic renewal of Medicaid eligibility is due on or after September 1, 2020.

"(2) Resume requesting post-eligibility verification information for Medicaid applications received on or after September 1, 2020.

§ 108A-25.2. Exemption from limitations for individuals convicted of certain drug-related felonies.

Individuals convicted of Class H or I controlled substance felony offenses in this State shall be eligible to participate in the Work First Program and the food and nutrition services program:

Six months after release from custody if no additional controlled substance felony offense is committed during that period and successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority; or
If not committed to custody, six months after the date of conviction if no additional controlled substance felony offense is committed during that period and successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority.

A county department of social services shall require individuals who are eligible for Work First Program assistance and electronic food and nutrition benefits pursuant to this section to undergo substance abuse treatment as a condition for receiving Work First Program or electronic food and nutrition benefits, if funds and programs are available and to the extent allowed by federal law.

History

(1997-443, s. 12.4; 2007-97, s. 4; 2008-187, s. 17.)

Editor's Note. - This section was amended by Session Laws 2007-97, s. 4, in the coded bill drafting format provided by G.S. 120-20.1. The redlining in the act resulted in the word "and" being duplicated in the introductory paragraph. Session Laws 2008-187, s. 17, amended the section by deleting the extra "and."

Effect of Amendments. - Session Laws 2007-97, s. 4, effective June 20, 2007, substituted "and the food and nutrition services program" for "food stamp program" in the introductory paragraph and substituted "electronic food and nutrition" for "food stamp" twice in the concluding paragraph.

Session Laws 2008-187, s. 17, effective August 7, 2008, deleted "and" following "Work First Program and" in the introductory paragraph.

§ 108A-25.3. Garnishment of wages to recoup fraudulent public assistance program payment.

The following definitions apply in this section:
1. Disposable income. - The part of the compensation paid or payable for personal services, whether denominated as wages, salary, commission, bonus, or otherwise which remains after the deduction of any amounts required by law to be withheld.
2. Fraudulent payment. - Any public assistance program payment made because of a recipient's false statement or representation or failure to disclose a material fact which occurs willfully and knowingly and with intent to deceive.
3. Garnishee. - The person, firm, association, or corporation owing compensation for personal services, whether denominated as wages, salary, commission, bonus, or otherwise.
4. Public assistance program. - Any means-tested benefit program administered or supervised by a county department of social services or the Department of Health and Human Services which is funded in whole or in part by federal, State, or county resources.
In any case in which a recipient or former recipient of a public assistance program, who while a recipient, obtained or benefited from a fraudulent payment, a judge of the district court in the county where the recipient or former recipient resides or is found, or in the county where the payment was made, may enter an order of garnishment to recoup a fraudulent payment after 10 days following the entry of a judgment for a sum certain for fraudulent payments pursuant to a petition filed in the action in accordance with subsection (c) of this section. Not more than twenty percent (20%) of the recipient's or former recipient's monthly disposable income may be garnished to recoup payment in cases of fraudulent payment. The order of garnishment shall be subject to all federal and State laws or regulations that may apply to recoupment of fraudulent payments. Garnishment shall not be a remedy under this section when the recipient or former recipient is required to pay restitution for fraudulent public assistance payments pursuant to a criminal court order.
A county department of social services or the Department of Health and Human Services may petition the court for an order of garnishment to recoup a fraudulent public assistance program payment. Garnishment shall be a remedy to recoup payment only after all administrative remedies are exhausted unsuccessfully. The petition shall be verified and provide the court with facts and circumstances of the fraudulent payment to or on behalf of the recipient or former recipient, the name and address of the garnishee, the recipient's or former recipient's monthly disposable income (which may be based on information and belief), and the amount sought to be garnished from the recipient's or former recipient's disposable income. The petition shall be served on both the recipient or former recipient and the garnishee in accordance with the provisions for service of process set forth in G.S. 1A-1, Rule 4. The time period for answering or otherwise responding to process issued pursuant to this section shall be in accordance with the time periods set forth in G.S. 1A-1, Rule 12.
Upon a hearing held pursuant to this section, the court may enter an order of garnishment. Provided, the court may not enter an order of garnishment if the court finds that the order jeopardizes the recipient's or former recipient's ability to become or remain financially self-sufficient and will result in the likelihood of an increased or recurring dependency on public assistance or an inability to secure basic necessities including, but not limited to, housing, food, health care, and utility costs. If an order of garnishment is entered, a copy of the same shall be served on both the recipient or the former recipient and the garnishee either personally or by certified or registered mail, return receipt requested. The order shall set forth sufficient findings of facts to support the action by the court and the amount to be garnished for each pay period. The amount garnished may be increased by an additional one dollar ($1.00) processing fee to be assessed and retained by the garnishee for each payment under the order. The order shall be subject to review for modification and dissolution upon the filing of a motion in the cause.
Upon receipt of the order of garnishment, the garnishee shall transmit without delay to the clerk of superior court the amount ordered by the court to be garnished. These funds shall be disbursed to the county department of social services to recoup fraudulent payments subject to the order of garnishment entered pursuant to this section.
A garnishee who violates the terms of an order of garnishment shall be subject to punishment for contempt.
The Social Services Commission shall adopt rules to implement this section. The rules shall ensure that a petition for an order of garnishment sought pursuant to this section is consistent with all federal and State laws and regulations.

History

(1997-443, s. 11A.122; 1997-497, s. 1.)

Editor's Note. - This section was enacted as G.S. 108A-25.1, and was recodified as G.S. 108A-25.3 by the Revisor of Statutes.

§ 108A-25.4. Use of payments under the Low-Income Energy Assistance Program and Crisis Intervention Program.

The Low-Income Energy Assistance Program Plan developed by the Department of Health and Human Services (Department) and submitted to the U.S. Department of Health and Human Services shall focus the annual energy assistance payments on the elderly population age 60 and above with income up to one hundred thirty percent (130%) of the federal poverty level and disabled persons receiving services through the Division of Aging and Adult Services. The energy assistance payment shall be paid directly to the service provider by the county department of social services. The Plan for Crisis Intervention Program (CIP) shall provide assistance for vulnerable populations who meet income eligibility criteria established by the Department. The CIP payment shall be paid directly to the service provider by the county department of social services and shall not exceed six hundred dollars ($600.00) per household in a fiscal year.
The Department shall submit the Plan for each program to the U.S. Department of Health and Human Services no later than September 1 of each year and implement the Plan no later than October 1 of each year.

History

(2011-145, s. 10.56(a).)

§ 108A-26. Certain financial assistance and in-kind goods not considered in determining assistance paid under Chapters 108A and 111.

Financial assistance and in-kind goods or services received from a governmental agency, or from a civic or charitable organization, shall not be considered in determining the amount of assistance to be paid any person under Chapters 108A and 111 of the General Statutes provided that such financial assistance and in-kind goods and services are incorporated in the rehabilitation plan of such person being assisted by the Division of Vocational Rehabilitation Services or the Division of Services for the Blind of the Department of Health and Human Services, except where such goods and services are required to be considered by federal law or regulations.

History

(1973, c. 716; 1981, c. 275, s. 1; 1997-443, s. 11A.118(a).)

§ 108A-26.1. Information sharing of outstanding arrest warrant of applicant for or recipient of program assistance.

A county department of social services shall notify an applicant for program assistance under Part 2 or Part 5 of this Article that release of confidential information from the applicant's records may not be protected if there exists an outstanding warrant for arrest against the applicant. A county department of social services shall notify a recipient under a program of public assistance under Part 2 or Part 5 of this Article at the time of renewal of the recipient's application for such program assistance that release of confidential information from the recipient's records may not be protected if there exists an outstanding warrant for arrest against the recipient.
Notwithstanding G.S. 108A-80, and to the extent otherwise allowed by federal and State law, a county department of social services shall ensure that the criminal history of an applicant, or of a recipient at the time of benefits renewal, is checked in a manner and to the extent necessary to verify whether an applicant for or recipient of program assistance under Part 2 or Part 5 of this Article is (i) fleeing to avoid prosecution, custody, or confinement after conviction under the laws of the place from which the individual flees, for a crime or an attempt to commit a crime, which is a felony under the laws of the place from which the individual flees, or (ii) violating a condition of probation or parole imposed under federal or State law.
Nothing in this section shall be construed to authorize the disclosure of any information otherwise protected by State or federal law or regulation.
This section applies to applicants for or recipients of program assistance under Part 2 or Part 5 of this Article only.
The Social Services Commission shall adopt any rules necessary to implement this section, including rules addressing the sharing of confidential information between county departments of social services and law enforcement agencies.
The Secretary of the Department of Health and Human Services shall promote cooperation among State and local agencies to perform the functions described in this section. The Department of Health and Human Services shall cooperate and collaborate with the Office of the State Controller, the Administrative Office of the Courts, the Department of Justice, the State Bureau of Investigation, and the Department of Public Safety to develop protocols to implement this section.
Annually on April 1, each county department of social services shall report to the Department of Health and Human Services on the number of individuals who are denied benefits under this section during the preceding calendar year.
Annually on May 1, the Department of Health and Human Services shall report to the Joint Legislative Oversight Committee on Health and Human Services of the General Assembly on the number of individuals who are denied assistance under this section. The report shall include a breakdown by county.

A criminal history check utilizing currently accessible databases shall be conducted by the county department of social services, subject to G.S. 114-19.34 and to the extent permitted by allocated county and State resources.

Nothing in this section requires fingerprints to be taken of every applicant for or recipient of a program of public assistance.

Counties are not required to allocate funds to comply with this section but are authorized to make such allocations on a voluntary basis.

History

(2013-417, s. 1.)

Legal Periodicals. - For comment, "Reemphasizing Impracticability in the Special Needs Analysis in Response to Suspicionless Drug Testing of Welfare Recipients," see 92 N.C. L. Rev. 948 (2014).

§ 108A-26.2. Fleeing felon or parole or probation violator; eligibility for program assistance; federal approval; review by department.

Subject to subsection (b) of this section, a department of social services shall not grant public assistance under Part 2 or Part 5 of Article 2 of Chapter 108A of the General Statutes if the department receives information described in G.S. 108A-26.1 that the applicant for or recipient of program assistance is subject to arrest under an outstanding warrant arising from a charge of violating conditions of parole or probation or from a felony charge against that applicant or recipient in any jurisdiction. This section does not affect the eligibility for assistance of other members of the applicant's or recipient's household. An applicant or recipient described in this section is eligible for program assistance if all other eligibility criteria of the law are met when the applicant or recipient is no longer subject to arrest under an outstanding warrant as described in this section.
If federal approval is required in order to prevent the loss of federal reimbursement as a result of the application of this section to an applicant for or recipient of program assistance, the Department of Health and Human Services shall promptly take any action necessary to obtain federal approval.

History

(2013-417, s. 2.)

Legal Periodicals. - For comment, "Reemphasizing Impracticability in the Special Needs Analysis in Response to Suspicionless Drug Testing of Welfare Recipients," see 92 N.C. L. Rev. 948 (2014).

§§ 108A-26.3, 108A-26.4: Reserved for future codification purposes.

§ 108A-26.5. NC FAST caseworker training and certification program.

The Department of Health and Human Services (Department) shall design and implement a training and certification program for caseworkers utilizing North Carolina Families Accessing Services Through Technology (NC FAST). The training and certification program shall be available on a statewide basis, and the Department shall provide training to caseworkers at county departments of social services at a location within reasonable travel distance from the county departments of social services multiples times per year. No later than 18 months after the Department has implemented the training and certification program, the Department shall require all caseworkers inputting data or making determinations for eligibility for State programs through NC FAST to be certified. A certification may last no longer than three years before an individual is required to be recertified. The Department may adopt and amend rules to implement this training and certification program.

History

(2017-57, s. 11H.22(g).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(g) was codified as this section at the direction of the Revisor of Statutes.

Session Laws 2017-57, s. 11H.22(h)-(j), provides: "(h) No later than 18 months after the Department has implemented the training and certification program under subsection (g) of this section [G.S. 108A-26.5], the Department shall include in its audits required under G.S. 108A-70.46 a verification that all county departments of social services are in compliance with the certification program requirements for individuals involved in the Medicaid eligibility determination process.

"(2) A plan of implementation of the training and certification program, including a specific time line of implementation.

"(4) Any other information the Department is able to provide regarding the training and certification program development."

"(j) The Department of Health and Human Services may adopt and amend rules to implement this section."

Session Laws 2017-57, s. 11H.22(k) made this section effective June 28, 2017.

"(b) Counties that were phased-in the NC FAST Child Welfare System after January 1, 2019, may elect to opt out of the utilization of the Intake and Assessment functionality of the NC FAST system.

"(e) This section is effective when it becomes law."

PART 2. WORK FIRST PROGRAM.

§ 108A-27. (See editor's note) Authorization and description of Work First Program; Work First Program changes; designation of Electing and Standard Program Counties.

The Department shall establish, supervise and monitor the Work First Program. The purpose of the Work First Program is to provide eligible families with short-term assistance to facilitate their movement to self-sufficiency through gainful employment, not the mere reduction of the welfare rolls. The Department shall ensure that the Work First Program focuses on this purpose of self-sufficiency. The ultimate goal of the Work First Program is the gradual elimination of generational poverty, and the Department shall ensure that all evaluations of the Work First Program, whether performed at the State or the county level, maintain this purpose and this goal of the Work First Program and effect an ongoing determination of whether the Work First Program is successful in facilitating families to move to self-sufficiency and in gradually eliminating generational poverty.
The Work First Program in all counties shall include program administration and three categories of assistance to participants:
1. Work First Diversion Assistance;
2. Work First Family Assistance; and
3. Work First Services.
The Department may change the Work First Program when required to comply with federal law. Any changes in federal law that necessitate a change in the Work First Program shall be effected by temporary rule until the next State Plan is approved by the General Assembly. Any change effective by the Department to comply with federal law shall be reported to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services and included in the State Plan submitted during the next session of the General Assembly following the change.
The Department shall allow counties maximum flexibility in the Work First Program while ensuring that the counties comply with federal and State laws and regulations. Subject to any limitations imposed by law, the Department shall allow counties to request to be designated as either Electing Counties or Standard Program Counties in the Work First Program.
All counties shall notify the Department in writing as to whether they desire to be designated as either Electing or Standard Program. A county shall submit in its notification to the Department documentation demonstrating that three-fifths of its county commissioners support its desired designation. Upon receipt of the notification from the county, the Department shall send to the county confirmation of the county's planning designation. A county that desires to be redesignated shall submit a request in writing to the Department at least six months prior to the effective date of the next State Plan. In its request for redesignation, the county shall submit documentation demonstrating that three-fifths of its county commissioners support the redesignation. Upon receipt of the notification from the county, the Department shall send to the county confirmation of the county's planning redesignation. A county's redesignation shall become effective on the effective date of the next State Plan following the redesignation. A county's designation or redesignation shall not be effected except as provided in this Article.
The board of county commissioners in an Electing County shall be responsible for development, administration, and implementation of the Work First Program in that county.
The county department of social services in a Standard Program County shall be responsible for administering and implementing the Standard Work First Program in that county.
The Department and Electing Counties, in developing their respective plans, may distinguish among potential groups of recipients on whatever basis necessary to enhance program purposes and to maximize federal revenues, so long as the rights, including the constitutional rights of equal protection and due process, of individuals are protected. The Department and Electing Counties shall provide Work First Program assistance to qualified immigrants on the same basis as citizens to the extent permitted by federal law.

History

(1981, c. 275, s. 1; 1997-443, s. 12.5; 1998-212, s. 12.27A(a1); 2001-424, s. 21.13(e); 2009-489, s. 2.)

Election of Fraud Control Program. - For provision that the Department of Human Resources is to elect the optional Aid to Families with Dependent Children Fraud Control Program pursuant to 45 C.F.R. 235.112, see editor's note under G.S. 105A-2.

Pilot Welfare Reform Program. - Session Laws 1995, c. 368, as amended by Session Laws 1996, Second Extra Session, c. 18, s. 24.16A, by Session Laws 1998-106, by Session Laws 2001-354, s. 1, by Session Laws 2001-487, s. 99, and by Session Laws 2003-188, s. 1, provides that, notwithstanding any law to the contrary, the Department of Health and Human Services shall designate Cabarrus County as a pilot county for the purpose of conducting a demonstration welfare reform program for certain Work First and Food Stamp recipients, that the Department shall ensure that all necessary federal waivers are obtained, and that to the extent that the act or the program conflicts with any State law, the program supersedes that law; further provides the tenets of the program and provides for funding, and for an evaluation of the program and report to the General Assembly on or before September 1, 2002. The act becomes effective July 1, 1995.

Editor's Note. - Session Laws 2008-107, s. 10.13(j) provides that "G.S. 108A-27(c) reads as rewritten" when in fact it is G.S. 108A-70.27(c) that is set out in the text of the amendment. At the direction of the Revisor of Statutes, the amendment has not been given effect.

Session Laws 2011-145, s. 10.55(b) provides: "The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan FY 2010-2012, as approved by this section are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson."

Session Laws 2011-145, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2011.'"

Session Laws 2011-145, s. 32.2, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2011-2013 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2011-2013 fiscal biennium."

Session Laws 2011-145, s. 32.5 is a severability clause.

Session Laws 2013-360, s. 12C.1(a)-(e), provides: "(a) The General Assembly approves the plan titled 'North Carolina Temporary Assistance for Needy Families State Plan 2012-2015,' prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2012, through September 30, 2015. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section and as amended by this act or any other act of the 2013 General Assembly, to the United States Department of Health and Human Services.

"(b) The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan 2012-2015, as approved by this section are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson.

"(c) Counties that submitted the letter of intent to remain as an Electing County or to be redesignated as an Electing County and the accompanying county plan for years 2012 through 2015 pursuant to G.S. 108A-27(e) shall operate under the Electing County budget requirements effective July 1, 2012. For programmatic purposes, all counties referred to in this subsection shall remain under their current county designation through September 30, 2015.

"(d) For each year of the 2013-2015 fiscal biennium, Electing Counties shall be held harmless to their Work First Family Assistance allocations for the 2012-2013 fiscal year, provided that remaining funds allocated for Work First Family Assistance and Work First Diversion Assistance are sufficient for payments made by the Department on behalf of Standard Counties pursuant to G.S. 108A-27.11(b).

"'(e) In the event that departmental projections of Work First Family Assistance and Work First Diversion Assistance for the 2013-2014 fiscal year or the 2014-2015 fiscal year indicate that remaining funds are insufficient for Work First Family Assistance and Work First Diversion Assistance payments to be made on behalf of Standard Counties, the Department is authorized to deallocate funds, of those allocated to Electing Counties for Work First Family Assistance in excess of the sums set forth in G.S. 108A-27.11, up to the requisite amount for payments in Standard Counties. Prior to deallocation, the Department shall obtain approval by the Office of State Budget and Management. If the Department adjusts the allocation set forth in subsection (d) of this section, then a report shall be made to the Joint Legislative Commission on Governmental Operations, the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division."

Session Laws 2015-241, s. 12C.1(a)-(f), as amended by Session Laws 2016-94, s. 12C.5(a), provides: "(a) The General Assembly approves the plan titled 'North Carolina Temporary Assistance for Needy Families State Plan FY 2013-2016,' prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2013, through September 30, 2016. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

"(b) The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan FY 2013-2016, as approved by this section, are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson.

"(c) Counties that submitted the letter of intent to remain as an Electing County or to be redesignated as an Electing County and the accompanying county plan for years 2013 through 2016, pursuant to G.S. 108A-27(e), shall operate under the Electing County budget requirements effective July 1, 2015. For programmatic purposes, all counties referred to in this subsection shall remain under their current county designation through September 30, 2016.

"(d) For each year of the 2015-2017 fiscal biennium, Electing Counties shall be held harmless to their Work First Family Assistance allocations for the 2014-2015 fiscal year, provided that remaining funds allocated for Work First Family Assistance and Work First Diversion Assistance are sufficient for payments made by the Department on behalf of Standard Counties pursuant to G.S. 108A-27.11(b).

"(e) In the event that departmental projections of Work First Family Assistance and Work First Diversion Assistance for the 2015-2016 fiscal year or the 2016-2017 fiscal year indicate that remaining funds are insufficient for Work First Family Assistance and Work First Diversion Assistance payments to be made on behalf of Standard Counties, the Department is authorized to deallocate funds, of those allocated to Electing Counties for Work First Family Assistance in excess of the sums set forth in G.S. 108A-27.11, up to the requisite amount for payments in Standard Counties. Prior to deallocation, the Department shall obtain approval by the Office of State Budget and Management. If the Department adjusts the allocation set forth in subsection (d) of this section, then a report shall be made to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division.

"(f) This section expires September 30, 2016."

For prior similar provisions, see Session Laws 2011-145, s. 10.55(b), and Session Laws 2013-360, s. 12C.1.

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2016-94, s. 12C.5(b)-(f), provides: "(b) Beginning October 1, 2016, the General Assembly approves the plan titled 'North Carolina Temporary Assistance for Needy Families State Plan FY 2016-2019,' prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2016, through September 30, 2019. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

"(c) The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan FY 2016-2019, as approved by this section, are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson.

"(d) Counties that submitted the letter of intent to remain as an Electing County or to be redesignated as an Electing County and the accompanying county plan for years 2016 through 2019, pursuant to G.S. 108A-27(e), shall operate under the Electing County budget requirements effective July 1, 2016. For programmatic purposes, all counties referred to in this subsection shall remain under their current county designation through September 30, 2019.

"(e) For the 2016-2017 fiscal year, Electing Counties shall be held harmless to their Work First Family Assistance allocations for the 2015-2016 fiscal year, provided that remaining funds allocated for Work First Family Assistance and Work First Diversion Assistance are sufficient for payments made by the Department on behalf of Standard Counties pursuant to G.S. 108A-27.11(b).

"(f) In the event that departmental projections of Work First Family Assistance and Work First Diversion Assistance for the 2016-2017 fiscal year indicate that remaining funds are insufficient for Work First Family Assistance and Work First Diversion Assistance payments to be made on behalf of Standard Counties, the Department is authorized to deallocate funds, of those allocated to Electing Counties for Work First Family Assistance in excess of the sums set forth in G.S. 108A-27.11, up to the requisite amount for payments in Standard Counties. Prior to deallocation, the Department shall obtain approval by the Office of State Budget and Management. If the Department adjusts the allocation set forth in subsection (d) of this section, then a report shall be made to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division."

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2017-57, s. 11C.1(a)-(e), provides: "(a) The General Assembly approves the plan titled "North Carolina Temporary Assistance for Needy Families State Plan FY 2016-2019," prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2016, through September 30, 2019. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

"(b) The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan FY 2016-2019, as approved by this section, are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson.

"(c) Counties that submitted the letter of intent to remain as an Electing County or to be redesignated as an Electing County and the accompanying county plan for years 2016 through 2019, pursuant to G.S. 108A-27(e), shall operate under the Electing County budget requirements effective July 1, 2017. For programmatic purposes, all counties referred to in this subsection shall remain under their current county designation through September 30, 2019.

"(d) For each year of the 2017-2019 fiscal biennium, Electing Counties shall be held harmless to their Work First Family Assistance allocations for the 2016-2017 fiscal year, provided that remaining funds allocated for Work First Family Assistance and Work First Diversion Assistance are sufficient for payments made by the Department on behalf of Standard Counties pursuant to G.S. 108A-27.11(b).

"(e) In the event that departmental projections of Work First Family Assistance and Work First Diversion Assistance for the 2017-2018 fiscal year or the 2018-2019 fiscal year indicate that remaining funds are insufficient for Work First Family Assistance and Work First Diversion Assistance payments to be made on behalf of Standard Counties, the Department is authorized to deallocate funds, of those allocated to Electing Counties for Work First Family Assistance in excess of the sums set forth in G.S. 108A-27.11, up to the requisite amount for payments in Standard Counties. Prior to deallocation, the Department shall obtain approval by the Office of State Budget and Management. If the Department adjusts the allocation set forth in subsection (d) of this section, then a report shall be made to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2019-223, s. 3.1, provides: "(a) Beginning October 1, 2019, the General Assembly approves the plan titled 'North Carolina Temporary Assistance for Needy Families State Plan FY 2019-2022,' prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2019, through September 30, 2022. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

"(b) The counties approved as Electing Counties in the North Carolina Temporary Assistance for Needy Families State Plan FY 2019-2022, as approved by this section, are Beaufort, Caldwell, Catawba, Lenoir, Lincoln, Macon, and Wilson.

"(c) Counties that submitted the letter of intent to remain as an Electing County or to be redesignated as an Electing County and the accompanying county plan for years 2019 through 2022, pursuant to G.S. 108A-27(e), shall operate under the Electing County budget requirements effective July 1, 2019. For programmatic purposes, all counties referred to in this subsection shall remain under their current county designation through September 30, 2022.

"(d) For each year of the 2019-2021 fiscal biennium, Electing Counties shall be held harmless to their Work First Family Assistance allocations for the 2018-2019 fiscal year, provided that remaining funds allocated for Work First Family Assistance and Work First Diversion Assistance are sufficient for payments made by the Department on behalf of Standard Counties pursuant to G.S. 108A-27.11(b).

"(e) In the event that departmental projections of Work First Family Assistance and Work First Diversion Assistance for the 2019-2020 fiscal year or the 2020-2021 fiscal year indicate that remaining funds are insufficient for Work First Family Assistance and Work First Diversion Assistance payments to be made on behalf of Standard Counties, the Department is authorized to deallocate funds, of those allocated to Electing Counties for Work First Family Assistance in excess of the sums set forth in G.S. 108A-27.11, up to the requisite amount for payments in Standard Counties. Prior to deallocation, the Department shall obtain approval by the Office of State Budget and Management. If the Department adjusts the allocation set forth in subsection (d) of this section, then a report shall be made to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division."

Effect of Amendments. - Session Laws 2009-489, s. 2, effective August 26, 2009, substituted "focuses on this purpose" for "focus on this purpose" in the second sentence of subsection (a); in subsection (b), deleted "First Stop Employment Registration," following "program administration" in the introductory language, and deleted the former last two sentences at the end of the subsection, which read: "All counties shall utilize the registration process of the First Stop Employment Assistance Program. All other provisions of the First Stop Employment Assistance Program shall be optional to the counties."; and, in subsection (h), substituted "their respective plans" for "an Electing County Work First Program or the Standard Work First Program" in the first sentence, and substituted "shall provide Work First Program assistance to qualified immigrants" for "may provide Work First Program assistance to legal immigrants" in the second sentence.

Legal Periodicals. - See legislative survey, 21 Campbell L. Rev. 323 (1999).

For article, "The Bootstrap Trap,” see 67 Duke L.J. 233 (2017).

CASE NOTES

Compliance with Federal Standards. - It is true that the State must administer its public assistance program in accordance with federal regulations. However, a State plan need not strictly follow the language of 42 U.S.C. § 602(a)(26)(A) in order to satisfy federal requirements, but may substitute an assignment by operation of law which is "substantially identical" to that described by the federal act. North Carolina's public assistance plan has been duly approved. State ex rel. Pender County Child Support Enforcement Agency ex rel. Crews v. Parker, 319 N.C. 354, 354 S.E.2d 501 (1987).

§ 108A-27.01. Income eligibility and payment level for Work First Family Assistance.

The maximum net family annual income eligibility standards for Work First Family Assistance are as provided in the table below. The payment level for Work First Family Assistance shall be fifty percent (50%) of the standard of need.

Family Size Income Level 1 $ 4,344 2 5,664 3 6,528 4 7,128 5 7,776 6 8,376 7 8,952 8 9,256

History

(2013-360, s. 12C.8; 2014-100, s. 12C.2.)

Editor's Note. - Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Effect of Amendments. - Session Laws 2014-100, s. 12C.2, effective July 1, 2014, rewrote the section.

§ 108A-27.1. Time limitations on assistance.

Under the Standard Work First Program, unless an extension or an exemption is provided pursuant to the provisions of the Part or the State Plan, any cash assistance provided to a person or family in the employment program shall only be provided for a cumulative total of 24 months. After having received cash assistance for 24 months, the person or the family may reapply for cash assistance, but not until after 36 months from the last month the person or the family received cash assistance. This subsection shall not apply to child-only cases.
Electing Counties may set any time limitations on assistance it finds appropriate, so long as the time limitations do not conflict with or exceed any federal time limitations.

History

(1997-443, s. 12.6; 1998-212, s. 12.27A(f).)

§ 108A-27.2. General duties of the Department.

The Department shall have the following general duties with respect to the Work First Program:

Ensure that the specifications of the general provisions of the State Plan regarding the procedures required when recipients are sanctioned, prescribed in G.S. 108A-27.9(c), are uniformly developed and implemented across the State;
Provide technical assistance to Electing Counties developing and implementing and to Standard Counties implementing their County Plans, including providing information concerning applicable federal law and regulations and changes to federal law and regulations that affect the permissible use of federal funds and scope of the Work First Program in a county;
Reserved for future codification purposes.
Ensure that all families with work eligible parents and parents with children under the age of 12 months receive Work First benefits in the month after compliance with their Mutual Responsibility Agreement. Failure to comply with their Mutual Responsibility Agreement shall result in no Work First Benefits the following month, unless there is good cause.
Describe authorized federal and State work activities. For up to twenty percent (20%) of Work First recipients, authorized State work activities shall include at least part-time enrollment in a postsecondary education program. In Standard Counties, recipients enrolled on at least a part-time basis in a postsecondary education program and maintaining a 2.5 grade point average or its equivalent shall have their two-year time limit suspended for up to three years.
Define requirements for assignment of child support income and compliance with child support activities;
Establish a schedule for Electing Counties to submit their County Plans to ensure that all Electing County Plans are adopted by Electing Counties by February 1 of each odd-numbered year and review and then recommend a State Plan to the General Assembly;
Ensure that the Electing County Plans comply with federal and State laws, rules, and regulations, are consistent with the overall purposes and goals of the Work First Program, and maximize federal receipts for the Work First Program;
Prepare the State Plan in accordance with G.S. 108A-27.9 and federal laws and regulations and submit it to the Budget Director for approval;
Submit the State Plan, as approved by the Budget Director, to the General Assembly for approval;
Repealed by Session Laws 2003-284, s. 10.57, effective July 1, 2003.
Develop and implement a system to monitor and evaluate the impact of the Work First Program on children and families, including the impact of the Work First Program on job retention and advancement, child abuse and neglect, caseloads for child protective services and foster care, school attendance, academic and behavioral performance, and other measures of the economic security and health of children and families. The system should be developed to allow monitoring and evaluation of impact based on both aggregated and disaggregated data. State and county agencies shall cooperate in providing information needed to conduct these evaluations, sharing data and information except where prohibited specifically by federal law or regulation;
Monitor the performance of Electing Counties relative to their respective Plans and the overall goals of the Work First Program. Monitor Standard Counties relative to the State Plan and the overall goals of the Standard Work First Program;
Repealed by Session Laws 2003-284, s. 10.57, effective July 1, 2003.
Report to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services the counties which have requested Electing status; provide copies of the proposed Electing County Plans to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services, if requested; and make recommendations to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services on which of the proposed Electing County Plans ensure compliance with federal and State laws, rules, and regulations and are consistent with the overall purposes and goals for the Work First Program; and
Make recommendations to the General Assembly for approval of counties to become Electing Counties which represent, in aggregate, no more than fifteen and one-half percent (15.5%) of the total Work First caseload at September 1 of each year and, for each county submitting a plan, the reasons individual counties were or were not recommended.
Review the county Work First Program of each Electing County and recommend whether the county should continue to be designated an Electing County or whether it should be redesignated as a standard county. In conducting its review and making its recommendation, the Department shall:
1. Examine and consider the results of the Department's monitoring and evaluation of the impact of the Electing County's Work First Program as required under subdivision (9) of this section;
2. Determine whether the Electing County's Work First Program's unique design requires implementation by an Electing County or whether the Work First Program could be implemented by a county designated as a standard county;
3. Determine whether the Electing County's Work First Program and policies are unique and innovative in meeting the purpose of the Work First Program as stated under G.S. 108A-27, and State and federal laws, rules, and regulations, as compared to other standard and Electing County Work First programs.

The Department shall make its recommendation and the reasons therefor to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services not later than three months prior to submitting the State Plan to the Commission for review as required under G.S. 108A-27.9(a).

History

(1997-443, s. 12.6; 1998-212, s. 12.27A(g); 1999-237, s. 7.10(b); 1999-359, ss. 1.2(a), 2(a), (b), 6; 2001-424, s. 21.13(b), (e); 2003-284, s. 10.57; 2009-489, s. 3.)

Effect of Amendments. - Session Laws 2009-489, s. 3, effective August 26, 2009, substituted "Electing Counties" for "counties" throughout the section; inserted "and to Standard Counties implementing" in subdivision (1a); rewrote subdivision (1c); deleted "all Standard County Plans are adopted by the Standard Program Counties by January 15 of each odd-numbered year and" following "ensure that" in subdivision (4); inserted "Electing" in subdivision (5); in subdivision (10), substituted "respective Plans" for "County Plans" in the first sentence, and added the second sentence; and made stylistic changes throughout subdivision (14).

§ 108A-27.3. Electing Counties - Duties of county boards of commissioners.

The duties of the county boards of commissioners in Electing Counties under the Work First Program are as follows:
1. Establish county outcome and performance goals based on county economic, educational, and employment factors and adopt criteria for determining the progress of the county in moving persons and families to self-sufficiency;
2. Establish eligibility criteria for recipients except for those criteria related to sanctioning procedures mandated across the State pursuant to G.S. 108A-27.9(c);
3. Prescribe the method of calculating benefits for recipients;
4. Repealed by Session Laws 2009-489, s. 4, effective August 26, 2009.
5. If made a part of the county's Work First Program, develop and enter into Mutual Responsibility Agreements with Work First Program recipients and ensure that the services and resources that are needed to assist participants to comply with the obligations under their Mutual Responsibility Agreements are available;
6. Ensure that participants engage in the minimum hours of work activities required by Title IV-A;
7. Consider providing community service work for any recipient who cannot find employment;
8. Authorize payments of Work First Diversion Assistance and Work First Family Assistance to recipients having MRAs;
9. Monitor compliance with Mutual Responsibility Agreements and enforce the agreement provisions;
10. Repealed by Session Laws 2009-489, s. 4, effective August 26, 2009.
11. Ensure that all Work First cases are reviewed no later than three months prior to expiration of time limitations for receiving cash assistance to:
  1. Ensure that time limitations on assistance have been computed correctly.
  2. Ensure that the family is informed in writing about public assistance benefits, including child care, Medicaid, and food and nutrition services, for which the family is eligible even while cash assistance is no longer available.
  3. Provide for an extension of cash assistance benefits if the family qualifies for an extension.
  4. Review family status and assist the family in identifying resources and support the family needs to maintain employment and family stability.
12. Ensure compliance with applicable State and federal laws, rules, and regulations for the Work First Program;
13. Develop, adopt, and submit to the Department a biennial County Plan;
14. Repealed by Session Laws 2009-489, s. 4, effective August 26, 2009.
15. Develop and implement an appeals process for the county's Work First Program that substantially complies with G.S. 108A-79 and comply with the procedures related to sanctioning by the Department for all counties in the State pursuant to G.S. 108A-27.2 and prescribed as general provisions in the State Plan pursuant to G.S. 108A-27.9(c)(1).
The county board of commissioners shall not delegate the responsibilities described in subdivisions (a)(1), (a)(11), and (a)(12) of this section but may delegate other duties to public or private entities. Notwithstanding any delegation of duty, the county board of commissioners shall remain accountable for its duties under the Work First Program.
The county board of commissioners shall appoint a committee of individuals to identify the needs of the population to be served and to review and assist in developing the County Plan to respond to the needs. The committee membership shall include, but is not limited to, representatives of the county board of social services, the board of the area mental health authority, the local public health board, the local school systems, the business community, the board of county commissioners and community-based organizations representative of the population to be served.
The county board of commissioners shall review and approve the County Plan for submission to the Department.

History

(1997-443, s. 12.6; 1998-212, s. 12.27A(h); 1999-359, s. 5(a); 2007-97, s. 5; 2009-489, s. 4.)

Effect of Amendments. - Session Laws 2007-97, s. 5, effective June 20, 2007, made minor punctuation changes throughout subdivision (a)(10a), substituted "food and nutrition services" for "food stamps" in subdivision (a)(10a)b., and deleted "and" at the end of subdivision (a)(10a)c.

Session Laws 2009-489, s. 4, effective August 26, 2009, deleted subdivision (a)(4), which read: "Determine and list persons and families eligible for the Work First Program"; substituted "Authorize" for "Make" at the beginning of subdivision (a)(8); deleted subdivision (a)(10), which read: "Monitor and evaluate the impact of the Work First Program on economic security and health of children and families, child abuse and neglect, caseloads for child protective services and foster care, school attendance, and academic and behavioral performance, and report the findings to the Department quarterly"; and deleted subdivision (a)(13), which read: "Provide monthly progress reports to the Department in a format to be determined by the Department".

CASE NOTES

Cited in Chatmon v. N.C. HHS, 175 N.C. App. 85, 622 S.E.2d 684 (2005), overruled in part by Meza v. Div. of Soc. Servs. & Div. of Med. Assistance of the N.C. HHS, 364 N.C. 61, 692 S.E.2d 96 (2010).

Opinions of Attorney General

Provisions Governing Appeals. - An Electing County cannot utilize the hearing officers provided by the State to Standard Counties and have them resolve Electing County appeals pursuant to G.S. G.S. 108A-79. See opinion of Attorney General to Kevin M. FitzGerald, Director, Division of Social Services. N.C. Dept. of Health and Human Services, N.C. General Assembly, 1999 N.C.A.G. 12 (4/9/99).

§ 108A-27.4. Electing Counties - County Plan.

Each Electing County shall submit to the Department, according to the schedule established by the Department and in compliance with all federal and State laws, rules, and regulations, a biennial County Plan.
An Electing County's County Plan shall have at least the following five parts:
1. Part I. Conditions Within the County;
2. Part II. Outcomes and Goals for the County;
3. Part III. Plans to Achieve and Measure the Outcomes and Goals;
4. Part IV. Administration; and
5. Part V. Funding Requirements.
Funding requirements shall, at least, identify the amount of a county block grant for Work First Diversion Assistance, a county block grant for Work First Family Assistance, a county block grant for Work First Services, and the county's maintenance of effort contribution. A county may establish a reserve.
Repealed by Session Laws 2009-489, s. 5, effective August 26, 2009.
Each county shall include in its County Plan the following:
1. Repealed by Session Laws 2009-489, s. 5, effective August 26, 2009.
2. A description of the county's plans for serving families who need child care, transportation, substance abuse services, and employment support based on the needs of the community and the availability of services and funding;
3. Repealed by Session Laws 2009-489, s. 5, effective August 26, 2009.
4. A description of the county's eligibility criteria, benefit calculation, and any other policies adopted by the county relating to eligibility, terms, and conditions for receiving Work First Program assistance, including sanctions, asset and income requirements, time limits and extensions, rewards, exemptions, and exceptions to requirements. If an Electing County Plan proposes to change eligibility requirements, benefits levels, or reduce maintenance of effort, the county shall describe the reasons for these changes and how the county intends to utilize the maintenance of effort savings;
5. A description of how the county plans to utilize public and private resources to assist in moving persons and families to self-sufficiency; and
6. Any request to the Department for waivers to rules or any proposals for statutory changes to remove any impediments to implementation of the County's Plan.
7. The process by which the county will review all Work First caseloads no later than three months prior to expiration of time limitations for receiving cash assistance to:
  1. Ensure that time limitations on assistance have been computed correctly.
  2. Ensure that the family is informed in writing about public assistance benefits, including child care, Medicaid, and food and nutrition services, for which the family is eligible even while cash assistance is no longer available.
  3. Provide for an extension of cash assistance benefits if the family qualifies for an extension.
  4. Review family status and assist the family in identifying resources and support the family needs to maintain employment and family stability.
Each county shall provide to the general public an opportunity to review and comment upon its County Plan prior to its submission to the Department.
A county may modify its County Plan once each biennium but not at any other time unless the county notifies the Department of the proposed modification and the Department determines that the proposed modification is consistent with State and federal law and the goals for the Work First Program.
Electing Counties shall have an emergency assistance program for Work First eligible families, as defined in the electing county plan. Counties may establish income eligibility for emergency assistance at or below two hundred percent (200%) of the federal poverty level.

History

(1997-443, s. 12.6; 1999-359, s. 5(b), (c); 2007-97, s. 6; 2007-484, s. 38; 2009-489, s. 5.)

Effect of Amendments. - Session Laws 2007-97, s. 6, as amended by Session Laws 2007-484, s. 38, effective June 20, 2007, substituted "food and nutrition services" for "food stamps" in subdivision (e)(7)b and made minor stylistic changes.

Session Laws 2009-489, s. 5, effective August 26, 2009, deleted subsection (d), which read: "The County Plans in Electing Counties may provide that in cases where benefits are paid only for a child, the case is considered a family case"; in subsection (e), deleted subdivision (e)(1), which read: "The number of MRAs entered into by the county" and deleted subdivision (e)(3), which read: "A list of the community service programs equivalent to full-time employment that are being offered to Work First Program recipients who are unable to find full-time employment"; and made a minor stylistic change in subsection (h).

§ 108A-27.5. Electing Counties - Duties of the Department.

In addition to the general duties prescribed in G.S. 108A-27.3, the Department shall have the following duties with respect to establishing, supervising, and monitoring the Work First Program in Electing Counties while allowing Electing Counties maximum flexibility in designing and implementing County Plans:

Repealed by Session Laws 2009-489, s. 6, effective August 26, 2009.
At the request of the counties, provide assistance to counties in their activities with private sector individuals and organizations relative to County Plans; and
Establish the baseline for the State maintenance of effort.

History

(1997-443, s. 12.6; 2009-489, s. 6.)

Effect of Amendments. - Session Laws 2009-489, s. 6, effective August 26, 2009, deleted subdivision (1), which read: "Coordinate activities of other State agencies providing technical support to counties developing their County Plans".

§ 108A-27.6. Standard Program Counties - Duties of county departments of social services and county boards of commissioners.

Except as otherwise provided in this Article, the Standard Work First Program shall be administered by the county departments of social services. The county departments of social services in Standard Program Counties shall:
1. In consultation with the Department and the county board of commissioners, establish outcome and performance measures for all Standard Program Counties. There exist two goals for the Work First Program: to meet or exceed the federal Work Participation Rate of fifty percent (50%) for all Work Eligible families and ninety percent (90%) for all two-parent families;
2. Determine eligibility of persons and families for the Work First Program;
3. Enter into Mutual Responsibility Agreements with participants if required under the State Plan and ensure that the services and resources that are needed to assist participants to comply with their obligations under their Mutual Responsibility Agreements are available;
4. Comply with State and federal law relating to Work First and Title IV-A;
5. Repealed by Session Laws 2009-489, s. 7, effective August 26, 2009.
6. Ensure that participants engage in the minimum hours of work activities required by the State Plan and Title IV-A;
7. Ensure that the components of the Work First Program are funded solely from authorized sources and that federal TANF funds are used only for purposes and programs authorized by federal and State law; and
8. , (9) Repealed by Session Laws 2009-489, s. 7, effective August 26, 2009.
  1. Ensure that time limitations on assistance have been computed correctly.
  2. Ensure that the family is informed about public assistance benefits, including child care, Medicaid, and food and nutrition services, for which the family is eligible even while cash assistance is no longer available.
  3. Provide for an extension of cash assistance benefits if the family qualifies for an extension.
  4. Review family status and assist the family in identifying resources and support the family needs to maintain employment and family stability.
In consultation with the Department, a county department of social services may delegate any of its duties under this Article to another public agency or private contractor. Prior to delegating any duty, a county department of social services shall submit its proposed delegation to the Department as the Department may provide. Notwithstanding any delegation of duty, a county department of social services shall remain accountable for its duties under the Work First Program.
, (d) Repealed by Session Laws 2009-489, s. 7, effective August 26, 2009.

(10) Ensure that all Work First cases are reviewed no later than three months prior to expiration of time limitations for receiving cash assistance to:

History

(1997-443, s. 12.6; 1999-359, s. 5(e); 2007-97, s. 7; 2009-489, s. 7.)

Effect of Amendments. - Session Laws 2007-97, s. 7, effective June 20, 2007, made minor punctuation changes throughout subdivision (a)(10), substituted "food and nutrition services" for "food stamps" in subdivision (a)(10)b., and deleted "and" at the end of subdivision (a)(10)c.

Session Laws 2009-489, s. 7, effective August 26, 2009, in subsection (a), rewrote subdivision (a)(1), and deleted subdivisions (a)(5), (a)(8) and (a)(9) pertaining to county departments monitoring, evaluating and reporting on the impact of the Work First Program on children and families; and deleted subsections (c) and (d) pertaining to duties of the county board of commissioners.

§ 108A-27.7. Standard Program County Plan.

Standard counties shall have an emergency assistance program for Work First eligible families, as defined in the standard county plan. Counties may establish income eligibility for emergency assistance at or below two hundred percent (200%) of the federal poverty level.

History

(1997-443, s. 12.6; 1999-359, s. 5(d); 2009-489, s. 8.)

Effect of Amendments. - Session Laws 2009-489, s. 8, effective August 26, 2009, rewrote the section.

§ 108A-27.8. Standard Program Counties - Duties of Department.

The Department shall establish, develop, supervise, and monitor the Standard Work First Program. In addition to its general duties prescribed in G.S. 108A-27.2, the Department shall have the following duties with respect to the Standard Work First Program and the Standard Program Counties:
1. Repealed by Session Laws 2009-489, s. 9, effective August 26, 2009.
2. Advise and assist the Social Services Commission in adopting rules necessary to implement the provisions of this Article;
3. Supervise disbursement of county block grants to the Standard Program Counties for Work First Services;
4. Make payments of Work First Family Assistance and Work First Diversion Assistance; and
5. , (6) Repealed by Session Laws 2009-489, s. 9, effective August 26, 2009.
The Secretary, in consultation with the Office of State Budget and Management, may adopt temporary rules when necessary to:
1. Implement provisions of the State Plan;
2. Maximize federal revenues to prevent the loss of federal funds;
3. Enhance the ability of the Department to prevent fraud and abuse in the Work First Program; and
4. Modify the provisions in the State Plan as necessary to meet changed circumstances after approval of the State Plan.
The Social Services Commission may adopt rules in accordance with G.S. 143B-153 when necessary to implement this Article and subject to delegation by the Secretary of any rule-making authority to implement the provisions of the State Plan.

(7) Develop a Mutual Responsibility Agreement for use by Standard Program Counties.

History

(1997-443, s. 12.6; 2000-140, s. 93.1(a); 2001-424, s. 12.2(b); 2009-489, s. 9.)

Effect of Amendments. - Session Laws 2009-489, s. 9, effective August 26, 2009, deleted subdivisions (a)(1), (a)(5) and (a)(6), pertaining to the department's establishing requirements for County Plans, coordinating activities of other state and county agencies, and working with other state and county agencies and private sector organizations to meet the goals of the Work First Program.

§ 108A-27.9. State Plan.

The Department shall prepare and submit to the Director of the Budget a biennial State Plan that proposes the goals and requirements for the State and the terms of the Work First Program for each fiscal year. Prior to submitting a State Plan to the General Assembly, the Department shall:
1. Consult with local government and private sector organizations regarding the design of the State Plan and allow 45 days to receive comments from those organizations; and
2. Upon complying with subdivision (1) of this subsection, submit the State Plan to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services for review.
The State Plan shall consist of generally applicable provisions and two separate sections, one proposing the terms of the Work First Program in Electing Counties, and the other proposing the terms for the Standard Work First Program.
The State Plan shall include the following generally applicable provisions:
1. Provisions to ensure that recipients who are sanctioned are provided a clear explanation of the sanction and that all recipients, including those under sanction or termination for rules infractions, are fully informed of their right to legal counsel and any other representatives they choose at their own cost;
2. Provisions to ensure that no Work First Program recipients, required to participate in work activities, shall be employed or assigned when:
  1. Any regular employee is on layoff from the same or substantially equivalent job;
  2. An employer terminates any regular employee or otherwise causes an involuntary reduction in the employer's workforce in order to hire Work First recipients; or
  3. An employer otherwise causes the displacement of any currently employed worker or positions, including partial displacements such as reductions in hours of nonovertime work, wages, or employment benefits, in order to hire Work First recipients;
3. Reserved for future codification purposes.
4. Provisions to ensure that all work eligible parents and all parents with a child under 12 months of age are subject to pay for performance requirements. Pay for performance requirements means that the family will receive Work First benefits in the month following a month that they comply with their Mutual Responsibility Agreement. Failure to comply with the Mutual Responsibility Agreement without good cause will result in no Work First benefits in the following month.
5. Provisions to ensure the establishment and maintenance of grievance procedures to resolve complaints by regular employees who allege that the employment or assignment of a Work First Program recipient is in violation of subdivision (1a) of this subsection, and grievance procedures to resolve complaints by Work First Participants made pursuant to subdivision (3) of this subsection;
6. Provisions to ensure that Work First Program participants, required to participate in work activities, shall be subject to and have the Work First Program employees in similarly situated work activities, including, but not limited to, wage and hour laws, health and safety standards, and nondiscrimination laws, provided that nothing in this subdivision shall be construed to prohibit Work First Program participants from receiving additional State or county services designed to assist Work First Program participants achieve job stability and self-sufficiency;
7. A description of eligible federal and State work activities. For up to twenty percent (20%) of Work First recipients, authorized State work activities shall include at least part-time enrollment in a postsecondary education program. In Standard Counties, recipients enrolled on at least a part-time basis in a postsecondary education program and maintaining a 2.5 grade point average or its equivalent shall have their two-year time limit suspended for up to three years.
8. Requirements for assignment of child support income and compliance with child support activities;
9. Incentives for high-performing counties, contingency plans for counties unable to meet financial commitments during the term of the State Plan, and sanctions against counties failing to meet performance expectations, including allocation of any federal penalties that may be assessed against the State as a result of a county's failure to perform; and
10. Anything else required by federal or State law, rule, or regulation to be included in the State Plan.
The section of the State Plan proposing the terms of the Work First Program in Electing Counties shall be based upon the aggregate of the Electing County Plans and shall include federal eligibility requirements and a description of the eligibility requirements and benefit calculation in each Electing County.
The section of the State Plan describing the Standard Work First Program shall include:
1. Benefit levels, limitations, and payments and the method for calculating benefit levels and payments;
2. Eligibility criteria, including asset and income standards;
3. Any exceptions or exemptions proposed to work requirements;
4. Provisions for when extensions may be granted to a person or family who reaches the time limit for receipt of benefits;
5. Provisions for exceptions and exemptions to criteria, time limits, and standards;
6. Provisions for sanctions for recipient failure to comply with program requirements; and
7. through (10) Repealed by Session Laws 2009-489, s. 7, effective August 26, 2009.
In addition to those items required to be included pursuant to subsection (e) of this section, the State Plan may include proposals to establish the following as part of the Standard Work First Program:
1. Demonstration projects in one or more counties to assess the value of any proposed changes in State policy or to test ways to improve programs; and
2. Requirement that recipients shall be required to enter into and comply with Mutual Responsibility Agreements as a condition of receiving benefits. If provided for in the State Plan, the terms and conditions of Mutual Responsibility Agreements shall be consistent with program purposes, federal law, and availability of funds.
The State Plan may provide for automatic Medicaid eligibility for all Work First Program recipients.
The State Plan may provide that in cases where benefits are paid only for a child, the case is considered a family case.

The Department may modify the section in the State Plan regarding Electing Counties once a biennium or except as necessary to reflect any modifications made by an Electing County. Any changes to the section of the State Plan regarding Electing Counties shall be reported to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division within one month following the changes.

(11) A description of the Department's consultation with local governments and private sector organizations and a summary of any comments received during the 45-day public comment period.

History

(1997-443, s. 12.6; 1997-456, s. 55.10; 1998-212, s. 12.27A(b), (b1); 1999-359, ss. 1.2(b), 2(c); 2001-424, s. 21.13(c), (e); 2007-323, s. 10.35A(a); 2009-489, s. 10.)

Effect of Amendments. - Session Laws 2007-323, s. 10.35A(a), effective July 1, 2007, in subsection (a), deleted "submit the State Plan to the Senate Appropriations Committee on Health and Human Services and the House of Representatives Appropriations Subcommittee on Health and Human Services for its review and then consult with local governments and private sector organizations regarding the design of the State Plan and allow 45 days to receive comments from them" following "shall" at the end of the introductory paragraph and added subdivisions (a)(1) and (a)(2).

Session Laws 2009-489, s. 10, effective August 26, 2009, rewrote subdivision (c)(1c); rewrote subsection (d); deleted subdivisions (e)(7)-(10) pertaining to the inclusion of terms and conditions for repayment and funding levels and allocation in the section of the State Plan describing the Standard Work First Program; and made minor stylistic changes.

§ 108A-27.10. Duties of the Director of the Budget/Governor.

The Director of the Budget shall, by May 15 of each odd-numbered year, approve and recommend adoption by the General Assembly of the State Plan.
At the beginning of every fiscal year, the Director of the Budget shall report to the General Assembly the number of permanent State employees who have been Work First Program recipients during the previous calendar year.
After the State Plan has become law, the Governor shall sign it and cause it to be submitted to federal officials in accordance with federal law.

History

(1997-443, s. 12.6; 2007-323, s. 10.35A(b).)

Effect of Amendments. - Session Laws 2007-323, s. 10.35A(b), effective July 1, 2007, substituted "odd-numbered" for "even numbered calendar" in the middle of subsection (a).

§ 108A-27.11. Work First Program funding.

County block grants, except funds for Work First Family Assistance, shall be computed based on the percentage of each county's total AFDC (including AFDC-EA) and JOBS expenditures, except expenditures for cash assistance, to statewide actual expenditures for those programs in fiscal year 1995-96. The resulting percentage shall be applied to the State's total certified budget enacted by the General Assembly for each fiscal year, except for State funds budgeted for State and county demonstration projects authorized by the General Assembly and for Work First Family Assistance payments.
The following shall apply to funding for Standard Program Counties:
1. The Department shall make payments of Work First Family Assistance and Work First Diversion Assistance subject to the availability of federal, State, and county funds.
2. The Department shall reimburse counties for county expenditures under the Work First Program subject to the availability of federal, State, and county funds.
Each Electing County's allocation for Work First Family Assistance shall be computed based on the percentage of each Electing County's total expenditures for cash assistance to statewide actual expenditures for cash assistance in 1995-96. The resulting percentage shall be applied to the federal TANF block grant funds appropriated for cash assistance by the General Assembly each fiscal year. The Department shall transmit the federal funds contained in the county block grants to Electing Counties as soon as practicable after they become available to the State and in accordance with federal cash management laws and regulations.

History

(1997-443, s. 12.6; 1998-212, s. 12.27A(i); 1999-359, s. 3; 2002-126, s. 10.37; 2003-284, s. 10.50.)

Local Modification. - Beaufort, Caldwell, Catawba, Iredell, Lenoir, Lincoln, Macon, Wilson: 2008-69 (as to hold-harmless provision for electing counties in the 2008-2009 fiscal year).

Editor's Note. - Session Laws 2015-241, s. 12C.1(a)-(f), as amended by Session Laws 2016-94, s. 12C.5(a), provides: "(a) The General Assembly approves the plan titled 'North Carolina Temporary Assistance for Needy Families State Plan FY 2013-2016,' prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2013, through September 30, 2016. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

"(f) This section expires September 30, 2016."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2016-94, s. 12C.5(b)-(f), provides: "(b) Beginning October 1, 2016, the General Assembly approves the plan titled "North Carolina Temporary Assistance for Needy Families State Plan FY 2016-2019," prepared by the Department of Health and Human Services and presented to the General Assembly. The North Carolina Temporary Assistance for Needy Families State Plan covers the period October 1, 2016, through September 30, 2019. The Department shall submit the State Plan, as revised in accordance with subsection (b) of this section, to the United States Department of Health and Human Services.

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-27.12. Maintenance of effort.

The Department shall define in the State Plan the services that can be provided with TANF federal funds and with State and county maintenance of effort funds. The Department shall work with counties to allow flexibility in the spending of county, State, and federal funds so as to maximize the use of resources while assuring that federal maintenance of effort requirements are met.
Counties that fail to meet maintenance of effort requirements and that fail to meet the performance indicators for reducing maintenance of effort shall submit a corrective action plan to the Department and shall be subject to G.S. 108A-27.14. The Department may reduce block grant allocations to counties that fail to meet maintenance of effort requirements and performance indicators or may use some of the county's block grant allocation to secure needed services for clients in that county. If a county fails to comply with maintenance of effort requirements, the Director of the Budget may also withhold State funds appropriated to the county pursuant to G.S. 108A-93.
The Department shall maintain the State's maintenance of effort at one hundred percent (100%) of the State certified budget enacted by the General Assembly for programs under this Part during fiscal year 1996-97. At no time shall the Department reduce or reallocate State funds previously obligated or appropriated for Work First or child welfare services.
Each standard county shall maintain funding in Work First, child welfare, and related activities as defined by the Department at one hundred percent (100%) of the county funds budgeted in State Fiscal Year 1996-97 for AFDC Administration, JOBS employment and training, and AFDC Emergency Assistance (cash and services). A county may request to reduce its block grant and maintenance of effort if that county can demonstrate that it is meeting all the needs of its clients, as defined by the Department's performance indicators, without spending all of the block grant funds. The needs of clients include child protection, employment services, and related supportive services such as child care. The Department may reallocate any State or federal funds released from a county that reduced its maintenance of effort or from counties not spending their block grants. Funds reallocated to counties will require county match.
During the first year a county operates as an Electing County, the county's maintenance of effort shall be no less than ninety percent (90%) of the amount the county budgeted for programs under this Part during fiscal year 1996-97. If during the first year of operation as Electing the Electing County achieves one hundred percent (100%) of its goals as set forth in its Electing County Plan, then the Electing County may reduce its maintenance of effort to eighty percent (80%) of the amount the county budgeted for programs under this Part during fiscal year 1996-97 for the second year of the Electing County's operation and for all years thereafter that the county maintains Electing Status.
The Department may realign funds if the realignment will assure that maintenance of effort requirements are met while maximizing federal revenues.
The Department of Health and Human Services shall report quarterly on the extent to which the State and counties are meeting federal maintenance of effort requirements under Temporary Assistance of Needy Families and on any realignment of funds. The Department and the counties shall work together to maximize full achievement of the State and county maintenance of effort. The Department shall make its report to members of the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Human Resources, and the Joint Legislative Public Assistance Committee, and to the Fiscal Research Division.

History

(1997-443, s. 12.6; 1998-212, s. 12.27A(j); 1999-359, s. 4(a), (c).)

Editor's Note. - Session Laws 1999-359, s. 4(c) was codified as subsection (g) of this section at the direction of the Revisor of Statutes.

Session Laws 1999-359, s. 4(d) provides that the Department shall continue to work with counties, area mental health authorities, and other public and private entities or partnerships that provide services to Temporary Assistance for Needy Families recipients paid for with state and local funds to identify those services and activities that meet federal maintenance of effort requirements. The Department shall report the status of identifying services and activities in its quarterly report on meeting federal maintenance of effort requirements as required under s. 4(c) (codified as subsection (g) of G.S. 108A-27.12).

§ 108A-27.13. Performance standards.

The Department, in consultation with the county department of social services and county board of commissioners, shall establish outcome and performance measures for all counties, both Electing and Standard. There exist two goals for the Work First Program: to meet or exceed the federal Work Participation rate of fifty percent (50%) for all Work Eligible families and ninety percent (90%) for all two-parent families. The two goals apply to both Standard and Electing Counties. The Department shall establish monitoring mechanisms and reporting requirements to assess progress toward the goals. The well-being of children and economic factors and conditions within the counties, including the increased numbers of persons employed and increased numbers of hours worked by and wages earned by recipients, shall be considered by the Department.
Repealed by Session Laws 2009-489, s. 11, effective August 26, 2009.
All adult recipients of Work First Program assistance are expected to achieve full-time employment, subject to applicable exceptions. Adult recipients of Work First Program assistance shall comply with the provisions and requirements in their MRAs.

History

(1997-443, s. 12.6; 2009-489, s. 11.)

Effect of Amendments. - Session Laws 2009-489, s. 11, effective August 26, 2009, in subsection (a), substituted "shall establish outcome and performance measures for all counties, both Electing and Standard" for "shall establish acceptable levels of performance for Standard Program Counties in meeting Work First expectations, measured by outcome and performance goals contained in the State Plan" at the end of the first sentence and added the present second and third sentences; and deleted subsection (b), which read: "Electing County performance shall be judged upon the county's ability to attain the outcomes and goals established in that county's County Plan."

§ 108A-27.14. Corrective action.

When any county fails to meet acceptable levels of performance, the Department may take one or more of the following actions to assist the county in meeting its Work First goals:
1. Notify the county of the deficiencies and add additional monitoring and reporting requirements.
2. Require the county to develop and submit for approval by the Department a corrective action plan.
If any Standard Program County fails to meet acceptable levels of performance for two consecutive years, or fails to comply with a corrective action plan developed pursuant to this section, the Department may assume control of the county's Work First Program, appoint an administrator to administer the county's Work First Program, and exercise the powers assumed to administer the Work First Program either directly or through contract with private or public agencies. County funding shall continue at levels established by the State Plan when the State has assumed control of a county Work First Program. At no time after the State has assumed control of a Work First Program shall a county withdraw funds previously obligated or appropriated to the Work First Program.
If an Electing County fails to achieve its Work First Program goals for two consecutive years, or fails to comply with a corrective action plan developed pursuant to this section, and as a result the federal government imposes a penalty upon the State, then the county shall lose its Electing County status.

History

(1997-443, s. 12.6.)

§ 108A-27.15. Assistance not an entitlement; appeals.

Any assistance programs established under this Part, whether administered by the Department or the counties, are not entitlements, and nothing in this Part shall create any property right.
The Standard Work First Program is a program of temporary public assistance for the purpose of an appeal under G.S. 108A-79.

History

(1997-443, s. 12.6.)

§ 108A-27.16: Repealed by Session Laws 1999-237, s. 6(h), effective July 1, 1999.

§§ 108A-28, 108A-28.1: Repealed by Session Laws 1997-443, s. 12.14.

§ 108A-29. Priority for employment services.

Repealed by Session Laws 2009-489, s. 12, effective August 26, 2009.
Individuals seeking to apply or reapply for Work First Program assistance and who are not exempt from work requirements shall register with the Division of Employment Security for employment services. The point of registration shall be at an office of the Division in the county in which the individual resides or at another location designated in a Memorandum of Understanding between the Division and the local department of social services.
Individuals who are not otherwise exempt shall present verification of registration for Work First Program assistance. Unless exempt, the individual shall not be approved for Work First Program assistance until verification is received. Child-only cases are exempt from this requirement.
Once an individual has registered as required in subsection (c) of this section and upon verification of the registration by the agency or contractor providing the Work First Program assistance, the individual's eligibility for Work First Program assistance may be evaluated and the application completed. Continued receipt of Work First Program benefits is contingent upon successful participation in employment services in the Mutual Responsibility Agreement, and lack of cooperation and participation in employment services may result in the termination of benefits to the individual.
Repealed by Session Laws 2009-489, s. 12, effective August 26, 2009.
Each county department of social services shall enter into a cooperative agreement with the local Division to operate the Job Search component on behalf of Work First Program registrants. The cooperative agreement shall include a provision for payment to the Division by the county department of social services for the cost of providing those services, not otherwise available to all clients of the Division, described in this subsection as the same are reflected as a component of the County Plan payable from fund allocations in the county block grant. The county department of social services may also enter into a cooperative agreement with the community college system or any other entity to operate the Job Preparedness component. This cooperative agreement shall include a provision for payment to that entity by the county department of social services for the cost of providing those services, not otherwise available to all clients of the Division, described in this subsection as the same are reflected as a component of the County Plan payable from fund allocations in the county block grant.
The Division shall further assist registrants through job search, job placement, or referral to community service, if contracted to do so.
An individual placed in the Job Search component of the Division or other agency providing Job Search services shall look for work and shall accept any suitable employment. If contracted, the Division shall refer individuals to current job openings and shall make job development contacts for individuals. Individuals so referred shall be required to keep a record of their job search activities on a job search record form provided by the Division, and the Division will monitor these activities. A "job search record" means a written list of dates, times, places, addresses, telephone numbers, names, and circumstances of job interviews. The Job Search component shall include at least one weekly contact with the Division. The Division shall adopt rules to accomplish this subsection.
The Division of Employment Security shall notify all employers in the State of the "Exclusive No-Fault" Referral Service available through the Division of Employment Security to employers who hire personnel through Job Service referrals.
All individuals referred to jobs through the Division of Employment Security shall be instructed in the procedures for applying for the Federal Earned Income Credit (FEIC). All individuals referred to jobs through the Division who qualify for the FEIC shall apply for the FEIC by filing a W-5 form with their employers.
The FEIC shall not be counted as income when eligibility is determined for Work First Program assistance, Medicaid, food and nutrition services, public housing, or Supplemental Security Income.
The Division of Employment Security shall work with the Department of Labor to develop a relationship with these private employment agencies to utilize their services and make referrals of individuals registered with the Division of Employment Security.
An individual who has not found a job within 12 weeks of being placed in the Job Search component of the Program may also be placed in the Community Service component at the county's option.
If after evaluation of an individual the Division of Employment Security believes it necessary, the Division or the county department of social services also may refer an individual to a Job Preparedness provider. The local community college should include adult high school equivalency diploma, Adult Basic Education, or Human Resources Development programs that are already in existence as a part of the Job Preparedness component. Additionally, the Division or the county department of social services may refer an individual to a literacy council. Through a Memorandum of Understanding between the Division of Employment Security, the local department of social services, and other contracted entities, a system shall be established to monitor an individual's progress through close communications with the agencies assisting the individual. The Division of Employment Security or Job Preparedness provider shall adopt rules to accomplish this subsection.
The Job Preparedness component of the Program shall last a maximum of 12 weeks unless the recipient is registered and is satisfactorily progressing in a program that requires additional time to complete. Every reasonable effort shall be made to place the recipient in part-time employment or part-time community service if the time required exceeds the 12-week maximum. The county department of social services may contract with service providers to provide the services described in this section and shall monitor the provision of the services by the service providers. Registrants may participate in more than one component at a time.
The Division shall expand its Labor Market Information System. The expansion shall at least include: statistical information on unemployment rates and other labor trends by county; and publications dealing with licensing requirements, economic development, and career projections, and information technology systems which can be used to track participants through the employment and training process.
, (r) Repealed by Session Laws 2009-489, s. 12, effective August 26, 2009.
Members of families with dependent children and with aggregate family income at or below the level required for eligibility for Work First Family Assistance, regardless of whether or not they have applied for such assistance, shall be given priority in obtaining employment services including training and community service provided by or through State agencies or counties or with funds which are allocated to the State of North Carolina directly or indirectly through prime sponsors or otherwise for the purpose of employment of unemployed persons.

History

(1961, c. 998; 1963, c. 1061; 1965, c. 939, s. 2; 1969, c. 546, s. 1; 1971, c. 283; 1973, c. 476, s. 138; 1977, c. 362; 1981, c. 275, s. 1; 1981 (Reg. Sess., 1982), c. 1282, s. 19; 1989 (Reg. Sess., 1990), c. 966, s. 1; 1997-443, s. 12.7(a); 1998-212, s. 12.27A( l ), (m); 1999-340, s. 9; 2001-424, s. 21.13(d), (e); 2007-97, s. 8; 2009-489, s. 12; 2011-401, s. 3.12; 2014-115, s. 28(d).)

Effect of Amendments. - Session Laws 2007-97, s. 8, effective June 20, 2007, substituted "food and nutrition services" for "food stamps, subsidies" in subsection (k).

Session Laws 2009-489, s. 12, effective August 26, 2009, rewrote the section heading; deleted subsection (a) pertaining to the establishment and administration of the First Stop Employment Assistance program; substituted "the Employment Security Commission for employment services" for "the First Stop Employment Assistance Program" at the end of the first sentence in subsection (b); deleted "at the time of applying" following "registration" in the first sentence of subsection (c); substituted "the employment services in the Mutual Responsibility Agreement, and lack of cooperation and participation in employment services" for "the First Stop Employment Program, and lack of cooperation and participation in the First Stop Employment Program" in subsection (d); deleted subsection (e), which read: "The county board of commissioners shall determine which agencies or nonprofit or private contractors will participate with the Employment Security Commission and the local department of social services in developing the rules to implement the First Stop Employment Program."; in subsection (f), deleted the former first sentence, which read: "At the county's option, the Employment Security Commission, in consultation with and with the assistance of the agencies specified in the Memorandum of Understanding described in subsection (b) of this section, shall provide to Work First Program registrants the continuum of services available through its Employment Security Commission.", and, in the present first sentence, substituted "Each county department of social services shall" for "Each County Plan may provide that the county department of social services enter" and inserted "local"; deleted the former first sentence in subsection (g), which read: "The Employment Security Commission shall be the primary job placement entity of the Work First Program."; substituted "Employment Security Commission or other agency providing Job Search services" for "First Stop Employment Program" in the first sentence of subsection (h); substituted "a Job Preparedness provider" for "the Job Preparedness component of the First Stop Employment Program" at the end of the first sentence of subsection (n); and deleted subsections (q) and (r) pertaining to a Job Service Employer Committee and "NC WORKS" studies.

Session Laws 2011-401, s. 3.12, effective November 1, 2011, throughout the section, substituted "Division of Employment Security" and "Division" for "Employment Security Commission."

Session Laws 2014-115, s. 28(d), effective August 11, 2014, substituted "adult high school equivalency diploma" for "General Education Development" in the second sentence of subsection (n).

Legal Periodicals. - For note on illegitimacy in North Carolina, see 46 N.C.L. Rev. 813 (1968).

For note on the "man in the house" or "substitute parent" rule in determining eligibility for aid to dependent children, see 47 N.C.L. Rev. 228 (1968).

Opinions of Attorney General

As to eligibility of children for aid to families with dependent children although parent does not qualify as a payee, see opinion of Attorney General to Colonel Clifton M. Craig, Commissioner, Department of Social Services, 40 N.C.A.G. 652 (1970), issued under former Chapter 108.

§ 108A-29.1. Drug screening and testing for Work First Program applicants and recipients.

The Department shall require a drug test to screen each applicant for or recipient of Work First Program assistance whom the Department reasonably suspects is engaged in the illegal use of controlled substances. The Department shall provide notice of drug testing to each applicant or recipient. The notice shall advise the applicant or recipient that drug screening, and testing if there is reasonable suspicion that an individual is engaged in the illegal use of controlled substances, will be conducted as a condition of receiving Work First Program assistance, and that the results of the drug tests will remain confidential and will not be released to law enforcement. Dependent children under the age of 18 are exempt from the requirements of this section. The Department shall require the following:
1. That for two-parent households, both parents comply with the requirements of this section.
2. That any teen parent who is emancipated pursuant to Article 35 of Chapter 7B of the General Statutes complies with the requirements of this section.
3. That each applicant or recipient be advised before drug testing that he or she may inform the agent administering the test of any prescription or over-the-counter medication he or she is taking.
4. That each applicant or recipient being tested signs a written acknowledgement that he or she has received and understood the notice and advice provided under this subsection.
5. That each applicant or recipient who fails a drug test understands that he or she has the right to take one or more additional tests at his or her own expense.
6. That each applicant or recipient who fails a drug test be provided with information regarding substance abuse, substance abuse counseling, and substance abuse treatment options, including a list of substance abuse treatment programs that may be available to the individual.
An applicant or recipient who tests positive for controlled substances as a result of a drug test required under this section is ineligible to receive Work First Program assistance for one year from the date of the positive drug test except as provided in subsections (b1) and (b2) of this section. The individual may reapply after one year. However, if the individual has any subsequent positive drug tests, the individual shall be ineligible for benefits for three years from the date of the subsequent positive drug test unless the individual reapplies pursuant to subsection (b1) or (b2) of this section.
An applicant or recipient deemed ineligible under subsection (b) of this section may reapply for Work First Program assistance after the expiration of 30 days from the date of the positive drug test if the individual can document either the successful completion of or the current satisfactory participation in a substance abuse treatment program offered by a provider under subsection (e) of this section and licensed by the Department. The applicant or recipient who reapplies for Work First Program assistance after successful completion of a substance abuse program shall pass a drug test. The cost of any drug testing and substance abuse program provided under this subsection shall be the responsibility of the individual being tested and receiving treatment. An applicant or recipient who reapplies for Work First Program assistance pursuant to this subsection may reapply one time only.
An applicant or recipient deemed ineligible under subsection (b) of this section may reapply for Work First Program assistance after the expiration of 30 days from the date of the positive drug test if a qualified professional in substance abuse or a physician certified by the American Society of Addiction Medicine determines a substance abuse program is not appropriate for the individual and that individual has passed a subsequent drug test. The cost of any drug testing provided under this subsection shall be the responsibility of the individual being tested. An applicant or recipient who reapplies for Work First Program assistance pursuant to this subsection may reapply one time only.
The children of any applicant or current recipient shall remain eligible for benefits, and these benefits shall be paid to a protective payee pursuant to G.S. 108A-38.
The Social Services Commission shall adopt rules pertaining to the testing of applicants and recipients under this section. The Social Services Commission shall adopt rules pertaining to the successful completion of, or the satisfactory participation in, a substance abuse treatment program under subsection (b1) of this section, including rules regarding timely reporting of completion of or participation in the substance abuse treatment programs.
Area mental health authorities organized pursuant to Article 4 of Chapter 122C of the General Statutes shall be responsible for administering the provisions of this section.
Repealed by Session Laws 2013-417, s. 4, as amended by Session Laws 2014-115, s. 66 (c), effective March 1, 2015.
For the purposes of this section, reasonable suspicion that an applicant for, or recipient of, Work First Program assistance is engaged in the illegal use of controlled substances may be established only by utilizing the following methods:
1. A criminal record check conducted under G.S. 114-19.34 that discloses a conviction, arrest, or outstanding warrant relating to illegal controlled substances within the three years prior to the date the criminal record check is conducted.
2. A determination by a qualified professional in substance abuse or a physician certified by the American Society of Addiction Medicine that an individual is addicted to illegal controlled substances.
3. A screening tool relating to the abuse of illegal controlled substances that yields a result indicating that the applicant or recipient may be engaged in the illegal use of controlled substances.
4. Other screening methods, as determined by the Social Services Commission under subsection (d) of this section.
Child only cases shall be exempt from the requirements of this section.

History

(1997-443, s. 12.8; 2009-489, s. 13; 2013-417, s. 4; 2014-115, s. 66(c).)

Editor's Note. - Session Laws 2013-417, s. 5, as amended by Session Laws 2014-115, s. 66(a), provides: "The Social Services Commission shall adopt rules implementing this act. The Social Services Commission shall issue temporary rules, in addition to its permanent rule-making authority, to enforce this act. Rules for the implementation of Section 4 of this act shall be adopted no later than October 31, 2014. The Department of Health and Human Services shall continue the substance abuse screening processes in place as of January 1, 2014, for applicants and recipients of Work First Program benefits until Section 4 of this act is fully implemented. The Department shall notify each county department of social services and the General Assembly of the date of full implementation of Section 4 of this act."

Session Laws 2013-417, s. 6, as amended by Session Laws 2014-155, s. 66(b), provides: "The Department of Health and Human Services shall report to the General Assembly no later than the first of each calendar quarter beginning April 1, 2014, and ending December 1, 2015, on the implementation of Section 4 of this act. The reports shall include a detailed timeline for implementation. Additionally, any changes to the timeline shall be included in the report with specific reasons for the timeline adjustment."

Session Law 2013-417, s. 8, as amended by Session Laws 2014-115, s. 66(c), provides: "Section 4 of this act becomes effective March 1, 2015. The remainder of this act becomes effective October 1, 2013."

Effect of Amendments. - Session Laws 2009-489, s. 13, effective August 26, 2009, substituted "Qualified Professional in Substance Abuse (QPSA)" for "Qualified Substance Abuse Professional (QSAP)" in the first sentence of subsection (a).

Session Laws 2013-417, s. 4, effective August 1, 2014, rewrote the section heading, which formerly read "Substance abuse treatment required; drug testing for Work First Program recipients"; rewrote subsections (a), (b), and (d); added subsections (b1), (b2), (g), and (h); and deleted subsection (f).

Legal Periodicals. - For comment, "Reemphasizing Impracticability in the Special Needs Analysis in Response to Suspicionless Drug Testing of Welfare Recipients," see 92 N.C. L. Rev. 948 (2014).

§ 108A-30: Repealed by Session Laws 1997-443, s. 12.14.

§ 108A-31. Application for assistance.

Any person who believes that the person is eligible to receive Work First Program assistance may apply for assistance to the county department of social services in the county in which the person resides, or, in the case of residents of Electing Counties, to the public or private entity designated by the board of county commissioners. Counties shall record inquiries for and accept applications from all persons requesting to apply for Work First Program assistance. Counties shall process applications in a reasonable and timely manner.

History

(1937, c. 288, ss. 15, 45; 1939, c. 395, s. 1; 1941, c. 232; 1945, c. 615, s. 1; 1947, c. 91, s. 3; 1953, c. 675, s. 12; 1959, c. 179, ss. 1, 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; c. 742; 1979, c. 702, s. 4; 1981, c. 275, s. 1; 1997-443, s. 12.8A.)

§§ 108A-32 through 108A-35: Repealed by Session Laws 1997-443, s. 12.14.

§ 108A-36. Assistance not assignable; checks payable to decedents.

The assistance granted by this Article shall not be transferable or assignable at law or in equity; and none of the money paid or payable as assistance shall be subject to execution, levy, attachment, garnishment, or other legal processes, or to the operation of any bankruptcy or insolvency law.

In the event of the death of a public assistance recipient during or after the first day of the month for which assistance was previously authorized by the county social services board, or county director if waived, any public assistance check or checks payable to such recipient not endorsed prior to such recipient's death shall be delivered to the clerk of superior court and by him administered under the provisions of G.S. 28A-25-6.

History

(1937, c. 288, ss. 17, 47; 1945, c. 615, s. 1; 1953, c. 213; 1969, c. 546, s. 1; 1971, c. 446, ss. 1, 2; 1977, c. 655, ss. 1, 2; 1981, c. 275, s. 1.)

Legal Periodicals. - For article analyzing North Carolina's exemptions law, see 18 Wake Forest L. Rev. 1025 (1982).

CASE NOTES

Cited in In re Hare, 32 Bankr. 16 (Bankr. E.D.N.C. 1983).

§ 108A-37. Personal representative for mismanaged public assistance.

Whenever a county director of social services shall determine that a recipient of assistance is unwilling or unable to manage such assistance to the extent that deprivation or hazard to himself or others results, the director shall file a petition before a district court or the clerk of superior court in the county alleging such facts and requesting the appointment of a personal representative to be responsible for receiving such assistance and to use it for the benefit of the recipient.
Upon receipt of such petition, the court shall promptly hold a hearing, provided the recipient shall receive five days' notice in writing of the time and place of such hearing. If the court, sitting without a jury, shall find at the hearing that the facts alleged in the petition are true, it may appoint some responsible person as personal representative. The personal representative shall serve without compensation and be responsible to the court for the faithful performance of his duties. He shall serve until the director of social services or the recipient shows to the court that the personal representative is no longer required or is unsuitable. All costs of court relating to proceedings under this section shall be waived.
Any recipient for whom a personal representative is appointed may appeal such appointment to superior court for a hearing de novo without a jury.
All findings of fact made under the proceedings authorized by this section shall not be competent as evidence in any case or proceeding which concerns any subject matter other than that of appointing a personal representative.

History

(1959, c. 1239, ss. 1, 3; 1961, c. 186; 1969, c. 546, s. 1; 1981, c. 275, s. 1.)

CASE NOTES

Grant to Be Used to Benefit Child. - This section requires that the caretaker use the Aid to Families with Dependent Children (AFDC) grant for the benefit of the dependent child, and provides for the appointment of a protective payee or personal representative. Morrell v. Flaherty, 338 N.C. 230, 449 S.E.2d 175 (1994), cert. denied, 515 U.S. 1122, 115 S. Ct. 2278, 132 L. Ed. 2d 282 (1995).

§ 108A-38. Protective and vendor payments.

When necessary to comply with any present or future federal law or regulation in order to obtain federal participation in public assistance payments, the payments may be made direct to vendors to reimburse them for goods and services provided the applicants or recipients, and may be made to protective payees who shall act for the applicant or recipient for receiving and managing assistance. Payments to vendors and protective payees shall be made to the extent provided in, and in accordance with, rules of the Social Services Commission or the Department, which rules shall be subject to applicable federal laws and regulations.

History

(1963, c. 380; 1969, c. 546, s. 1; c. 747; 1973, c. 476, s. 138; 1977, 2nd Sess., c. 1219, s. 20; 1981, c. 275, s. 1; 1997-443, s. 12.9.)

CASE NOTES

Cited in Morrell v. Flaherty, 338 N.C. 230, 449 S.E.2d 175 (1994), cert. denied, 515 U.S. 1122, 115 S. Ct. 2278, 132 L. Ed. 2d 282 (1995).

§ 108A-39. Fraudulent misrepresentation.

Any person whether provider or recipient, or person representing himself as such, who willfully and knowingly and with intent to deceive makes a false statement or representation or who fails to disclose a material fact and as a result of making a false statement or representation or failing to disclose a material fact obtains, for himself or another person, attempts to obtain for himself or another person, or continues to receive or enables another person to continue to receive public assistance in the amount of not more than four hundred dollars ($400.00) is guilty of a Class 1 misdemeanor.
Any person, whether provider or recipient, or person representing himself as such who willfully and knowingly with the intent to deceive makes a false statement or representation or fails to disclose a material fact and as a result of making a false statement or representation or failing to disclose a material fact, obtains for himself or another person, attempts to obtain for himself or another person, or continues to receive or enables another person to continue to receive public assistance in an amount of more than four hundred dollars ($400.00) is guilty of a Class I felony.
As used in this section the word "person" means person, association, consortium, corporation, body politic, partnership, or other group, entity, or organization.

History

(1937, c. 288, ss. 27, 57; 1963, cc. 1013, 1024, 1062; 1969, c. 546, s. 1; 1977, c. 604, s. 1; 1979, c. 510, s. 2; c. 907; 1981, c. 275, s. 1; 1993, c. 539, s. 813; 1994, Ex. Sess., c. 24, s. 14(c).)

CASE NOTES

Purpose. - This section was passed to define and punish a particular, specific crime. State v. Bass, 53 N.C. App. 40, 280 S.E.2d 7 (1981), decided under former Chapter 108.

All of the elements of G.S. 14-100 are not required to sustain a charge under this section. State v. Bass, 53 N.C. App. 40, 280 S.E.2d 7 (1981), decided under former Chapter 108.

The agency making the payments does not have to be deceived. State v. Bass, 53 N.C. App. 40, 280 S.E.2d 7 (1981), decided under former Chapter 108.

Who May Be Guilty. - An employee of the agency providing the funds, or the provider of the funds, can be guilty of violating this section. State v. Bass, 53 N.C. App. 40, 280 S.E.2d 7 (1981), decided under former Chapter 108.

§ 108A-39.1: Repealed by Session Laws 1997-443, s. 12.14.

§ 108A-39.2: Repealed by Session Laws 1989 (Regular Session, 1990), c. 966, s. 3.

PART 3. STATE-COUNTY SPECIAL ASSISTANCE.

§ 108A-40. Authorization of State-County Special Assistance Program.

The Department is authorized to establish and supervise a State-County Special Assistance Program. This program is to be administered by county departments of social services under rules and regulations of the Social Services Commission.

History

(1981, c. 275, s. 1; 2010-31, s. 10.19A(c).)

State-County Special Assistance. - Session Laws 2009-451, s. 10.57(a)-(e), provides: "The eligibility of Special Assistance recipients residing in adult care homes on August 1, 1995, shall not be affected by an income reduction in the Special Assistance eligibility criteria resulting from adoption of the Rate Setting Methodology Report and Related Services, providing these recipients are otherwise eligible. The maximum monthly rate for these residents in adult care home facilities shall be one thousand two hundred thirty-one dollars ($1,231) per month per resident.

"Effective October 1, 2009, the maximum monthly rate for residents in adult care home facilities shall be one thousand one hundred eighty-two dollars ($1,182) per month per resident unless adjusted by the Department in accordance with subsection (d) of this section. The eligibility of Special Assistance recipients residing in adult care homes on September 30, 2009, shall not be affected by an income reduction in the Special Assistance eligibility criteria resulting from the adoption of this maximum monthly rate, provided these recipients are otherwise eligible.

"The maximum monthly rate for residents in Alzheimer/Dementia special care units shall be one thousand five hundred fifteen dollars ($1,515) per month per resident unless adjusted by the Department in accordance with subsection (d) of this section.

"Notwithstanding any other provision of this section, the Department of Health and Human Services shall review activities and costs related to the provision of care in adult care homes and shall determine what costs may be considered to properly maximize allowable reimbursement available through Medicaid personal care services for adult care homes (ACH-PCS) under federal law. As determined, and with any necessary approval from the Centers for Medicare and Medicaid Services (CMS), and the approval of the Office of State Budget and Management, the Department may transfer necessary funds from the State-County Special Assistance program within the Division of Social Services to the Division of Medical Assistance and may use those funds as State match to draw down federal matching funds to pay for such activities and costs under Medicaid's personal care services for adult care homes (ACH-PCS), thus maximizing available federal funds. The established rate for State-County Special Assistance set forth in subsections (b) and (c) of this section shall be adjusted by the Department to reflect any transfer of funds from the Division of Social Services to the Division of Medical Assistance and related transfer costs and responsibilities from State-County Special Assistance to the Medicaid personal care services for adult care homes (ACH-PCS). Subject to approval by the Centers for Medicare and Medicaid Services (CMS) and prior to implementing this section, the Department may disregard a limited amount of income for individuals whose countable income exceeds the adjusted State-County Special Assistance rate. The amount of the disregard shall not exceed the difference between the Special Assistance rate prior to the adjustment and the Special Assistance rate after the adjustment and shall be used to pay a portion of the cost of the ACH-PCS and reduce the Medicaid payment for the individual's personal care services provided in an adult care home. In no event shall the reimbursement for services through the ACH-PCS exceed the average cost of the services as determined by the Department from review of cost reports as required and submitted by adult care homes. The Department shall report any transfers of funds and modifications of rates to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division.

"The Department of Health and Human Services shall recommend rates for State-County Special Assistance and for Adult Care Home Personal Care Services. The Department may recommend rates based on appropriate cost methodology and cost reports submitted by adult care homes that receive State-County Special Assistance funds and shall ensure that cost reporting is done for State-County Special Assistance and Adult Care Home Personal Care Services to the same standards as apply to other residential service providers."

For prior similar provisions, see Session Laws 2007-323, s. 10.13(a)-(f), as amended by Session Laws 2008-107, s. 10.2.

Tiered Rate Structure Pilot Program. - Session Laws 2013-360, s. 12D.2(a)-(e), provides: "(a) As used in this section, the term 'group home' means any facility that (i) is licensed under Chapter 122C of the General Statutes, (ii) meets the definition of a supervised living facility under 10A NCAC 27G.5601(c)(1) or 10A NCAC 27G.5601(c)(3), and (iii) serves adults whose primary diagnosis is mental illness or a developmental disability but may also have other diagnoses.

"(b) It is the intent of the General Assembly to create a State-County Special Assistance program that allows counties greater flexibility in serving individual needs within their communities and greater control over how county funds are used to support this program in light of the fact that counties are required to pay for fifty percent (50%) of the costs of this program. To that end, the General Assembly directs the Department of Health and Human Services to establish a pilot program in accordance with subsection (c) of this section.

"(c) The Department of Health and Human Services, Division of Aging and Adult Services (Department), shall establish a pilot program to implement a tiered rate structure within the State-County Special Assistance program for individuals residing in group homes, in-home living arrangements, and assisted living residences as defined in G.S. 131D-2.1. The purposes of the pilot program are to (i) determine the best way to implement a block grant for this program statewide and (ii) test the feasibility and effectiveness of implementing a tiered rate structure to address program participants' intensity of need, including medication management. The Department shall select a minimum of four and a maximum of six counties to participate in the pilot program, at least two of which shall be rural counties and at least two of which shall be urban counties. The pilot program shall (i) be implemented during the 2013-2014 fiscal year, (ii) operate for at least a 12-month period, and (iii) comply with any agreements in effect between the State of North Carolina and the United States government.

"(d) The Department shall implement the pilot program in collaboration with the local departments of social services in the counties selected for participation. As part of the pilot program, the selected counties shall receive a State General Fund allocation as a block grant to be equally matched with county general funds. The General Fund allocation provided to each county participating in the pilot program shall be calculated based upon the average annual Special Assistance expenditures for that county during the 2011-2013 fiscal biennium, adjusted for the amount of projected annual growth in the number of Special Assistance recipients in that county during the 2013-2015 fiscal biennium. These funds may be used to pay for room, board, and personal care services, including medication management, for individuals eligible to receive State-County Special Assistance, subject to the following limitations and requirements:

"(1) These funds shall not be used to cover any portion of the cost of providing services for which an individual receives Medicaid coverage.

"(2) The pilot program shall comply with all federal and State requirements governing the existing State-County Special Assistance program, except that Section 12D.3 does not apply to the pilot program.

"(3) The tiered rate structure shall be based upon intensity of need, and an individual's placement within a tier shall be based upon an independent assessment of the individual's need for room, board, and assistance with activities of daily living, including medication management.

"(e) By February 1, 2014, the Department shall submit a progress report on the implementation and operation of the pilot program, including any obstacles to implementation; and by February 1, 2015, the Department shall submit a final report on the results of the pilot program, along with any recommendations based on these results, to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division. The report due by February 1, 2015, shall include information from all participating counties on at least all of the following:

"(1) The amount of the tiered rates implemented as part of the pilot program.

"(2) The cost methodology for determining these tiered rates.

"(3) The number of individuals participating in the pilot program while residing in a group home.

"(4) The number of individuals participating in the pilot program while residing in an in-home living arrangement.

"(5) The number of individuals participating in the pilot program while residing in an assisted living residence as defined by G.S. 131D-2.1, broken down by facility type.

"(6) A comparison of the number of recipients of State-County Special Assistance prior to and during the pilot program, broken down by county and living arrangement.

"(7) Any other information the Department deems relevant for determining the best way to implement a block grant statewide for the State-County Special Assistance program."

Editor's Note. - Session Laws 2009-451, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2009'."

Session Laws 2009-451, s. 28.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2009-2011 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2009-2011 fiscal biennium."

Session Laws 2009-451, s. 28.5 is a severability clause.

Session Laws 2010-31, s. 10.25(a), provides: "The Department of Health and Human Services, Division of Medical Assistance, shall initiate a study or contract out for a study of reimbursement rates for Medicaid providers and program benefits. The study shall include the following information:

"(1) A comparison of Medicaid reimbursement rates in North Carolina with reimbursement rates in surrounding states and with rates in two additional states; and

"(2) A comparison of Medicaid program benefits in North Carolina with program benefits provided in surrounding states and with rates in two additional states. Selected provider rates shall be studied for the initial report."

Session Laws 2010-31, s. 10.25(b), provides: "The Department shall report its initial findings to the Governor, the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division by April 1, 2011."

Session Laws 2010-31, s. 10.25(c), provides: "Funds appropriated to the Department of Health and Human Services may be used to complete this study."

Session Laws 2010-31, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2010'."

Session Laws 2010-31, s. 32.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2010-2011 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2010-2011 fiscal year."

Session Laws 2010-31, s. 32.6 is a severability clause.

Session Laws 2013-360, s. 12D.3(a), (b), provides: "(a) For each year of the 2013-2015 fiscal biennium, the maximum monthly rate for residents in adult care home facilities shall be one thousand one hundred eighty-two dollars ($1,182) per month per resident.

"(b) For each year of the 2013-2015 fiscal biennium, the maximum monthly rate for residents in Alzheimer's/Dementia special care units shall be one thousand five hundred fifteen dollars ($1,515) per month per resident."

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.2, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2013-2015 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2013-2015 fiscal biennium."

Session Laws 2013-360, s. 38.5 is a severability clause.

Editor's Note. - Session Laws 2016-94, s. 12C.7(a)-(g), as amended by Session Laws 2016-123, s. 5.3, provides: "(a) The following definitions apply in this section:

"(1) Facility licensed to accept State-County Special Assistance payments or facility. - Any residential care facility that is (i) licensed by the Department of Health and Human Services and (ii) authorized to accept State-County Special Assistance payments from its residents.

"(2) State-County Special Assistance. - The program authorized by G.S. 108A-40. "

"(b) Nonrecurring funds appropriated in this act to the Department of Health and Human Services, Division of Social Services (DSS), for the 2016-2017 fiscal year for facilities licensed to accept State-County Special Assistance payments shall be used to provide temporary financial assistance in the form of a monthly payment to these facilities on behalf of each resident who is a recipient of State-County Special Assistance. The counties shall pay to the State fifty percent (50%) of the cost of providing these monthly payments to these facilities. The monthly payments provided by DSS to these facilities shall be subject to all of the following requirements and limitations:

"(1) The amount of the monthly payments authorized by this section is equal to thirty-four dollars ($34.00) per month for each resident who is a recipient of State-County Special Assistance.

"(2) A facility that receives the monthly payments authorized by this section shall not, under any circumstances, use these payments for any purpose other than to offset the cost of serving residents who are recipients of State-County Special Assistance.

"(3) The DSS shall make monthly payments authorized by this section to a facility on behalf of a resident only for the period commencing October 1, 2016, and ending June 30, 2017.

"(4) The DSS shall make monthly payments authorized by this section only to the extent sufficient State and county funds allocated to the DSS for the 2016-2017 fiscal year are available for this purpose.

"(5) The DSS shall not make monthly payments authorized by this section to a facility on behalf of a resident whose eligibility determination for State-County Special Assistance is pending.

"(6) The DSS shall terminate all monthly payments pursuant to this section on the earlier of the following:

"a. June 30, 2017.

"b. Upon depletion of the State and county funds allocated to the DSS for the 2016-2017 fiscal year for this purpose.

"(c) Notwithstanding any provision of this act or any other provision of law to the contrary, the DSS shall not be required to provide any temporary financial assistance to facilities beyond June 30, 2017, or upon depletion of the State and county funds allocated to the DSS for the 2016-2017 fiscal year for this purpose, whichever is earlier.

"(d) If possible, the DSS shall use an existing mechanism to administer these funds in the least restrictive manner that ensures compliance with this section and timely and accurate payments to facilities. The DSS shall not, under any circumstances, use any portion of the State and county funds allocated to the DSS for the 2016-2017 fiscal year for the purpose of this section for any other purpose.

"(e) By no later than April 1, 2017, the Department of Health and Human Services shall submit to the House Appropriations Committee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, and the Fiscal Research Division a detailed plan for a long-term solution on how to ensure adequate reimbursement to facilities for serving recipients of State-County Special Assistance without increasing the Medicaid eligibility income limit for State-County Special Assistance recipients and thereby expanding Medicaid..

"(f) Nothing in this section shall be construed as an obligation by the General Assembly to appropriate funds for the purpose of this section, or as an entitlement by any facility, resident of a facility, or other person to receive temporary financial assistance under this section.

"(g) This section expires on June 30, 2017."

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2015-57, s. 11C.13(a)-(g), provides: "(a) The following definitions apply in this section:

"(2) State-County Special Assistance. - The program authorized by G.S. 108A-40.

"(b) Nonrecurring funds appropriated in this act to the Department of Health and Human Services, Division of Social Services (DSS), for each year of the 2017-2019 fiscal biennium for facilities licensed to accept State-County Special Assistance payments shall be used to provide temporary financial assistance in the form of a monthly payment to these facilities on behalf of each resident who is a recipient of State-County Special Assistance. The counties shall pay to the State fifty percent (50%) of the cost of providing these monthly payments to these facilities. The monthly payments provided by DSS to these facilities shall be subject to all of the following requirements and limitations:

"(1) The amount of the monthly payments authorized by this section is equal to thirty-four dollars ($34.00) per month for each resident of the facility as of the first day of the month who is a recipient of State-County Special Assistance.

"(3) The DSS shall make monthly payments authorized by this section to a facility on behalf of a resident only for the period commencing July 1, 2017, and ending June 30, 2019.

"(4) The DSS shall make monthly payments authorized by this section only to the extent sufficient State and county funds allocated to the DSS for each year of the 2017-2019 fiscal biennium are available for this purpose.

"(5) The DSS shall not make monthly payments authorized by this section to a facility on behalf of a resident whose eligibility determination for State-County Special Assistance is pending.

"(6) The DSS shall terminate all monthly payments pursuant to this section on the earlier of the following:

"a. June 30, 2019.

"b. Upon depletion of the State and county funds allocated to the DSS for each year of the 2017-2019 fiscal year for this purpose.

"(c) Notwithstanding any provision of this act or any other provision of law to the contrary, the DSS shall not be required to provide any temporary financial assistance to facilities beyond June 30, 2019, or upon depletion of the State and county funds allocated to the DSS for each year of the 2017-2019 fiscal biennium for this purpose, whichever is earlier.

"(d) If possible, the DSS shall use an existing mechanism to administer these funds in the least restrictive manner that ensures compliance with this section and timely and accurate payments to facilities. The DSS shall not, under any circumstances, use any portion of the State and county funds allocated to the DSS for each year of the 2017-2019 fiscal biennium for the purpose of this section for any other purpose.

"(e) Nothing in this section shall be construed as an obligation by the General Assembly to appropriate funds for the purpose of this section, or as an entitlement by any facility, resident of a facility, or other person to receive temporary financial assistance under this section.

"(f) Of the funds appropriated in this act to the DSS for each year of the 2017-2019 fiscal biennium for facilities licensed to accept State-County Special Assistance payments, the DSS shall not use more than two hundred fifty thousand dollars ($250,000) in nonrecurring funds for each year of the 2017-2019 fiscal biennium for administrative purposes.

"(g) This section expires on June 30, 2019."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(c), effective July 1, 2010, in the Part 3 heading, section catchline and the text of this section, deleted "for Adults" following "Special Assistance."

§ 108A-41. (See editor's note) Eligibility.

Assistance shall be granted under this Part to all persons in adult care homes for care found to be essential in accordance with the rules and regulations adopted by the Social Services Commission and prescribed by G.S. 108A-42(b). As used in this Part, the term "adult care home" includes a supervised living facility for adults with intellectual and developmental disabilities licensed under Article 2 of Chapter 122C of the General Statutes.
Assistance shall be granted to any person who meets all of the following criteria:
1. Meets one of the following:
  1. Is 65 years of age or older.
  2. Is between the ages of 18 and 65, and is permanently and totally disabled or is legally blind pursuant to G.S. 111-11.
2. (Effective until contingency met - see Editor's note) Has insufficient income or other resources to provide a reasonable subsistence compatible with decency and health as determined by the rules and regulations of the Social Services Commission; and.
3. Is one of the following:
  1. A resident of North Carolina for at least 90 days immediately prior to receiving this assistance.
  2. Repealed by Session Laws 2014-100, s. 12D.1(c), effective November 1, 2014.
  3. A person discharged from a State facility who was a patient in the facility as a result of an interstate mental health compact that requires the State to continue treating the person within the State. As used in this sub-subdivision the term State facility is a facility listed under G.S. 122C-181.
When determining whether a person has insufficient resources to provide a reasonable subsistence compatible with decency and health, there shall be excluded from consideration the person's primary place of residence and the land on which it is situated, and in addition there shall be excluded real property contiguous with the person's primary place of residence in which the property tax value is less than twelve thousand dollars ($12,000).
The county shall also have the option of granting assistance to Certain Disabled persons as defined in the rules and regulations adopted by the Social Services Commission. Nothing in this Part should be interpreted so as to preclude any individual county from operating any program of financial assistance using only county funds.

(2) (For contingent effective date, see Editor's note) Has both (i) income at or below one hundred percent (100%) of the federal poverty level guidelines published by the United States Department of Health and Human Services and (ii) insufficient income or other resources to provide a reasonable subsistence compatible with decency and health as determined by the rules and regulations of the Social Services Commission.

History

(1949, s. 1038, s. 2; 1961, c. 186; 1969, c. 546, s. 1; 1973, c. 717, s. 1; 1977, 2nd Sess., c. 1252, s. 1; 1979, c. 702, s. 8; 1981, c. 275, s. 1; c. 849, s. 1; 1983, c. 14, s. 2; 1995, c. 535, s. 5; 1997-210, s. 1; 2001-209, s. 3; 2010-31, s. 10.19A(d); 2014-100, s. 12D.1(a)-(c).)

Subdivision (b)(2) Set out Twice. - The first version of subdivision (b)(2) set out above is effective until the contingency described in Session Laws 2014-100, s. 12D.1(h), has been met. The second version of subdivision (b)(2) set out above is effective after the contingency has been met. For contingent effective date, see Editor's note.

Editor's Note. - Session Laws 2008-184, s. 1, enacted provisions pertaining to an income disregard policy for those on special assistance. Session Laws 2008-184, s. 1, provides: "The eligibility of Special Assistance residents residing in adult care homes on and after July 1, 2009, shall not be affected because of annual Social Security, SSI, Veteran, and Railroad Retirement Cost of Living Adjustments (COLAs). This policy shall apply only in cases where Special Assistance income eligibility is affected only by Social Security, SSI, Veteran, and Railroad Retirement COLAs and shall not render a Special Assistance recipient eligible if all other eligibility requirements are not met. The maximum monthly rate for these residents shall be the same as for all other residents according to the provisions as set in the Current Operations Appropriations Act, as amended. The Department of Health and Human Services shall apply for the approvals, if any, which are necessary to implement the policy change directed by this section."

Session Laws 2010-31, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2010'."

Session Laws 2010-31, s. 32.6 is a severability clause.

Session Laws 2014-100, s. 12D.1(d), provides: "Subsections (a) and (c) of this section [which amend G.S. 108A-41(b)(1) and (b)] shall not affect the eligibility of State-County Special Assistance applicants approved to receive State-County Special Assistance benefits prior to November 1, 2014."

Session Laws 2014-100, s. 12D.1(e), provides: "Subsection (b) of this section [which amends G.S. 108A-41(b)(2)] shall not affect the eligibility of State-County Special Assistance applicants approved to receive State-County Special Assistance benefits prior to the effective date of subsection (b) of this section [for contingent effective date, see Editor's note for Session Laws 2014-100, s. 12D.1(h)]."

Session Laws 2014-100, s. 12D.1(f), provides: "Not later than October 31, 2014, the Department of Health and Human Services, Division of Medical Assistance, shall submit to the federal Centers for Medicare and Medicaid Services (CMS) an amendment to the Medicaid State Plan to allow Medicaid recipients who were approved to receive State-County Special Assistance benefits prior to the effective date of subsection (b) of this section to retain their eligibility for Medicaid. G.S. 108A-54.1A(e) [repealed] does not apply to this subsection."

Session Laws 2014-100, s. 12D.1(g), provides: "Effective date provision for subsections (a), (c), and (d) - effective November 1, 2014, and for subsections (f), (g), and (h) - effective August 7, 2014."

Session Laws 2014-100, s. 12D.1(h), provides: "Subsections (b) and (e) of this section become effective 30 days after the date CMS approves the Medicaid State Plan Amendment submitted by the Department of Health and Human Services pursuant to subsection (f) of this section. The Secretary of the Department of Health and Human Services shall report to the Revisor of Statutes when CMS approval is obtained and the date of the approval. Subsections (b) and (e) of this section shall not become effective if CMS disapproves the Medicaid State Plan Amendment submitted by the Department of Health and Human Services pursuant to subsection (f) of this section." The contingency was not met. CMS did not approve the State Plan Amendment.

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(d), effective July 1, 2010, in the last sentence in subsection (a), substituted "adults with intellectual and developmental disabilities" for "developmentally disabled adults"; and in subdivision (b)(1), added "or is legally blind pursuant to G.S. 111-11" and made minor stylistic changes.

Session Laws 2014-100, s. 12D.1(a), effective November 1, 2014, substituted the present provisions of the introductory paragraph of subsection (b) and subdivision (b)(1) for the former provisions which read: "(b) Assistance shall be granted to any person who: (1) Is 65 years of age and older, is between the ages of 18 and 65, and is permanently and totally disabled or is legally blind pursuant to G.S. 111-11; and."

Session Laws 2014-100, s. 12D.1(b), in subdivision (b)(2), inserted "both (i) income at or below one hundred percent (100%) of the federal poverty level guidelines published by the United States Department of Health and Human Services and (ii)" and substituted a period for "and;" at the end. For effective date, see Editor's note.

Session Laws 2014-100, s. 12D.1(c), effective November 1, 2014, substituted a period for a semicolon at the end of subdivision (b)(3)a, deleted former subdivision (b)(3)b. relating to a person residing with a close relative, and added "that requires the State to continue treating the person within the State" at the end of the first sentence in subdivision (b)(3)c.

Opinions of Attorney General

§ 108A-42. Determination of disability.

For purposes of G.S. 108A-41(b)(1), a person is permanently and totally disabled if:
1. This person was receiving aid to the disabled assistance in December 1973, and continues to be disabled under the definition of disability, having a physical or mental impairment which substantially precludes him from obtaining gainful employment and this impairment appears reasonably certain to continue without substantial improvement throughout his lifetime; or
2. This person applied for assistance on or after January 1, 1974, and is disabled under the Social Security standards.
For purposes of G.S. 108A-41(d), a "Certain Disabled" person is a person in a private living arrangement who is age 18 but less than age 65, having a physical or mental impairment which substantially precludes him from obtaining gainful employment, which impairment appears reasonably certain to continue without substantial improvement throughout his lifetime.
Disability shall be reviewed by medical consultants employed by the Department. The final decision on the disability shall be made by these medical consultants under rules and regulations adopted by the Social Services Commission.

History

(1979, c. 702, s. 9; 1981, c. 275, s. 1; 1983, c. 14, s. 1.)

CASE NOTES

Federal Decisions Are Persuasive But Not Binding. - Federal decisions interpreting the disability definitions for Old Age, Survivors and Disability Benefits (Title II) and SSI benefits (Title XVI) are not binding on this state's courts, but are deemed to be persuasive authority. Lackey v. North Carolina Dep't of Human Resources, 306 N.C. 231, 293 S.E.2d 171 (1982), decided under former G.S. 108-26.

§ 108A-43. Application procedure.

Applications under this Part shall be made to the county director of social services who, with the approval of the county board of social services and in conformity with the rules and regulations of the Social Services Commission, shall determine whether assistance shall be granted and the amount of such assistance; but the county board of social services may delegate to the county director the authority to approve or reject all applications for assistance under this Part, in which event the county director shall not be required to report his actions to the board.
The amount of assistance which any eligible person may receive shall be determined with regard to the resources and necessary expenditures of the applicant, in accordance with the appropriate rules and regulations of the Social Services Commission.

History

(1949, c. 1038, s. 2; 1961, c. 186; 1969, c. 546, s. 1; 1973, c. 476, s. 138; c. 717, s. 4; 1981, c. 275, s. 1.)

§ 108A-44. State funds to counties.

Appropriations made under this Part by the General Assembly to the Department, together with grants of the federal government (when such grants are made available to the State) shall be used exclusively for assistance to needy persons eligible under this Part.
Allotments shall be made annually by the Department to the counties participating in the program established by this Part.
No allotment shall be used, either directly or indirectly, to replace county appropriations or expenditures.

History

(1949, c. 1038, s. 2; 1955, c. 310, s. 3; 1961, c. 186; 1969, c. 546, s. 1; 1973, c. 717, s. 5; 1975, c. 92, s. 2; 1981, c. 275, s. 1.)

§ 108A-45. Participation.

The State-County Special Assistance Program established by this Part shall be administered by all the county departments of social services under rules and regulations adopted by the Social Services Commission and under the supervision of the Department. Provided that, assistance for certain disabled persons shall be provided solely at the option of the county.

History

(1949, c. 1038, s. 2; 1969, c. 546, s. 1; 1973, c. 476, s. 138; c. 717, s. 6; 1975, c. 92, s. 3; 1977, 2nd Sess., c. 1252, s. 2; 1981, c. 275, s. 1; 2010-31, s. 10.19A(e).)

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(e), effective July 1, 2010, deleted "for Adults" following "Special Assistance."

§ 108A-46: Repealed by Session Laws 2003-284, s. 10.53(a), effective July 1, 2003.

Cross References. - For present similar provisions, see G.S. 108A-46.1.

§ 108A-46.1. Transfer of assets for purposes of qualifying for State-county Special Assistance.

Notwithstanding any other provision of law to the contrary, Supplemental Security Income (SSI) policy applicable to transfer of assets and estate recovery, as prescribed by federal law, shall apply to applicants for State-county Special Assistance.

History

(2003-284, s. 10.53(b); 2010-31, s. 10.19A(f).)

Editor's Note. - This section was enacted as G.S. 108A-46A and was redesignated as G.S. 108A-46.1 at the direction of the Revisor of Statutes.

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(f), effective July 1, 2010, deleted "for adults" from the end of the catchline.

§ 108A-47. Limitations on payments.

No payment of assistance under this Part shall be made for the care of any person in a licensed facility that is owned or operated in whole or in part by any of the following:

A member of the Social Services Commission, of any county board of social services, or of any board of county commissioners;
An official or employee of the Department, unless the official or employee has been appointed temporary manager of the facility pursuant to G.S. 131E-237, or of any county department of social services;
A spouse of a person designated in subdivisions (1) and (2).

History

(1979, c. 702, s. 10; 1981, c. 275, s. 1; 1995, c. 298, s. 1; c. 535, s. 6; 2010-31, s. 10.19A(g).)

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(g), effective July 1, 2010, substituted "for the care of any person in a licensed facility" for "for the care of any person in an adult care home" in the introductory paragraph.

§ 108A-47.1. Special Assistance in-home payments.

The Department of Health and Human Services may use funds from the existing State-County Special Assistance budget to provide Special Assistance payments to eligible individuals 18 years of age or older in in-home living arrangements. These payments may be made for up to fifteen percent (15%) of the caseload for all State-County Special Assistance. The standard monthly payment to individuals enrolled in the Special Assistance in-home program shall be one hundred percent (100%) of the monthly payment the individual would receive if the individual resided in an adult care home and qualified for Special Assistance, except if a lesser payment amount is appropriate for the individual as determined by the local case manager. The Department shall implement Special Assistance in-home eligibility policies and procedures to assure that in-home program participants are those individuals who need and, but for the in-home program, would seek placement in an adult care home facility. The Department's policies and procedures shall include the use of a functional assessment.
All county departments of social services shall participate in the State-County Special Assistance in-home program by making Special Assistance in-home slots available to individuals who meet the eligibility requirements established by the Department pursuant to subsection (a) of this section. By February 15, 2013, the Department shall establish a formula to determine the need for additional State-County Special Assistance in-home slots for each county. Beginning July 1, 2014, and each July 1 thereafter, the Department shall review and revise the formula as necessary.

History

(2007-323, s. 10.14(a); 2010-31, s. 10.19A(h); 2012-142, s. 10.23(a).)

Editor's Note. - Session Laws 2017-57, s. 11D.1A(a), (b), provides: "(a) Notwithstanding the provisions of G.S. 108A-47.1 or any other provision of law to the contrary, and within existing appropriations for State-County Special Assistance, the Secretary of the Department of Health and Human Services may waive the fifteen percent (15%) cap on the number of Special Assistance in-home payments, as the Secretary deems necessary.

"(b) This section expires on June 30, 2019."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2020-78, s. 4A.1(a), (b), provides: "(a) Notwithstanding the provisions of G.S. 108A-47.1 or any other provision of law to the contrary, and within existing appropriations for State-County Special Assistance, the Secretary of the Department of Health and Human Services may waive the fifteen percent (15%) cap on the number of Special Assistance in-home payments, as the Secretary deems necessary.

"(b) This section expires on June 30, 2021."

Session Laws 2020-78, s. 22.1, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2019-2021 fiscal biennium, the textual provisions of this act apply only to the 2019-2021 fiscal biennium."

Session Laws 2020-78, s. 22.3, is a severability clause.

Effect of Amendments. - Session Laws 2010-31, s. 10.19A(h), effective July 1, 2010, in the first sentence, deleted "for Adults" following "State-County Special Assistance" and inserted "18 years of age or older," and in the second sentence, deleted "for Adults" from the end.

Session Laws 2012-142, s. 10.23(a), effective February 15, 2013, added the subsection (a) designation, and, in subsection (a), in the third sentence, substituted "one hundred percent (100%)" for "seventy five percent (75%)", and deleted the last two sentences, which read: "The Department shall make this in-home option available to all counties on a voluntary basis. To the maximum extent possible, the Department shall consider geographic balance in the dispersion of payments to individuals across the State."; and added subsection (b).

PART 4. FOSTER CARE AND ADOPTION ASSISTANCE PAYMENTS.

§ 108A-48. State Foster Care Benefits Program.

The Department is authorized to establish a State Foster Care Benefits Program with appropriations by the General Assembly for the purpose of providing assistance to children who are placed in foster care facilities by county departments of social services in accordance with the rules and regulations of the Social Services Commission. Such appropriations, together with county contributions for this purpose, shall be expended to provide for the costs of keeping children in foster care facilities.
Repealed by Session Laws 2015, c. 241, s. 12C.9(a).
The Department may continue to provide benefits pursuant to this section to an individual who has attained the age of 18 years and chosen to continue receiving foster care services until reaching 21 years of age if the individual is (i) completing secondary education or a program leading to an equivalent credential, (ii) enrolled in an institution that provides postsecondary or vocational education, (iii) participating in a program or activity designed to promote, or remove barriers to, employment, (iv) employed for at least 80 hours per month, or (v) incapable of completing the educational or employment requirements of this subsection due to a medical condition or disability.
With monthly supervision and oversight by the director of the county department of social services or a supervising agency, an individual receiving benefits pursuant to subsection (c) of this section may reside outside a foster care facility in a college or university dormitory or other semi-supervised housing arrangement approved by the director of the county department of social services and continue to receive benefits pursuant to this section.

History

(1981, c. 275, s. 1; 2015-241, s. 12C.9(a).)

Editor's Note. - Session Laws 2015-241, s. 12C.9( l ), made the amendments to this section by Session Laws 2015-241, s. 12C.9(a), applicable to agreements entered into on or after January 1, 2017.

Session Laws 2015-241, s. 12C.9(i)-(k), provides: "(i) The Department of Health and Human Services, Division of Social Services (Division), shall develop a plan for the expansion of foster care services for individuals who have attained the age of 18 years and opt to continue receiving foster care services until reaching 21 years of age. The Division shall report on the plan to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division by March 1, 2016. The Division shall report on the plan as implemented to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division by March 1, 2017.

"(j) No later than 60 days after the Department implements the plan for the expansion of foster care services as required under subsection (i) of this section, the Division shall submit a State plan amendment to the U.S. Department of Health and Human Services Administration for Children and Families to make federal payments for foster care and adoption assistance, as applicable, under Title IV-E, available to a person meeting the requirements of G.S. 108A-48(c), as enacted in subsection (a) of this section.

"(k) Any agreement entered into pursuant to G.S. 108A-48(b) prior to the effective date of subsection (a) of this section shall remain in full force and effect, and no provision of this section shall be construed to affect or alter such an agreement."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Effect of Amendments. - Session Laws 2015-241, s. 12C.9(a), effective January 1, 2017, repealed subsection (b), which formerly read: "No benefits provided by this section shall be granted to any individual who has passed his eighteenth birthday unless he is less than 21 years of age and is a full-time student or has been accepted for enrollment as a full-time student for the next school term pursuing a high school diploma or its equivalent; a course of study at the college level; or a course of vocational or technical training designed to fit him for gainful employment"; and added subsections (c) and (d). For applicability, see editor's note.

§ 108A-49. Foster care and adoption assistance payments.

Benefits in the form of foster care assistance shall be granted in accordance with the rules of the Social Services Commission to any dependent child who would have been eligible to receive Aid to Families with Dependent Children (as that program was in effect on June 1, 1995), but for his or her removal from the home of a specified relative for placement in a foster care facility; provided, that the child's placement and care is the responsibility of a county department of social services. A county department of social services shall pay, at a minimum, the monthly graduated foster care assistance payments for eligible children as set by the General Assembly. A county department of social services may make foster care assistance payments in excess of the monthly graduated rates set by the General Assembly.
Adoption assistance payments for certain adoptive children shall be granted in accordance with the rules of the Social Services Commission to adoptive parents who adopt a child eligible to receive foster care maintenance payments or supplemental security income benefits; provided, that the child cannot be returned to his or her parents; and provided, that the child has special needs which create a financial barrier to adoption. A county department of social services shall pay, at a minimum, the monthly graduated adoption assistance payments for eligible children as set by the General Assembly. A county department of social services may make adoption assistance payments in excess of the monthly graduated rates set by the General Assembly.
The Department is authorized to use available federal payments to states under Title IV-E of the Social Security Act for foster care and adoption assistance payments.
Except as otherwise prohibited by federal law, the Department of Health and Human Services, Division of Social Services, shall not require a redetermination of a child's eligibility for vendor payments under any adoption assistance agreement established prior to July 1, 2011. Nothing in this subsection shall make vendor assistance an entitlement.
If all other eligibility criteria are met, adoption assistance payments may continue until the beneficiary reaches the age of 21 if the beneficiary was adopted after reaching the age of 16 but prior to reaching the age of 18.

History

(1981, c. 275, s. 1; 1997-443, s. 12.10; 1999-190, s. 3; 2011-383, s. 1; 2015-241, s. 12C.9(b).)

Cross References. - As to rules on vendor payments, see 10 N.C.A.C. 70M.0401 et seq.

Foster Care and Adoption Assistance Payments. - Session Laws 2009-451, s. 10.45(a)-(f), provides: "The maximum rates for State participation in the foster care assistance program are established on a graduated scale as follows:

"(1) $475.00 per child per month for children aged birth through 5;

"(2) $581.00 per child per month for children aged 6 through 12; and

"(3) $634.00 per child per month for children aged 13 through 18.

"The maximum rates for the State adoption assistance program are established consistent with the foster care rates as follows:

"(1) $475.00 per child per month for children aged birth through 5;

"(2) $581.00 per child per month for children aged 6 through 12; and

"(3) $634.00 per child per month for children aged 13 through 18.

"In addition to providing board payments to foster and adoptive families of HIV-infected children, as prescribed in Section 23.28 of Chapter 324 of the 1995 Session Laws, any additional funds remaining that were appropriated for this purpose shall be used to provide medical training in avoiding HIV transmission in the home.

"The maximum rates for the State participation in HIV foster care and adoption assistance are established on a graduated scale as follows:

"(1) $800.00 per child per month with indeterminate HIV status;

"(2) $1,000 per child per month confirmed HIV-infected, asymptomatic;

"(3) $1,200 per child per month confirmed HIV-infected, symptomatic; and

"(4) $1,600 per child per month terminally ill with complex care needs.

"The State and a county participating in foster care and adoption assistance shall each contribute fifty percent (50%) of the nonfederal share of the cost of care for a child placed by a county department of social services or child placing agency in a family foster home or residential child care facility. A county shall be held harmless from contributing fifty percent (50%) of the nonfederal share of the cost for a child placed in a family foster home or residential child care facility under an agreement with that provider as of October 31, 2008, until the child leaves foster care or experiences a placement change.

"The Department of Health and Human Services may establish foster care and adoption assistance rates based on the United States Department of Agriculture (USDA) 'Expenditures on Children by Families' index subject to State appropriations for each fiscal year."

For prior similar provisions, see Session Laws 2007-3123, s. 10.29(a)-(g), as amended by Session Laws 2008-107, s. 10.

Editor's Note. - Session Laws 2009-451, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2009'."

Session Laws 2009-451, s. 28.5 is a severability clause.

Session Laws 2011-383, s. 1, effective June 27, 2011, was codified as subsection (d) of this section at the direction of the Revisor of Statutes.

Session Laws 2015-241, s. 12C.9( l ), made subsection (e) of this section, as added by Session Laws 2015-241, s. 12C.9(b), effective January 1, 2017.

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Effect of Amendments. - Session Laws 2015-241, s. 12C.9(b), effective January 1, 2017, added subsection (e).

§ 108A-49.1. Foster care and adoption assistance payment rates.

The maximum rates for State participation in the foster care assistance program are established on a graduated scale as follows:
1. $475.00 per child per month for children from birth through five years of age.
2. $581.00 per child per month for children six through 12 years of age.
3. $634.00 per child per month for children at least 13 but less than 21 years of age.
The maximum rates for the State adoption assistance program are established consistent with the foster care rates as follows:
1. $475.00 per child per month for children from birth through five years of age.
2. $581.00 per child per month for children six through 12 years of age.
3. $634.00 per child per month for children at least 13 but less than 21 years of age.
The maximum rates for the State participation in human immunodeficiency virus (HIV) foster care and adoption assistance are established on a graduated scale as follows:
1. $800.00 per child per month with indeterminate HIV status.
2. $1,000 per child per month with confirmed HIV infection, asymptomatic.
3. $1,200 per child per month with confirmed HIV infection, symptomatic.
4. $1,600 per child per month when the child is terminally ill with complex care needs.
The State and a county participating in foster care and adoption assistance shall each contribute fifty percent (50%) of the nonfederal share of the cost of care for a child placed by a county department of social services or child-placing agency in a family foster home or residential child care facility. A county shall be held harmless from contributing fifty percent (50%) of the nonfederal share of the cost for a child placed in a family foster home or residential child care facility under an agreement with that provider as of October 31, 2008, until the child leaves foster care or experiences a placement change.
A county shall be held harmless from contributing fifty percent (50%) of the nonfederal share of the cost for an individual receiving benefits pursuant to G.S. 108A-48(c).

In addition to providing board payments to foster and adoptive families of HIV-infected children, any additional funds remaining that are appropriated for purposes described in this subsection shall be used to provide medical training in avoiding HIV transmission in the home.

History

(2011-145, s. 10.51; 2015-241, s. 12C.9(c).)

Editor's Note. - Session Laws 2015-241, s. 12C.9( l ), made the amendments to this section by Session Laws 2015-241, s. 12C.9(c), effective January 1, 2017.

Session Laws 2015-241, s. 12C.4, provides: "Of the funds available for the provision of foster care services, the Department of Health and Human Services, Division of Social Services, may provide for the financial support of children who are deemed to be (i) in a permanent family placement setting, (ii) eligible for legal guardianship, and (iii) otherwise unlikely to receive permanency. No additional expenses shall be incurred beyond the funds budgeted for foster care for the Guardianship Assistance Program (GAP). The Division of Social Services shall design the Guardianship Assistance Program (GAP) to include provisions for extending guardianship services for individuals who have attained the age of 18 years and opt to continue to receive guardianship services until reaching 21 years of age if the individual is (i) completing secondary education or a program leading to an equivalent credential, (ii) enrolled in an institution that provides postsecondary or vocational education, (iii) participating in a program or activity designed to promote, or remove barriers to, employment, (iv) employed for at least 80 hours per month, or (v) incapable of completing the educational or employment requirements of this section due to a medical condition or disability. The Guardianship Assistance Program rates shall reimburse the legal guardian for room and board and be set at the same rate as the foster care room and board rates in accordance with rates established under G.S. 108A-49.1. The Social Services Board shall adopt rules establishing a Guardianship Assistance Program to implement this section, including defining the phrase 'legal guardian' as used in this section."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2017-57, s. 11C.4, provides: "Of the funds available for the provision of foster care services, the Department of Health and Human Services, Division of Social Services, may continue to provide for the financial support of children who are deemed to be (i) in a permanent family placement setting, (ii) eligible for legal guardianship, and (iii) otherwise unlikely to receive permanency. No additional expenses shall be incurred beyond the funds budgeted for foster care for the Guardianship Assistance Program (GAP). The Guardianship Assistance Program (GAP) shall include provisions for extending guardianship services for individuals who have attained the age of 18 years and opt to continue to receive guardianship services until reaching 21 years of age if the individual is (i) completing secondary education or a program leading to an equivalent credential, (ii) enrolled in an institution that provides postsecondary or vocational education, (iii) participating in a program or activity designed to promote, or remove barriers to, employment, (iv) employed for at least 80 hours per month, or (v) incapable of completing the educational or employment requirements of this section due to a medical condition or disability. The Guardianship Assistance Program rates shall reimburse the legal guardian for room and board and be set at the same rate as the foster care room and board rates in accordance with rates established under G.S. 108A-49.1."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Effect of Amendments. - Session Laws 2015-241, s. 12C.9(c), effective January 1, 2017, substituted "at least 13 but less than 21 years of age" for "13 through 18 years of age" at the end of subdivisions (a)(3) and (b)(3); and added subsection (e).

§ 108A-50. State benefits for certain adoptive children.

The Department is authorized to establish a program of State benefits for certain adoptive children from appropriations made by the General Assembly and from grants available from the federal government to the State. This program shall be used exclusively for the purpose of meeting the needs of adoptive children who are physically or mentally handicapped, older, or otherwise hard to place for adoption.
The purpose of this program is to encourage, within the limits of available funds, the adoption of certain hard-to-place children in order to make it possible for children living in, or likely to be placed in foster homes or institutions, to benefit from the stability and security of permanent homes where such children can receive continuous care, guidance, protection and love to reduce the number of such children who might be placed or remain in foster homes or institutions until they become adults.
Eligibility for an adoptive child to receive assistance shall be determined by the Department under the rules and regulations of the Social Services Commission.
Financial assistance under this program shall not be provided when the needed services are available free of cost to the adoptive child; or are covered by an insurance policy of the adoptive parents; or are available to the child under the Adoption Assistance Program specified in G.S. 108A-49.

History

(1975, c. 953, s. 3; 1981, c. 275, s. 1.)

§ 108A-50.1. Special Needs Adoptions Incentive Fund.

There is created a Special Needs Adoptions Incentive Fund to provide financial assistance to facilitate the adoption of certain children residing in licensed foster care homes. These funds shall be used to remove financial barriers to the adoption of these children and shall be available to foster care families who adopt children with special needs, as defined by the Social Services Commission. These funds shall be matched by county funds.
This program shall not constitute an entitlement and is subject to the availability of funds.
The Social Services Commission shall adopt rules to implement the provisions of this section.

History

(2003-284, s. 10.45.)

Editor's Note. - This section was enacted as G.S 108A-50A and was redesignated as G.S. 108A-50.1 at the direction of the Revisor of Statutes.

Session Laws 2000-67, s. 11.16, effective July 1, 2000, creates a Special Needs Adoptions Incentive Fund to provide financial assistance to facilitate the adoption of special needs children residing in licensed foster care homes, effective January 1, 2001. These funds are to be matched by county funds. This program does not constitute an entitlement and is subject to availability of funds. The Social Services Commission is to adopt rules to implement the provisions of this section.

Session Laws 2000-67, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2000.' "

§ 108A-50.2. Adoption Promotion Fund.

Funds appropriated by the General Assembly to the Department of Health and Human Services, Division of Social Services, for the Adoption Promotion Fund shall be used as provided in this section. The Division of Social Services of the Department of Health and Human Services, in consultation with the North Carolina Association of County Directors of Social Services and representatives of licensed private adoption agencies, shall develop guidelines for the awarding of funds to licensed public and private adoption agencies upon the adoption of children described in G.S. 108A-50 and in foster care. Payments received from the Adoption Promotion Fund by participating agencies shall be used exclusively to enhance the adoption services. No local match shall be required as a condition for receipt of these funds. In accordance with State rules for allowable costs, the Adoption Promotion Fund may be used for post-adoption services for families whose income exceeds two hundred percent (200%) of the federal poverty level.
Of the total funds appropriated for the Adoption Promotion Fund each year, twenty percent (20%) of the total funds available shall be reserved for payment to participating private adoption agencies. If the funds reserved in this subsection for payments to private agencies have not been spent on or before March 31 of each State fiscal year, the Division of Social Services may reallocate those funds, in accordance with this section, to other participating adoption agencies.
The Division of Social Services shall monitor the total expenditures in the Adoption Promotion Fund and redistribute unspent funds to ensure that the funds are used in accordance with the guidelines established in subsection (a) of this section.

History

(2009-451, s. 10.48; 2013-360, s. 12C.10(c).)

Effect of Amendments. - Session Laws 2013-360, s. 12C.10(c), effective July 1, 2013, substituted "Adoption Promotion" for "Special Children Adoption" throughout the section.

PART 5. FOOD AND NUTRITION SERVICES.

§ 108A-51. Authorization for Food and Nutrition Services.

The Department is authorized to establish a statewide food and nutrition services program as authorized by the Congress of the United States. The Department of Health and Human Services is designated as the State agency responsible for the supervision of the food and nutrition services program. The boards of county commissioners through the county departments of social services are held responsible for the administration and operation of the food and nutrition services program.

History

(1981, c. 275, s. 1; 1997-443, s. 11A.118(a); 2007-97, s. 9.)

Effect of Amendments. - Session Laws 2007-97, s. 9, effective June 20, 2007, substituted "Food and Nutrition Services" for "Food Stamp Program" in the section heading; substituted "and nutrition services" for "stamp" in the first sentence; substituted "the food and nutrition services program" for "such programs" in the second sentence; and substituted "food and nutrition services program" for "programs" in the third sentence.

§ 108A-51.1. Prohibition on certain waivers.

Except for waivers for the Disaster Supplemental Nutrition Assistance Program sought for an area that has received a Presidential disaster declaration of Individual Assistance from the Federal Emergency Management Agency, the Department shall not seek waivers to time limits established by federal law for food and nutrition benefits for able-bodied adults without dependents required to fulfill work requirements to qualify for those benefits.

History

(2015-294, s. 16(a).)

Editor's Note. - Session Laws 2015-294, s. 17, made this section effective October 1, 2015.

Session Laws 2015-294, s. 16(b), as amended by Session Laws 2015-264, s. 91.2, provides: "The Department of Health and Human Services shall withdraw any pending request for waivers to time limits established by federal law for food and nutrition benefits for able-bodied adults without dependents required to fulfill work requirements to qualify for those benefits submitted but not granted prior to the effective date of this section [October 1, 2015] unless the request can be amended so that the period covered by the waiver will not extend beyond March 1, 2016. If a pending waiver request is granted prior to the effective date of this section, the Department shall discontinue the waiver as of that effective date unless the waiver can be amended so that the period covered by the waiver will not extend beyond March 1, 2016. The Department shall not submit a new request for a waiver unless the period covered by the waiver will not extend beyond July 1, 2016. Nothing in this section shall be construed to require termination of a waiver in place as of September 1, 2015."

CASE NOTES

Cited in Williford v. N.C. HHS, 250 N.C. App. 491, 792 S.E.2d 843 (2016).

§ 108A-52. Determination of eligibility.

Any person who believes that he or another person is eligible to receive electronic food and nutrition benefits may apply for such assistance to the county department of social services in the county in which the applicant resides. The application shall be made in such form and shall contain such information as the Social Services Commission may require. Upon receipt of an application for electronic food and nutrition benefits, the county department of social services shall make a prompt evaluation or investigation of the facts alleged in the application in order to determine the applicant's eligibility for such assistance and to obtain such other information as the Department may require. Upon the completion of such investigation, the county department of social services shall, within a reasonable period of time, determine eligibility.

History

(1981, c. 275, s. 1; 2007-97, s. 10.)

Effect of Amendments. - Session Laws 2007-97, s. 10, effective June 20, 2007, substituted "electronic food and nutrition benefits" for "food stamps" twice in the section.

§ 108A-53. Fraudulent misrepresentation.

Any person, whether provider or recipient or person representing himself as such, who knowingly obtains or attempts to obtain, or aids or abets any person to obtain by means of making a willfully false statement or representation or by impersonation or by failing to disclose material facts or in any manner not authorized by this Part or the regulations issued pursuant thereto, transfers with intent to defraud any electronic food and nutrition benefit to which that person is not entitled in the amount of four hundred dollars ($400.00) or less shall be guilty of a Class 1 misdemeanor. Whoever knowingly obtains or attempts to obtain, or aids or abets any person to obtain by means of making a willfully false statement or representation or by impersonation or by failing to disclose material facts or in any manner not authorized by this Part or the regulations issued pursuant thereto, transfers with intent to defraud any electronic food and nutrition benefit to which he is not entitled in an amount more than four hundred dollars ($400.00) shall be guilty of a Class I felony.
Whoever presents, or causes to be presented, electronic food and nutrition benefits for payment or redemption, knowing the same to have been received, transferred, or used in any manner in violation of the provisions of this Part or the regulations issued pursuant to this Part shall be guilty of a Class 1 misdemeanor.
Whoever receives any electronic food and nutrition benefits for any consumable item knowing that such benefits were procured fraudulently under subsections (a) and/or (b) of this section shall be guilty of a Class 1 misdemeanor.
Whoever receives any electronic food and nutrition benefits for any consumable item whose exchange is prohibited by the United States Department of Agriculture shall be guilty of a Class 1 misdemeanor.

History

(1981, c. 275, s. 1; 1991, c. 523, s. 5; 1993, c. 539, ss. 814, 1299; 1994, Ex. Sess., c. 24, s. 14(c); 1995, c. 507, s. 19.5(n); 1996, 2nd Ex. Sess., c. 18, s. 24.31(a); 2007-97, s. 11; 2008-187, s. 18.)

Effect of Amendments. - Session Laws 2007-97, s. 11, effective June 20, 2007 in subsection (a), substituted "electronic food and nutrition benefit" for "food stamps or authorization cards" in the first sentence, and substituted "electronic and nutrition benefit" for "food stamps or authorization cards" in the second sentence; substituted "electronic food and nutrition benefits" for "food stamps or authorization cards" in subsection (b); substituted "electronic food and nutrition benefits" for "food stamps" in subsections (c) and (d), and substituted "benefits" for "food stamps" in subsection (c).

Session Laws 2008-187, s. 18, effective August 7, 2008, inserted "food" following "defraud any electronic" in subsection (a).

CASE NOTES

Successive Acts of Misrepresentation. - Amounts that defendant received after making false statements could be combined to reach the felony threshold of "more than four hundred dollars ($400.00) (now $2,000)," where defendant's successive acts of misrepresentation were in essence a continuing act to reach her desired result: obtain food stamps in an amount for which she would not have been otherwise qualified. State v. Williams, 101 N.C. App. 412, 399 S.E.2d 348 (1991).

Evidence Sufficient. - Evidence defendant aided or abetted his wife in obtaining food benefits by providing his employer's letterhead to create a fraudulent letter from defendant's employer regarding his income, and that defendant faxed a falsified wage form to a supervisor at the Department of Social Services was sufficient to support defendant's conviction for food stamp fraud. State v. Davis, 230 N.C. App. 50, 748 S.E.2d 189 (2013).

Cited in State v. Wells, 78 N.C. App. 769, 338 S.E.2d 573 (1986).

§ 108A-53.1. Illegal possession or use of electronic food and nutrition benefits.

Any person who knowingly buys, sells, distributes, or possesses with the intent to sell, or distribute electronic food and nutrition benefits or access devices in any manner contrary to that authorized by this Part or the regulations issued pursuant thereto shall be guilty of a Class H felony.
Any person who knowingly uses, transfers, acquires, alters, or possesses electronic food and nutrition benefits or access devices in any manner contrary to that authorized by this Part or the regulations issued pursuant thereto, other than as set forth in subsection (a) of this section, shall be guilty of a Class 1 misdemeanor if the value of such electronic food and nutrition benefits or access devices is less than one hundred dollars ($100.00), or a Class A1 misdemeanor if the value of such electronic food and nutrition benefits or access devices is equal to at least one hundred dollars ($100.00) but less than five hundred dollars ($500.00), or a Class I felony if the value of such electronic food and nutrition benefits or access devices is equal to at least five hundred dollars ($500.00) but less than one thousand dollars ($1,000), or a Class H felony if the value of such electronic food and nutrition benefits or access devices equals or exceeds one thousand dollars ($1,000).

History

(1997-497, s. 2; 2007-97, s. 12.)

Effect of Amendments. - Session Laws 2007-97, s. 12, effective June 20, 2007, substituted "electronic food and nutrition benefits" for "food stamps" in the section heading and substituted "electronic food and nutrition benefits" for "food stamp coupons, authorization cards" throughout this section.

PART 6. MEDICAL ASSISTANCE PROGRAM.

§ 108A-54. Authorization of Medical Assistance Program; administration.

The Department is authorized to establish a Medicaid Program in accordance with Title XIX of the federal Social Security Act. The Department may adopt rules to implement the Program. The State is responsible for the nonfederal share of the costs of medical services provided under the Program. In addition, the State shall pay one hundred percent (100%) of the federal Medicare Part D clawback payments under the Medicare Modernization Act of 2004, P.L. 108-173, as amended. A county is responsible for the county's cost of administering the Program in that county.
Recodified as G.S. 108A-54.1B(a) by Session Laws 2013-360, s. 12H.9(a), effective July 1, 2013.
The Medicaid Program shall be administered and operated in accordance with this Part and the North Carolina Medicaid State Plan and Waivers, as periodically amended by the Department of Health and Human Services in accordance with G.S. 108A-54.1A and approved by the federal government.
The Department of Health and Human Services shall ensure that the North Carolina Families Accessing Services through Technology (NC FAST) information technology system can provide Medicaid eligibility determinations for the federally facilitated Health Benefit Exchange that will operate in North Carolina and shall provide such determinations for the Exchange.
The Department of Health and Human Services shall continue to administer and operate the Medicaid and NC Health Choice programs through the Division of Medical Assistance until the Division of Medical Assistance is eliminated at which time all functions, powers, duties, obligations, and services vested in the Division of Medical Assistance are vested in the Division of Health Benefits. Prior to and following the exchange of powers and duties from the Division of Medical Assistance to the Division of Health Benefits, and in addition to the powers and duties already vested in the Secretary of the Department of Health and Human Services, the Secretary of the Department of Health and Human Services shall have the following powers and duties:
1. Administer and operate the Medicaid and NC Health Choice programs, provided that the total expenditures, net of agency receipts, do not exceed the authorized budget for the Medicaid program and NC Health Choice program. None of the powers and duties enumerated in the other subdivisions of this subsection shall be construed to limit the broad grant of authority to administer and operate the Medicaid and NC Health Choice programs.
2. Employ clerical and professional staff of the Division of Health Benefits, including consultants and legal counsel, necessary to carry out the powers and duties of the division. In hiring staff for the Division of Health Benefits, the Secretary may offer employment contracts for a term and set compensation for the employees, which may include performance-based bonuses based on meeting budget or other targets.
3. Notwithstanding G.S. 143-64.20, enter into contracts for the administration of the Medicaid and NC Health Choice programs, as well as manage such contracts, including contracts of a consulting or advisory nature.
4. Establish and adjust all program components, except for eligibility categories, resource limits, and income thresholds, of the Medicaid and NC Health Choice programs within the appropriated and allocated budget.
5. Adopt rules related to the Medicaid and NC Health Choice programs.
6. Develop midyear budget correction plans and strategies and then take midyear budget corrective actions necessary to keep the Medicaid and NC Health Choice programs within budget.
7. Approve or disapprove and oversee all expenditures to be charged to or allocated to the Medicaid and NC Health Choice programs by other State departments or agencies.
8. Develop and present to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Office of State Budget and Management by January 1 of each year, beginning in 2017, the following information for the Medicaid and NC Health Choice programs:
  1. A detailed four-year forecast of expected changes to enrollment growth and enrollment mix.
  2. What program changes will be made by the Department in order to stay within the existing budget for the programs based on the next fiscal year's forecasted enrollment growth and enrollment mix.
  3. The cost to maintain the current level of services based on the next fiscal year's forecasted enrollment growth and enrollment mix.
9. Publish on its Web site and update on at least a monthly basis, at a minimum, the following information about the Medicaid and NC Health Choice programs:
  1. Enrollment by program aid category by county.
  2. Per member per month spending by category of service.
  3. Spending and receipts by fund along with a detailed variance analysis.
  4. A comparison of the above figures to the amounts forecasted and budgeted for the corresponding time period.
The General Assembly shall determine the eligibility categories, resource limits, and income thresholds for the Medicaid and NC Health Choice programs. The Department of Health and Human Services is expressly authorized to adopt temporary and permanent rules regarding eligibility requirements and determinations, to the extent that they do not conflict with the parameters set by the General Assembly.
Repealed by Session Laws 2016-121, s. 2(h), effective June 1, 2016.
Repealed by Session Laws 2017-57, s. 11F.16, effective July 1, 2017.
1. An analysis of claims payments prior to the implementation compared to post implementation by major provider category that identifies any variations in claims payment levels.
2. For variations attributable to the implementation of ICD-10, the report shall include corrective actions and communications that resulted from the identification of the variation.
3. An update on hardship advances made to providers for payment issues arising for the implementation of ICD-10 that specifies the total amount advanced and the total amount recovered to date listed by provider."

History

(1965, c. 1173, s. 1; 1969, c. 546, s. 1; 1973, c. 476, s. 138; 1977, 2nd Sess., c. 1219, s. 24; 1981, c. 275, s. 1.; 2007-323, s. 31.16.1(c); 2008-107, s. 10.10(c); 2011-399, s. 5; 2012-75, s. 1; 2013-5, s. 2; 2013-360, ss. 12H.3, 12H.9(a); 2013-363, s. 4.9(a); 2015-245, s. 13; 2016-94, s. 12H.4; 2016-121, s. 2(h); 2018-5, s. 11H.10(a), (b).)

Cross References. - As to Medicaid and Health Choice provider requirements, see Chapter 108C, G.S. 108C-1 et seq.

As to billing Medicaid for the cost of public health program services by local health departments, district health departments, and consolidated human services agencies, see G.S. 130A-34.2.

As to Medicaid appeals, see Part 6A (G.S. 108A-70.9A et seq.).

As to actions by the Secretary to ensure effective management of behavioral health services under the 1915(b)/(c) Medicaid Waiver, see G.S. 122C-124.2.

Medical Coverage Policy Under State Medicaid Program. - Session Laws 2001-424, s. 21.20(a) provides: "(a) In order to promote consistency among providers and to ensure that medical coverage criteria are uniformly applied to Medicaid recipients throughout the State, the Department of Health and Human Services shall adopt medical coverage policies for the State Medicaid Program that are consistent with national standards or Department-defined standards. If the Department determines that application of a national standard would likely cause significant deterioration in the quality of or access to appropriate medical care, then the Department shall substitute for that national standard an evidence-based, best-practice standard that will not compromise quality of or access to appropriate medical care. The adoption of new or amended medical coverage policies under the State Medicaid Program are exempt from the rule-making requirements of Chapter 150B of the General Statutes."

Session Laws 2001-424, s. 21.20(b) sets out criteria for the development, amendment and adoption of medical coverage policy.

Pilot Program/Increase Access to Public Benefits for Older Dual Eligible Seniors. - Session Laws 2016-94, s. 12C.3(a)-(c), provides: "(a) The Department of Health and Human Services, Division of Social Services (Division), shall establish an evidence-based pilot program to increase access to public benefits for seniors aged 65 and older who are dually enrolled in Medicare and Medicaid to (i) improve the health and independence of seniors and (ii) reduce health care costs. On or before January 1, 2017, the Division shall partner with a not-for-profit firm for the purposes of engaging in a data-driven campaign to help seniors aged 65 and older who are dually enrolled in Medicare and Medicaid meet their basic social needs. The not-for-profit firm shall have demonstrated experience in assisting with these types of services and the partnership shall accomplish each of the following:

"(1) Identify through data sharing, dual eligible seniors aged 65 and older who qualify for the Supplemental Nutrition and Assistance Program (SNAP) but are not currently enrolled.

"(2) Conduct an outreach program towards those seniors for the purpose of enrolling them into SNAP.

"(3) Provide comprehensive application assistance through outreach specialists to complete public benefits application processes.

"(4) Evaluate project effectiveness and explore how data can be utilized to achieve optimal outcomes.

"(5) Make recommendations regarding policy options available to the State to streamline access to benefits.

"(b) The Division of Social Services shall report to the Office of the Governor and the Joint Legislative Oversight Committee on Health and Human Services on its progress in the pilot program by February 1 following each year the pilot program is in place. The report shall, at a minimum, include the following:

"(1) The number of seniors age 65 and older who are dual eligibles but are not enrolled in SNAP.

"(2) The number of those identified that would be included in the sample population.

"(3) Methods of outreach toward those seniors in the sample population.

"(4) Number of to date enrollments in SNAP as a direct result of outreach during the pilot program.

"(5) Participation rate to date in SNAP of those seniors in the sample population.

"(6) Any other findings the Division deems relevant.

"(c) If funding and capacity exist, the Division of Social Services may expand the pilot program to include other public benefits programs."

Session Laws 2017-57, s. 11C.8(a)-(c), provides: "(a) The Department of Health and Human Services, Division of Social Services (Division), shall continue implementing an evidence-based pilot program to increase access to public benefits for seniors aged 65 and older who are dually enrolled in Medicare and Medicaid to (i) improve the health and independence of seniors and (ii) reduce health care costs. The Division shall continue to partner with a not-for-profit firm for the purposes of engaging in a data-driven campaign to help seniors aged 65 and older who are dually enrolled in Medicare and Medicaid meet their basic social needs. The not-for-profit firm shall have demonstrated experience in assisting with these types of services and the partnership shall accomplish each of the following:

"(1) Identify, through data sharing, dual eligible seniors aged 65 and older who qualify for the Supplemental Nutrition and Assistance Program (SNAP) but are not currently enrolled.

"(2) Conduct an outreach program toward those seniors for the purpose of enrolling them into SNAP.

"(3) Provide comprehensive application assistance through outreach specialists to complete public benefits application processes.

"(4) Evaluate project effectiveness and explore how data can be utilized to achieve optimal outcomes.

"(5) Make recommendations regarding policy options available to the State to streamline access to benefits.

"(b) The Division shall report to the Office of the Governor and the Joint Legislative Oversight Committee on Health and Human Services on its progress in the pilot program by February 1 following each year the pilot program is in place. The report shall, at a minimum, include the following:

"(1) The number of seniors age 65 and older who are dual eligibles but are not enrolled in SNAP.

"(2) The number of those identified that would be included in the sample population.

"(3) Methods of outreach toward those seniors in the sample population.

"(4) Number of to date enrollments in SNAP as a direct result of outreach during the pilot program.

"(5) Participation rate to date in SNAP of those seniors in the sample population.

"(6) Any other findings the Division deems relevant.

"(c) Any nonrecurring funds remaining in the 2016-2017 fiscal year from implementation of the pilot program under this section shall not revert, but shall remain available for continued implementation of the pilot program, along with any private or nonprofit funding provided to the Division for use in the pilot program. If funding and capacity exist, the Division of Social Services may expand the pilot program to include other public benefits programs."

Use of AIDS Drug Assistance Program (ADAP) Funds to Purchase Health Insurance. - Session Laws 2016-94, s. 12E.1(a), (b), provides: "(a) The Department of Health and Human Services, Division of Public Health, shall create within the North Carolina AIDS Drug Assistance Program (ADAP) a health insurance premium assistance program that utilizes federal funds from Part B of the Ryan White HIV/AIDS Program and ADAP funds to provide eligible beneficiaries with premium and cost-sharing assistance for the purchase or maintenance of private health insurance coverage, including premiums, co-payments, and deductibles. In creating this program, the Department shall ensure full compliance with federal Health Resources and Services Administration (HRSA) guidance, including the methodology used to do all of the following:

"(1) Assess and compare the cost of providing prescription drugs to eligible beneficiaries through the health insurance premium assistance program created pursuant to this section versus the existing ADAP program.

"(2) Ensure that insurance premium assistance program funds are used solely to pay for premium and cost-sharing assistance for the purchase or maintenance of private health insurance coverage that provides, at a minimum, prescription coverage equivalent to the formulary available under Part B of the Ryan White HIV/AIDS Program.

"(3) Limit the total annual amount of funds expended for the health insurance premium assistance program authorized by this section to no more than the total annual cost of maintaining the same individuals on the existing ADAP Program.

"(b) By March 1, 2017, the Department shall submit a report to the House Appropriations Committee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division on the operation of the program authorized by subsection (a) of this section, including any obstacles to implementation."

Session Laws 2017-57, s. 11E.8(a), (b), provides: "(a) The Department of Health and Human Services, Division of Public Health, shall continue to implement within the North Carolina AIDS Drug Assistance Program (ADAP) a health insurance premium assistance program that (i) is cost neutral or achieves savings; (ii) utilizes federal funds from Part B of the Ryan White HIV/AIDS Program and ADAP funds to provide individual ADAP participants or subsets of ADAP participants with premium and cost-sharing assistance for the purchase or maintenance of private health insurance coverage, including premiums, co-payments, and deductibles; and (iii) meets the requirements of Section 12E.1 of S.L. 2016-94.

"(b) By March 1, 2018, the Department shall submit a report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division on implementation of the health insurance premium assistance program authorized by subsection (a) of this section. The report must include at least all of the following components:

"(1) A detailed explanation of the program design.

"(2) A demonstration of cost neutrality, which shall include a comparison of the cost of providing prescription drugs to eligible beneficiaries through the health insurance premium program created pursuant to subsection (a) of this section and the cost of providing prescription drugs to eligible beneficiaries through the existing ADAP program.

"(3) Information on health outcomes of program participants.

"(4) Any obstacles to program implementation."

County Medicaid Cost-Share. - Session Laws 2000-67, s. 11.6(a), provides: "Of the funds appropriated in this act to the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services for the 1999-2000 fiscal year, the Department shall transfer to the Mental Health Restricted Reserve not more than the amount of actual expenditures for Medicaid payments for the 1998-99 fiscal year for services provided by area mental health authorities. The Department shall transfer from the Division of Medical Assistance the estimated amount needed to match Medicaid payments for the former Carolina Alternatives Programs. The Department shall not transfer from area program allocations funds to cover Medicaid payment expenditures that exceed the amount of funds in the Reserve for the 1999-2000 fiscal year."

Session Laws 2000-67, s. 11.6(c), provides: "Effective July 1, 2000, the county share of the cost of Medicaid Personal Care Services paid to adult care homes shall be decreased incrementally each fiscal year until the county share reaches fifteen percent (15%) of the nonfederal share by State fiscal year 2009-2010."

Pilot Program to Test New Approaches to Managing Access to and Utilization of Health Care Service to Medicaid Recipients. - Session Laws 2004-124, s. 10.11 provides: "The Department of Health and Human Services shall establish and implement two or more pilot programs to test new approaches to management of access to and utilization of health care services to Medicaid recipients. The purpose of the pilot programs is to determine if additional cost savings can be achieved in addition to that provided by the Community Care of North Carolina program. With respect to at least two of the pilot programs, the Department shall contract with a physician-owned and managed network that has demonstrated success in improving the cost-effectiveness of Medicaid services in at least one state other than North Carolina. The Department shall develop a payment methodology that may include sharing savings with contractors providing medical management services but the methodology shall not allow increased spending relative to current appropriations. The Department may apply for federal waivers necessary to implement this section. The Department shall report on the implementation of the pilot programs to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division not later than February 1, 2005."

PACE Pilot Program Funds. - Session Laws 2004-124, s. 10.12(a) - (d) provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall develop a pilot program to implement the Program for All-Inclusive Care for the Elderly (PACE). One pilot site shall be planned for the southeastern area of the State and the other pilot site shall be planned for the western area of the State. The Division shall design the pilot program to access federal Medicaid and Medicare dollars to provide acute and long-term care services for older patients through the use of interdisciplinary teams. When implemented, services provided through the PACE pilot program may include physician visits, drugs, rehabilitation services, personal care services, hospitalization, and nursing home care. The PACE pilot program may also offer social services intervention, case management, respite care, or extended home care nursing.

"(b) Of the funds appropriated to the Department of Health and Human Services, Division of Medical Assistance, for the 2004-2005 fiscal year, the sum of one hundred twenty-three thousand one hundred fifty-six dollars ($123,156) shall be used to support two positions in the Division of Medical Assistance to develop the pilot programs in accordance with subsection (a) of this section. These funds may also be used to contract for actuarial analysis as part of the development of the pilot programs.

"(c) The Department of Health and Human Services shall report to the House of Representatives Appropriations Subcommittee on Health and Human Services and the Senate Appropriations Committee on Health and Human Services on March 1, 2005, on PACE pilot program development. The report shall include services proposed to be offered under the pilot program, administrative structure of the pilot program, number of Medicare and Medicaid eligible recipients anticipated to receive services from the PACE pilot sites, and the projected savings to the State from PACE pilot program implementation.

"(d) Nothing in this section obligates the General Assembly to appropriate funds to implement the PACE program statewide."

Report on PACE Program. - Session Laws 2014-100, s. 12H.34(a), (b), provides: "(a) By October 1, 2014, the Department of Health and Human Services, Division of Medical Assistance, shall report to the Joint Legislative Oversight Committee on Health and Human Services with the following information on the Program of All-Inclusive Care for the Elderly (PACE):

"(1) The number of individuals being served in each of the PACE service areas.

"(2) A description of the program enrollment criteria and enrollment process.

"(3) Detailed figures showing how funding for the program has been spent during the past two fiscal years.

"(4) The per member per month cost of serving individuals through the PACE program compared to the cost of serving individuals in a nursing home.

"(5) An estimate of how many PACE participants would enter a nursing home if they were not enrolled with the PACE program.

"(b) By January 1, 2015, the Department of Health and Human Services, Division of Medical Assistance, shall submit an additional report to the Joint Legislative Oversight Committee on Health and Human Services with the following information on the Program of All-Inclusive Care for the Elderly (PACE):

"(1) An update on all of the information required by subsection (a) of this section.

"(2) A comparison of North Carolina's PACE program to PACE programs in other states.

"(3) Recommendations for how to make the program sustainable."

Session Laws 2017-57, s. 11H.25(a), (b), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance (Department), shall conduct a study of the efficacy of the Program of All-Inclusive Care for the Elderly (PACE). In conducting the study, the Department shall engage a variety of stakeholders, including existing PACE organizations, PACE consumers, and the general public. The study shall consist of the following:

"(1) An evaluation of the existing program to include information on and an assessment of the following:

"a. An update on all of the information required to be reported on under Section 12H.34(b) of S.L. 2014-100.

"b. The structures of the various PACE organizations.

"c. Any clinical outcome or quality measures available for each PACE service or PACE organization.

"(2) A statewide assessment of anticipated long-term care needs over the next 10 years, broken down by county.

"(3) A review of PACE experiences in other states, including an analysis of costs and quality.

"(4) An evaluation of State regulations placed upon PACE providers. The study shall include the identification of any regulations that could be eliminated in order to reduce cost or unnecessary duplication.

"(5) An assessment of the role of PACE in the continuum of care, including opportunities to apply the PACE model to additional populations under the PACE Innovations Act of 2015, P.L. 114-85.

"(b) No later than March 1, 2018, the Department shall submit to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice a report containing the information outlined in subsection (a) of this section, as well as any recommendations and proposed legislative changes that further the goal of providing the highest quality programs at a low cost to keep aging individuals in their homes."

Expansion of Community Care of NC Care Management Model. - Session Laws 2007-323, s. 10.46, provides: "(a) The Department of Health and Human Services shall continue its efforts to expand the scope of Community Care of NC care management model to recipients of Medicaid and dually eligible individuals with a chronic condition and long-term care needs. In expanding the scope, the Department shall focus on the Aged, Blind, and Disabled, and CAP-DA populations for improvement in management, cost-effectiveness, and local coordination of services through Community Care of NC and in collaboration with local providers of care. The Department shall target personal care services, private duty nursing, home health, durable medical equipment, ancillary professional services, specialty care, residential services, including skilled nursing facilities, home infusion therapy, pharmacy, and other services determined target-worthy by the Department. The Department shall pilot communitywide initiatives and shall expand statewide successful models. The initiatives may include one or more pilot projects to control costs and improve quality of care for the Aged, Blind, and Disabled recipients of Medicaid.

"(b) The Department of Health and Human Services shall report not later than March 1, 2008, on the status of the implementation and findings of this pilot project with regard to improving the quality of care and controlling the cost of care for the Aged, Blind, and Disabled recipients of Medicaid. The report shall also address the Department's plans for expanding the pilot project and implementing the practices for all Aged, Blind, and Disabled Medicaid recipients in the State. The Department shall submit the report to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division."

For a prior provision similar to G.S. 108A-54, see S.L. 2005-276, s. 10.17(a)-(e).

North Carolina Long-Term Care Partnership Program. - Session Laws 2006-66, s. 10.10, provides: "The Department of Health and Human Services shall, pursuant to authority under section 1917(b) of the Social Security Act (42 USC § 1396p(c)), as amended by Public Law 109-171 effective January 1, 2007, develop a North Carolina Long-Term Care Partnership Program. The purpose of the Program is to reduce future Medicaid costs for long-term care by delaying or eliminating dependence on Medicaid. The Department shall structure and administer the Program in accordance with applicable federal law and guidelines for qualified State long-term care partnerships. The Program, including the treatment of assets for Medicaid eligibility and estate recovery, notwithstanding statutory provisions on treatment of assets and estate recovery to the contrary, shall offer incentives to individuals to ensure against the substantial costs of providing for their long-term care needs. The Department shall submit the proposed Program to the Senate Appropriations Committee on Health and Human Services, the House of Representative Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division prior to submitting the Program for federal approval of the necessary State Plan amendment. The Program shall not become effective until reviewed in accordance with this section.

Pilot Program/Medicaid Dual Eligible Special Needs Plan. - Session Laws 2007-323, s. 10.40F, provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall evaluate and establish a pilot program in at least two but not more than four regions of the State to offer nursing facility certifiable (NFC) dual eligible Medicaid recipients services through a Special Needs Plan (SNP). The SNP will work with the Department's Community Care Networks. The SNP must be currently licensed in the State, have expertise in managing NFC dually eligible Medicaid recipients, have expertise or a relationship with experts in geriatrics and be capable and willing to work directly with Community Care North Carolina (CCNC). The SNP must also have no citations or ongoing investigations from the State, the Centers for Medicaid and Medicare Services, or other regulatory agency.

"(b) In establishing the pilot program, the Department shall select up to four regions (county clusters) based on the number of NFC dual eligible Medicaid recipients, number of skilled nursing facilities, and other factors. These regions and their respective CCNC will work with the SNP to promote enhanced care, greater efficiency, and cost savings.

"(c) The Department shall report on the evaluation, selection, and implementation of the pilot program to the Senate Appropriations Committee on Health and Human Services, the House of Representatives Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division not later than May 1, 2008. The Department shall include in its report information on increased primary care visits, hospital admission and readmission rates, mortality rates, results of pharmacy management, measurable quality outcomes, and associated cost savings for NFC managed through this pilot. The Department shall also include in its report the feasibility of expansion of the pilot to other regions of the State or expansion into the assisted living and home-based populations."

Smart Card Pilot Program. - Session Laws 2012-142, s. 10.9(b)-(j), provides: "(b) The Department of Health and Human Services shall implement a smart card pilot program that involves enrollment, distribution, and use of smart cards by designated vendors and recipients as replacements for currently used Medicaid assistance cards. The Provider and Recipient Services Unit of the Division of Medical Assistance (DMA) shall administer the pilot program. The Department may contract with a third-party vendor or vendors to develop and execute the pilot program. If the Department elects to use a third-party vendor or vendors to develop and execute the pilot program, the Department shall select the vendor or vendors through a Request for Proposal process conducted prior to implementation of the pilot program. In developing and implementing the pilot program, the Department shall comply with all applicable information technology procurement requirements. The smart card pilot program shall not expand beyond the areas described in subsection (c) of this section unless the expansion is approved by an act of the General Assembly.

"(c) The purpose of the pilot program is to evaluate the feasibility of the smart card program in different geographical regions of the State. DMA shall select a region of the State to participate in the pilot program that is served by Community Care of North Carolina and meets all other requirements set forth in this section. The pilot program shall be conducted in two urban areas and two rural areas with a representative group of Medicaid recipients from each area.

"(d) The pilot program shall include and evaluate the use of at least two different types of available technology that are designed to do all of the following:

"(1) Authenticate recipients at the onset and completion of each point of transaction in order to prevent card sharing and other forms of fraud.

"(2) Deny ineligible persons at the point of transaction.

"(3) Authenticate providers at the point of transaction to prevent phantom billing and other forms of provider fraud.

"(4) Secure and protect the personal identity and information of recipients.

"(5) Reduce the total amount of medical assistance expenditures by reducing the average cost per recipient.

"(e) The pilot program may include all of the following:

"(1) A secure Web-based information system for recording and reporting authenticated transactions.

"(2) A secure Web-based information system that interfaces with the appropriate State databases to determine eligibility of recipients.

"(3) A system that gathers analytical information to be provided to business intelligence companies in order to assist in business intelligence processes.

"(4) A smart card with the ability to store multiple recipients' information on one card.

"(5) An image of the recipient stored on both the smart card and database.

"(f) The pilot program shall not include a requirement for preenrollment of recipients.

"(g) In conducting the pilot program, the Department may do any of the following:

"(1) Incorporate additional or alternative methods of authentication of recipients.

"(2) Enter and store billing codes, deductible amounts, and bill confirmations.

"(3) Allow electronic prescribing services and prescription database integration and tracking in order to prevent medical error through information sharing and to reduce pharmaceutical abuse and lower health care costs.

"(4) Implement quick-pay incentives for providers who use electronic prescribing services, electronic health records, electronic patient records, or computerized patient records that automatically synchronize with recipients' smart cards and electronically submit a claim.

"(5) Adapt smart cards, fingerprint scanners, and card readers for use by other State programs administered by the Department in order to reduce costs associated with the necessity of multiple cards per recipient.

"(h) During the pilot program, the Department shall evaluate the feasibility of expanding the pilot program, including the need to develop rules and policies related to all of the following:

"(1) Lost, forgotten, or stolen cards.

"(2) Enrollment of all recipients, regardless of age, for participation in the program.

"(3) Distribution and activation of smart cards for designated recipients.

"(i) The Department shall work with the Division of Motor Vehicles to ensure that State data, such as drivers license photos and other identification data, is leveraged to reduce program cost.

"(j) By no later than March 1, 2013, the Department shall submit a detailed written report to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Senate Committee on Health and Human Services, the House Appropriations Subcommittee on Health and Human Services, and the Fiscal Research Division. The report shall include (i) detailed results of the pilot in the four different geographic regions of the State, including cost savings achieved in each region; (ii) costs associated with implementation of the pilot program, including payments to vendors; and (iii) an evaluation of the feasibility of, and issues associated with, implementing the smart card program statewide."

Similar provisions contained in Session Laws 2011-117, ss. 1-6, were repealed by Session Laws 2012-142, s. 10.9(a).

Community Care of North Carolina. - Session Laws 2009-451, s. 10.36(f)-(k), as added by Session Laws 2010-31, s. 10.15, provide: "(f) The Department of Health and Human Services (Department) shall conduct a Request for Proposal process to solicit bids from qualified outside entities with proven experience in conducting actuarial and health care studies and evaluations to annually report on the Medicaid cost savings achieved by the Community Care of North Carolina (CCNC) networks during a 12-month period. Beginning March 1, 2011, and every year thereafter, the Department shall submit a report on the Medicaid cost savings achieved by the CCNC networks, which shall include children, adults, and the aged, blind, and disabled, to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division.

"(g) By October 1, 2010, the Department and the Division of Medical Assistance (DMA) shall contract with North Carolina Community Care Networks, Inc., (NCCCN, Inc.) and the 14 participating local CCNC networks represented by NCCCN, Inc., to provide standardized clinical and budgetary coordination, oversight, and reporting for a statewide Enhanced Primary Care Case Management System for Medicaid enrollees. The contract with NCCCN, Inc., shall build upon and expand the existing successful CCNC primary care case management model to include comprehensive statewide quantitative performance goals and deliverables which shall include all of the following areas: (i) service utilization management, (ii) budget analytics, (iii) budget forecasting methodologies, (iv) quality of care analytics, (v) participant access measures, and (vi) predictable cost containment methodologies.

"(h) NCCCN, Inc., shall report quarterly to the Department and to the Office of State Budget and Management (OSBM) on the development of the statewide Enhanced Primary Care Case Management System and its defined goals and deliverables as agreed upon in the contract. Beginning July 1, 2010, NCCCN, Inc., shall submit a quarterly report to the Secretary of Health and Human Services, OSBM, the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division on the progress and results of implementing the quantitative, analytical, utilization, quality, cost containment, and access goals and deliverables set out in the contract. NCCCN, Inc., shall conduct its own analysis of the CCNC system to identify any variations from the development plan for the Enhanced Primary Care Case Management System and its defined goals and deliverables set out in the contract between DMA and NCCCN, Inc. Upon identifying any variations, NCCCN, Inc., shall develop and implement a plan to address the variations. NCCCN, Inc., shall report the plan to DMA within 30 days after taking any action to implement the plan.

"(i) By January 1, 2012, the Department and OSBM shall assess the performance of NCCCN, Inc., and CCNC regarding the goals and deliverables established in the contract. Based on this assessment, the Department and DMA shall expand, cancel, or alter the contract with NCCCN, Inc., and CCNC effective April 1, 2012. Expansion or alteration of the contract may reflect refinements based on clearly identified goals and deliverables in the areas of quality of care, participant access, cost containment, and service delivery.

"(j) By July 1, 2012, the Department, DMA, and NCCCN, Inc., shall finalize a comprehensive plan that establishes management methodologies which include all of the following: (i) quality of care measures, (ii) utilization measures, (iii) recipient access measures, (iv) performance incentive models in which past experience indicates a benefit from financial incentives, (v) accountable budget models, (vi) shared savings budget models, and (vii) budget forecasting analytics as agreed upon by the Department, DMA, and NCCCN, Inc. In the development of these methodologies, the Department, DMA, and NCCCN, Inc., shall consider options for shared risk. The Department and DMA shall provide assistance to NCCCN, Inc., in meeting the objectives of this section.

"(k) Beginning with the 2010-2011 fiscal year, the Department shall establish a separate line item in Budget Code 14445 for all expenditures in DMA associated with managed care activities pertaining to the utilization of Medicaid expenditures through CCNC."

Implementation of Medicaid Management Information System (MMIS). - Session Laws 2009-451, s. 10.41(b) and (d)-(f) provides: "(b) The Department shall make full development of the replacement MMIS a top priority. During the development and implementation of MMIS, the Department shall develop plans to ensure the timely and effective implementation of enhancements to the system to provide the following capabilities:

"(1) Receiving and tracking premiums or other payments required by law.

"(2) Compatibility with the administration of the Health Information System.

"The Department shall make every effort to expedite the implementation of the enhancements. The Office of Information Technology Services shall work in cooperation with the Department to ensure the timely and effective implementation of the MMIS and enhancements. The contract between the Department and the contract vendor shall contain an explicit provision requiring that the MMIS have the capability to fully implement the administration of NC Health Choice, NC Kids' Care, Ticket to Work, Families Pay Part of the Cost of Services under the CAP MR/DD, CAP Children's Program, and all relevant Medicaid waivers and the Medicare 646 waiver as it applies to Medicaid eligibles. The Department must have detailed cost information for each requirement before signing the contract. Any contract between the Department and a vendor for the MMIS that does not contain the explicit provision required under this subsection is void on its face. Notwithstanding any other provision of law to the contrary, the Secretary of the Department does not have the authority to sign a contract for the MMIS if the contract does not contain the explicit provision required under this section.

"(d) The Department shall develop a comprehensive schedule for the development and implementation of the MMIS that fully incorporates federal and State project management and review requirements. The Department shall ensure that the schedule is as accurate as possible. Any changes to the design, development, and implementation schedule shall be reported as part of the Department's quarterly MMIS reporting requirements. The Department shall submit the schedule to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division. Any change to key milestones in either schedule shall be immediately reported to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division with a full explanation of the reason for the change.

"(e) Beginning July 1, 2009, the Department shall make quarterly reports on changes in the functionality and projected costs of the MMIS. The first quarterly submission shall contain a final report on the contract award to include total costs and functionality of the MMIS. Each report shall be made to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division. A copy of the final report on the contract award also shall be submitted to the Joint Legislative Commission on Governmental Operations.

"(f) Upon initiation of the NC MMIS Program Reporting and Analytics Project and the Division of Health Services Regulation Project, the Department shall submit all reports regarding functionality, schedule, and cost in the next regular cycle of reporting identified in subsections (d) and (e) of this section. The Department shall ensure that the solution developed in the Reporting and Analytics Project supports the capability, in its initial implementation, to interface with the North Carolina Teachers' and State Employees' Health Plan. The costs for this capability shall be negotiated prior to the award of the Reporting and Analytics Project contract. The Reporting and Analytics Project solution must be completed simultaneously with the replacement MMIS."

For prior similar provisions, see Session Laws 2008-107, s. 10.9(c)-(e).

Session Laws 2011-145, s. 10.29(a)-(i), provides: "(a) By August 1, 2011, the Secretary of the Department of Health and Human Services shall provide detailed cost information on the replacement Medicaid Management Information System (MMIS) to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Appropriations Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and Base Budget and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. This information shall include the following:

"(1) The original total cost of MMIS, by year, to include five years of operations and maintenance.

"(2) The current total cost of MMIS, to include five years of operations and maintenance.

"(3) Detailed information on costs associated with each MMIS project, to include the original cost, the current cost, and the reasons for any changes.

"(4) A list of change requests and amendments to the original contract and the costs associated with each.

"(5) Costs for continuing the legacy MMIS beyond the original completion date for the new MMIS, with detailed information on funding sources for those costs.

"(6) Original costs for each vendor associated with the contract, the current costs for each, and the reasons for any increases in cost.

"(b) The Secretary may utilize prior year earned revenue received for the replacement MMIS in the amount of three million two hundred thirty-two thousand three hundred four dollars ($3,232,304) in fiscal year 2011-2012 and twelve million dollars ($12,000,000) in fiscal year 2012-2013. The Department shall utilize prior year earned revenues received for the procurement, design, development, and implementation of the replacement MMIS. In the event the Department does not receive prior year earned revenues in the amounts authorized by this section, or funds are insufficient to advance the project, the Department is authorized, with approval of the Office of State Budget and Management (OSBM), and after consulting with the Joint Legislative Commission on Governmental Operations, to utilize overrealized receipts and funds appropriated to the Department to achieve the level of funding specified in this section for the replacement MMIS. If the department requires funding beyond the prior year earned revenue specified in this section, the Department shall immediately report to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. The report shall include the following:

"(1) The amount of the shortfall.

"(2) The sources of funding the Department plans to use to make up for the shortfall.

"(3) The impact on the programs or operations from which the funding is to be taken.

"(c) The Department shall make full development of the replacement MMIS a top priority. During the development and implementation of the replacement MMIS, the Department shall develop plans to ensure the timely and effective implementation of enhancements to the system to provide the following capabilities:

"(1) Receiving and tracking premiums or other payments required by law.

"(2) Compatibility with the Health Information System.

"(d) The Department shall make every effort to expedite the implementation of the enhancements. The contract between the Department and each contract vendor shall contain an explicit provision requiring the replacement MMIS to have the capability to fully implement the administration of NC Health Choice, NC Kids' Care, Ticket to Work, Families Pay Part of the Cost of Services under the CAP-MR/CC, CAP Children's Program, and all relevant Medicaid waivers and the Medicare 646 waiver as it applies to Medicaid eligibles. The Department must have detailed cost information for each requirement before signing the contract and must immediately provide that cost information to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. Any sole source contract must meet all State requirements and must have the written approval of the State CIO. Any decision to sole source any portion of the contract shall immediately be reported to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management.

"(e) The Office of the State Chief Information Officer (SCIO) and the Office of Information Technology Services (ITS) shall work in cooperation with the Department to ensure the timely and effective implementation of the replacement MMIS and enhancements. The SCIO shall ensure that the replacement MMIS meets all State requirements for project management and shall immediately report any failure to meet State project management requirements to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. The SCIO shall also immediately report if any replacement MMIS project, or portion of a project, is listed as red in the project portfolio management tool.

"(f) Notwithstanding G.S. 114-2.3, the Department shall engage the services of private counsel with pertinent information technology and computer law expertise to review requests for proposals and to negotiate and review contracts associated with the replacement MMIS. This shall include amendments exceeding ten million dollars ($10,000,000). The counsel engaged by the Department shall review the replacement MMIS contracts and amendments between the Department and the vendor to ensure that the requirements of subsection (d) of this section are met in their entirety and that the terms of the contract are in the State's best interest.

"(g) By August 1, 2011, the Department shall develop a revised comprehensive schedule for the development and implementation of the replacement MMIS that fully incorporates federal and State project management and review standards. The Department shall ensure that the schedule is accurate. Any changes to the design, development, and implementation schedule shall be reported as part of the Department's monthly MMIS reporting requirements. The Department shall submit the schedule to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. This submission shall include a detailed explanation of schedule changes that have occurred since the initiation of the project and the cost associated with each change. Any changes to key milestones shall be immediately reported to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management, with a full explanation of the reason for the change and any associated costs.

"(h) Beginning July 1, 2011, the Department shall make quarterly reports on the progress of the development and implementation of the replacement MMIS. This report shall include any changes, or anticipated changes, in the scope, functionality, or projected costs. This report shall include any changes to any replacement MMIS vendor contracts and shall provide a detailed explanation of those changes and the associated cost increases. Each report shall be made to the Chairs of the House of Representatives Committee on Appropriations and the House of Representatives Subcommittee on Health and Human Services, the Chairs of the Senate Committee on Appropriations and the Senate Appropriations Committee on Health and Human Services, the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. A copy of the final report on each contract or amendment award shall also be submitted to the Joint Legislative Oversight Commission on Governmental Operations.

"(i) Upon initiation of the NC MMIS Program Reporting and Analytics Project, and the Division of Health Services Regulation Project, the Department shall submit all reports regarding functionality, schedule, and cost in the next regular cycle of reports identified in this section. The Department shall ensure that the solution developed in the Reporting and Analytics Project supports the capability, in its initial implementation, to interface with the State Health Plan for Teachers and State Employees. The costs for this capability shall be negotiated prior to the award of the Reporting and Analytics Project contract. The Reporting and Analytics Project solution must be completed simultaneously with the replacement MMIS."

Funds for Replacement Medicaid Management Information System / Implementation of Replacement MMIS. - Session Laws 2013-360, s. 12A.4, as amended by Session Laws 2013-363, s. 4.11, and as amended by Session Laws 2014-100, ss. 12A.4(a), (b), and 12A.5, provides: "(a) The Secretary of the Department of Health and Human Services may utilize prior year earned revenue received for the replacement MMIS in the amount of nine million six hundred fifty-eight thousand one hundred fifty-two dollars ($9,658,152) for the 2013-2014 fiscal year and in the amount of six million eight hundred ninety thousand six hundred dollars ($6,890,600) for the 2014-2015 fiscal year. In the event the Department does not receive prior year earned revenues in the amounts authorized by this section, or funds are insufficient to advance the project, the Department may, with prior approval from the Office of State Budget and Management (OSBM), utilize overrealized receipts and funds appropriated to the Department to achieve the level of funding specified in this section for the replacement MMIS.

"(b) The Department shall make full development of the replacement MMIS a top priority. During development and implementation of the replacement MMIS, the Department shall develop plans to ensure the timely and effective implementation of enhancements to the system to provide the following capabilities:

"(1) Receiving and tracking premiums or other payments required by law.

"(2) Compatibility with the Health Information System.

"(c) The Department shall make every effort to expedite the implementation of the enhancements. The replacement MMIS shall have the capability to fully implement the administration of NC Health Choice, Ticket to Work, CAP Children's Program, all relevant Medicaid waivers, and the Medicare 646 waiver as it applies to Medicaid eligibles.

"(d) The Office of the State Chief Information Officer (SCIO) and the Office of Information Technology Services (ITS) shall work in cooperation with the Department to ensure the timely and effective implementation of the replacement MMIS and any enhancements. The SCIO shall ensure that the replacement MMIS meets all State requirements for project management and shall immediately report any failure to meet these requirements to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management. The SCIO shall also immediately report if any replacement MMIS project, or portion of a project, is listed as red in the project portfolio management tool.

"(e) Notwithstanding G.S. 114-2.3, the Department shall consult with the Office of the SCIO concerning the retention of private counsel for the replacement MMIS, and as directed by the Office of the SCIO, retain private counsel with expertise in pertinent information technology and computer law to negotiate and review contract amendments associated with the replacement MMIS. The private counsel engaged by the Department shall review the replacement MMIS contract amendments between the Department and the vendors to ensure that the requirements of subsection (c) of this section are met in their entirety and that the terms of the contract amendments are in the State's best interest.

"(f) The Department shall immediately report any changes to the replacement MMIS implementation schedules to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management, with a full explanation of the reason for the change and any associated costs.

"(g) The Department shall provide the following reports on the replacement MMIS by the dates specified in this subsection to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, the Fiscal Research Division, and the Office of State Budget and Management:

"(1) By no later than September 1, 2013, a progress report on full implementation of the replacement MMIS, which shall include at least all of the following:

"a. Any issues encountered following the 'go live' date of July 1, 2013, and how each issue was resolved.

"b. Any system requirements for manual workarounds and the time line for implementing an automated solution for each manual workaround.

"c. Required capabilities that are not available in the replacement MMIS on the 'go live' date of July 1, 2013, with a date for the implementation of each.

"(2) By no later than November 1, 2013, a progress report on full implementation of the replacement MMIS, which shall include at least all of the following:

"a. An updated estimate of the costs associated with operating and maintaining the system during the 2013-2014 and 2014-2015 fiscal years, with an explanation for any changes from previous submissions.

"b. The cost, if any, associated with the resolution of each issue encountered following the 'go live' date of July 1, 2013, and the source of funding for the associated cost.

"c. The cost, if any, associated with any system requirements for manual workarounds, the source of funding used to pay for the associated cost, the cost associated with transitioning to each automated solution, and the source of funding for each identified cost.

"d. A comparison of timeliness and accuracy of payments for legacy system and replacement system transactions, using the same criteria for both.

"e. The cost, if any, associated with implementation of any required capabilities that are not available in the replacement MMIS on the 'go live' date of July 1, 2013.

"(3) By no later than December 1, 2013, a plan for the elimination of the Office of Medicaid Management Information System Services (OMMISS) and the transfer of its remaining operations to other Divisions within the Department of Health and Human Services. This plan shall include at least all of the following:

"a. The specific operations to be transferred to other Divisions within the Department, the specific Division to which each operation will be transferred, the State personnel that will be impacted by each transfer, costs associated with each transfer, and sources of funding to enable the identified Divisions to assume these transferred operations.

"b. Any State personnel costs that will result from the dissolution of OMMISS, including the costs of any severance payments and any compensatory time earned during the course of the project, broken down by employee; and any identified sources of funding to pay for these personnel costs.

"c. A plan for transitioning out of the space currently leased by the State for OMMISS, costs associated with this transition, and any savings that will result from the transition.

"(4) By no later than January 15, 2014, a preliminary report on the Department's plan for achieving system certification, which shall include at least all of the following:

"a. A description of the process.

"b. A detailed time line.

"c. Any issues that could impact the timing of system certification and plans to mitigate identified issues.

"d. Any costs associated with system certification.

"e. Any identified funding sources to pay for costs associated with system certification.

"(h) The Department shall complete the Reporting and Analytics Project solution simultaneously with the implementation of the replacement MMIS.

"(i) Notwithstanding any other provision of law and to the extent permitted by federal law, the Department shall not approve any overtime or compensatory time related to the replacement MMIS after August 1, 2013, without the prior written approval of the Office of State Personnel for each specific instance of overtime or compensatory time. Beginning August 1, 2013, the Department shall submit a monthly report to the Joint Legislative Oversight Committee on Health and Human Services, the Joint Legislative Oversight Committee on Information Technology, and the Fiscal Research Division on the total amount of approved overtime and compensatory time related to the replacement MMIS for the preceding calendar month.

"(j) Repealed by Session Laws 2014-100, s. 12A.4(a), (b), effective July 1, 2014.

"(k) Repealed by Session Laws 2014-100, s. 12A.4(a), (b), effective July 1, 2014."

Community Alternatives Programs Reimbursement System. - Session Laws 2009-451, s. 10.62 provides: "Full implementation for the Community Alternatives Programs reimbursement system shall be not later than 12 months after the date on which the replacement Medicaid Management Information System becomes operational and stabilized."

For prior similar provisions, see Session Laws 2007-323, s. 10.44.

Session Laws 2008-107, s. 10.15A(h2)-(h6), as added by Session Laws 2008-118, s. 3.13(b), and amended by Session Laws 2009-526, s. 2(b), and Session Laws 2009-550, s. 1.1(b) provides: "(h2)(1) Application. - This subsection applies only to contested Medicaid cases commenced by Medicaid applicants or recipients under subsection 10.15A(h1) of this act. Except as otherwise provided by subsection 10.15A(h1) and this subsection governing time lines and procedural steps, a contested Medicaid case commenced by a Medicaid applicant or recipient is subject to the provisions of Article 3 of Chapter 150B. To the extent any provision in this subsection or subsection 10.15A(h1) of this act conflicts with another provision in Article 3 of Chapter 150B, this subsection and subsection 10.15A(h1) controls.

"(2) Simple Procedures. - Notwithstanding any other provision of Article 3 of Chapter 150B of the General Statutes, the chief administrative law judge may limit and simplify the procedures that apply to a contested Medicaid case involving a Medicaid applicant or recipient in order to complete the case as quickly as possible. To the extent possible, the Office of Administrative Hearings shall schedule and hear all contested Medicaid cases within 55 days of submission of a request for appeal. Hearings shall be conducted telephonically or by video technology, however the recipient or applicant, or the recipient's or applicant's representative may request that the hearing be conducted before the administrative law judge in person. An in-person hearing shall be conducted in Wake County, however for good cause shown, the in-person hearing may be conducted in the county of residence of the recipient or applicant. Good cause shall include but is not limited to the applicant's or recipient's impairments limiting travel or the unavailability of the applicant's or recipient's treating professional witnesses. The Department shall provide written notice to the recipient or applicant of the use of telephonic hearings, hearings by video conference, and in-person hearings before the administrative law judge, and how to request a hearing in the recipient's or applicant's county of residence. 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. An administrative law judge assigned to a contested Medicaid case shall make reasonable efforts in a case involving a Medicaid applicant or recipient who is not represented by an attorney to assure a fair hearing and to maintain a complete record of the hearing. The administrative law judge may allow brief extensions of the time limits contained in this section for good cause and to ensure that the record is complete. Good cause includes delays resulting from untimely receipt of documentation needed to render a decision and other unavoidable and unforeseen circumstances. Continuances shall only be granted in accordance with rules adopted by the Office of Administrative Hearings, and shall not be granted on the day of the hearing, except for good cause shown. If a petitioner fails to make an appearance at a hearing that has been properly noticed via certified mail by the Office of Administrative Hearings, the Office of Administrative Hearings shall immediately dismiss the contested case provision.

"(3) Mediation. - Upon receipt of an appeal request form as provided by subdivision 10.15A(h1)(4) of this act or other clear request for a hearing by a Medicaid applicant or recipient, the Office of Administrative Hearings shall immediately notify the Mediation Network of North Carolina which shall within five days contact the petitioner to offer mediation in an attempt to resolve the dispute. If mediation is accepted, the mediation must be completed within 25 days of submission of the request for appeal. Upon completion of the mediation, the mediator shall inform the Office of Administrative Hearings and the Department within 24 hours of the resolution by facsimile or electronic messaging. If the parties have resolved matters in the mediation, the case shall be dismissed by the Office of Administrative Hearings. The Office of Administrative Hearings shall not conduct any contested Medicaid cases hearings until it has received notice from the mediator assigned that either: (i) the mediation was unsuccessful, or (ii) the petitioner has rejected the offer of mediation, or (iii) the petitioner has failed to appear at a scheduled mediation. Nothing in this subdivision shall restrict the right to a contested case hearing.

"(4) Burden of Proof. - The petitioner has the burden of proof to show entitlement to a requested benefit or the propriety of requested agency action when the agency has denied the benefit or refused to take the particular action. The agency has the burden of proof when the appeal is from an agency determination to impose a penalty or reduce, terminate, or suspend a benefit previously granted. The party with the burden of proof on any issue has the burden of going forward, and the administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence.

"(4a) New Evidence. - The petitioner shall be permitted to submit evidence regardless of whether obtained prior to or subsequent to the Department's actions and regardless of whether the Department had an opportunity to consider the evidence in making its determination to deny, reduce, terminate or suspend a benefit. When such evidence is received, at the request of the Department, the administrative law judge shall continue the hearing for a minimum of 15 days and a maximum of 30 days to allow for the Department's review of the evidence. Subsequent to review of the evidence, if the Department reverses its original decision, it shall immediately inform the administrative law judge.

"(4b) Issue for Hearing. - For each penalty imposed or benefit reduced, terminated, or suspended, the hearing shall determine whether the Department substantially prejudiced the rights of the petitioner and if the Department, based upon evidence at the hearing:

"a. Exceeded its authority or jurisdiction;

"b. Acted erroneously;

"c. Failed to use proper procedure;

"d. Acted arbitrarily or capriciously; or

"e. Failed to act as required by law or rule.

"(5) Decision. - The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The Office of Administrative Hearings shall send a copy of the audiotape or diskette of the hearing to the agency within five days of completion of the hearing. The judge shall prepare a written decision and send it to the parties. The decision must be sent together with the record to the agency within 20 days of the conclusion of the hearing.

"(h3) From funds available to the Department of Health and Human Services for the 2008-2009 fiscal year, the sum of two million dollars ($2,000,000) shall be transferred by the Department of Health and Human Services to the Office of Administrative Hearings. These funds shall be allocated by the Office of Administrative Hearings for mediation services provided for Medicaid applicant and recipient appeals and to contract for other services necessary to conduct the appeals process.

"(h4) Effective October 1, 2008, the Department of Health and Human Services shall discontinue its current informal appeals process for Medicaid applicants and recipients appealing a determination made by the Department to deny, terminate, suspend, or reduce Medicaid covered services. All such informal appeals by Medicaid applicants or recipients under the current system which are pending on that date and for which a hearing has not been held shall be discontinued and the applicant or recipient offered an opportunity to appeal to the Office of Administrative Hearings in accordance with the provisions of subsection 10.15A(h1) of this act. The Department shall make every effort to resolve or settle all of the backlogged cases prior to the effective date of this act.

"(h5) Nothing in this act shall prevent the Department of Health and Human Services from engaging in an informal review of the case with the applicant or recipient prior to issuing a notice of adverse determination as provided by subsection 10.15A(h1) of this act.

"(h6) The appeals process for Medicaid applicants and recipients established under this section shall expire July 1, 2010. The Department of Health and Human Services and the Office of Administrative Hearings shall each report to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Subcommittee on Health and Human Services, the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services, and the Fiscal Research Division on March 1, 2009, October 1, 2009, and March 1, 2010, on the costs, effectiveness, and efficiency of the appeals process for Medicaid applicants and recipients and make recommendations regarding the continuation of the process."

Community Care of North Carolina. - Session Laws 2011-145, s. 10.28(a)-(e), provides: "(a) The Department of Health and Human Services (Department) shall submit a report annually from a qualified entity with proven experience in conducting actuarial and health care studies on the Medicaid cost-savings achieved by the CCNC networks, which shall include children, adults, and the aged, blind, and disabled, to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division.

"(b) The Department and the Division of Medical Assistance (DMA) shall enter into a three-party contract between North Carolina Community Care Networks, Inc., (NCCCN, Inc.) and each of the 14 participating local CCNC networks and shall require NCCCN, Inc., to provide standardized clinical and budgetary coordination, oversight, and reporting for a statewide Enhanced Primary Care Case Management System for Medicaid enrollees. The contracts shall require NCCCN, Inc., to build upon and expand the existing successful CCNC primary care case management model to include comprehensive statewide quantitative performance goals and deliverables which shall include all of the following areas: (i) service utilization management, (ii) budget analytics, (iii) budget forecasting methodologies, (iv) quality of care analytics, (v) participant access measures, and (vi) predictable cost containment methodologies.

"(c) NCCCN, Inc., shall report quarterly to the Department and to the Office of State Budget and Management (OSBM) on the development of the statewide Enhanced Primary Care Case Management System and its defined goals and deliverables as agreed upon in the contract. NCCCN, Inc., shall submit biannual reports to the Secretary of Health and Human Services, OSBM, the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division on the progress and results of implementing the quantitative, analytical, utilization, quality, cost containment, and access goals and deliverables set out in the contract. NCCCN, Inc., shall conduct its own analysis of the CCNC system to identify any variations from the development plan for the Enhanced Primary Care Case Management System and its defined goals and deliverables set out in the contract between DMA and NCCCN, Inc. Upon identifying any variations, NCCCN, Inc., shall develop and implement a plan to address the variations. NCCCN, Inc., shall report the plan to DMA within 30 days after taking any action to implement the plan.

"(d) By January 1, 2012, the Department and OSBM shall assess the performance of NCCCN, Inc., and CCNC regarding the goals and deliverables established in the contract. Based on this assessment, the Department and DMA shall expand, cancel, or alter the contract with NCCCN, Inc., and CCNC effective April 1, 2012. Expansion or alteration of the contract may reflect refinements based on clearly identified goals and deliverables in the areas of quality of care, participant access, cost containment, and service delivery.

"(e) By July 1, 2012, the Department, DMA, and NCCCN, Inc., shall finalize a comprehensive plan that establishes management methodologies which include all of the following: (i) quality of care measures, (ii) utilization measures, (iii) recipient access measures, (iv) performance incentive models in which past experience indicates a benefit from financial incentives, (v) accountable budget models, (vi) shared savings budget models, and (vii) budget forecasting analytics as agreed upon by the Department, DMA, and NCCCN, Inc. In the development of these methodologies, the Department, DMA, and NCCCN, Inc., shall consider options for shared risk. The Department and DMA shall provide assistance to NCCCN, Inc., in meeting the objectives of this section."

Program Integrity. - Session Laws 2011-145, s. 10.39, provides: "In order to ensure all claims presented by a provider for payment by the Department of Health and Human Services meet the Department's medical necessity criteria and all other applicable Medicaid, Health Choice, or other federal or State documentation requirements, a provider may be required to undergo prepayment claims review by DHHS. Claims reviews conducted pursuant to this section shall be in accordance with the provisions of the Patient Protection and Affordable Care Act, P.L. 111-148, and any implementing regulations."

Medication Therapy Management Pilot Program. - Session Laws 2011-145, s. 10.42(a)-(c), provides: "(a) The Department of Health and Human Services shall develop a two-year medication therapy management pilot program to be administered through Community Care of North Carolina (CCNC) in order to determine (i) the best method of adapting the ChecKmedsNC program to the Medicaid program and CCNC's Medical Homes and (ii) the most effective and efficient role for community-based pharmacists as active members of CCNC's care management teams. The pilot program created pursuant to this section shall consist of the following components:

"(1) Identification of at least 20 community-based pharmacies that are geographically distributed and sufficiently representative to generalize pilot findings among pharmacies that dedicate pharmacist time to work with patients, their care team members, and their Medical Home practices to improve patient outcomes. To the extent that available resources allow, other types of community-based pharmacists may be involved, including those working with long-term care residents or their attending physicians.

"(2) Targeting of Medicaid recipients with co-occurring illnesses or conditions that are especially susceptible to poor patient outcomes when medication is underused, misused, or poorly coordinated.

"(3) Allowing pharmacists identified pursuant to subdivision (1) of this section to have access to CCNC's Web-based Pharmacy Portal, which allows CCNC to establish and monitor patients' prescriptions and to communicate with other care team members.

"(b) On January 1, 2012, and every six months thereafter, CCNC shall report to the Department of Health and Human Services, the House and Senate Appropriations Subcommittees on Health and Human Services, and the Fiscal Research Division on the development and implementation of this pilot program. This reporting requirement shall terminate with the filing of the third report on January 1, 2013. In addition to any other information, the reports required by this section shall include the following additional information:

"(1) The July 1, 2012, report shall include an interim evaluation of the pharmacists' demonstrated use of the CCNC Pharmacy Home Model and the pharmacists' role in intervening and successfully managing the medication therapy of Medicaid recipients with chronic illnesses.

"(2) The January 1, 2013, report shall include an evaluation of the pharmacists' role in CCNC's management of Medicaid recipients with mental health diagnoses or who receive Home Health or Nursing Home care, and a determination of the appropriate per member/per month pharmacists should receive for participating in the Medical Home Model of CCNC.

"(c) Funding for this pilot program shall be made available through the Enhanced Federal Funding for Health Homes for the Chronically Ill."

Meeting Behavioral Health Needs of Military Personnel, Veterans, and Their Families. - Session Laws 2011-185, s. 2(a), provides: "The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services of the Department of Health and Human Services shall collaborate with military agencies and other appropriate organizations to determine gaps in the care of current and former members of the reserve or active components of the Armed Forces of the United States with traumatic brain injury, shall develop recommendations for an accessible community-based neurobehavioral system of care for those service members, and shall report its recommendations by July 1, 2012, to the Chairs of the House of Representatives and Senate Appropriations Subcommittees on Health and Human Services and Justice and Public Safety, to the Chairs of the House of Representatives Committee on Homeland Security, Military, and Veterans Affairs, and to the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services. The recommendations shall be tailored so that, if implemented, services would be available to service members, veterans, and their families and would consist of neurobehavioral programs, residential programs, comprehensive day programs, and home-based programs."

Session Laws 2011-185, s. 2(b), provides: "The Division of Medical Assistance of the Department of Health and Human Services, MedSolutions, Inc., and the appropriate health professionals at the United States Department of Veterans Affairs shall work together to ensure that MedSolutions, Inc., is using the appropriate evidence-based diagnostic testing (including imaging, biomarker testing, and other tests) for screening and assessment of traumatic brain injury."

Session Laws 2011-185, s. 3(a) and (b), provides: "(a) The North Carolina Area Health Education Centers (AHEC) Program shall facilitate and continue to provide health education and skills training for health professional students; primary care, mental health, and substance abuse service providers; and hospital administrators about the health, mental health, and substance abuse needs of the military and their families. This training shall include information about the following:

"(1) The number of North Carolinians who are serving or who have served in the active or reserve components of the Armed Forces of the United States.

"(2) Military culture.

"(3) The average number of deployments, length of time in conflict zones, and potential injuries these members may have faced, particularly those who have served recently in Iraq or Afghanistan.

"(4) The types of health, mental health, and substance abuse disorders that service personnel may have experienced, including traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), military sexual trauma (MST), depression, substance use disorders, potential suicide risks, or domestic violence.

"(5) The potential impact of the deployment cycle on family members and children. This information shall include information about resiliency skills, intervention skills, resources, and community supports.

"(6) Evidence-based screening and assessment instruments.

"(7) Evidence-based case management, treatment, and medication management for different mental health and substance abuse problems, and potential adverse effects of prescribed medications, particularly for people with comorbidities.

"(8) Information about the TRICARE system, payment, and enrollment procedures.

"(9) Available referral sources through TRICARE, the United States Department of Veterans Affairs, Military One Source, Army One Source, Defense Centers of Excellence, Deployment Health Clinical Center, the North Carolina National Guard's Integrated Behavioral Health System, Local Management Entities, the North Carolina Department of Health and Human Services (DHHS) Office of Citizen Services, North Carolina Health Info, Federally Qualified Health Centers, professional advocacy and support services, and other community resources.

"(b) In carrying out the requirements of Section 3(a) of this act, the AHEC Program shall collaborate with the Citizen Soldier Support Program; North Carolina health professional training programs; the United States Department of Veterans Affairs; the North Carolina Division of Veterans Affairs; The University of North Carolina; Operation Re-Entry North Carolina; the North Carolina Community College System; health care professional associations; the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services; Governor's Focus on Servicemembers, Veterans, and Their Families; and academic health programs."

Similar provisions contained in Session Laws 2011-117, ss. 1-6, were repealed by Session Laws 2012-142, s. 10.9(a).

1915(b)/(c) Medicaid Waivers. - Session Laws 2011-264, s. 1, as amended by Session Laws 2012-151, s. 13, provides: "(a) The Department of Health and Human Services (Department) shall proceed with statewide restructuring of the management responsibilities for the delivery of services for individuals with mental illness, intellectual and developmental disabilities, and substance abuse disorders through expansion of the 1915(b)/(c) Medicaid Waiver. It is the intent of the General Assembly that expansion of the 1915(b)/(c) Medicaid Waiver will be completed by July 1, 2013, and will result in the establishment of a system that is capable of managing all public resources that may become available for mental health, intellectual and developmental disabilities, and substance abuse services, including federal block grant funds, federal funding for Medicaid and Health Choice, and all other public funding sources. In implementing the restructuring and expansion authorized in this section, the Department shall do all of the following:

"(1) Establish accountability for the development and management of a local system that ensures easy access to care, the availability and delivery of necessary services, and continuity of care for consumers in need of mental health, intellectual and developmental disabilities, and substance abuse services.

"(2) Maintain fidelity to the Piedmont Behavioral Health (PBH) demonstration model, a proven system for the operation of all public resources for mental health, developmental disabilities, and substance abuse services.

"(3) Designate an area authority for mental health, developmental disabilities, and substance abuse services to assume responsibility for all aspects of Waiver management. The following operational models are acceptable:

"a. Merger model: A single larger LME is formed from the merger of two or more LMEs.

"b. Interlocal agreement among LMEs: A single LME is identified as the leader for all Waiver operations, financial management, and accountability for performance measures.

"(4) Use managed care strategies, including care coordination and utilization management, to reduce the trend of escalating costs in the State Medicaid program while ensuring medically necessary care and deploy a system for the allocation of resources based on the reliable assessment of intensity of need. The Department shall design these strategies to efficiently direct consumers to appropriate services and to ensure that consumers receive no more and no less than the amount of services determined to be medically necessary and at the appropriate funding level.

"(5) As the 1915(b)/(c) Medicaid Waiver expands statewide, phase out the current CAP-MR/DD Waiver as well as the utilization management functions currently performed by public and private contractors.

"(6) Design the Innovations Waiver in such a way as to serve the maximum number of individuals with intellectual and developmental disabilities within aggregate funding.

"(7) Require LMEs approved to operate a 1915(b)/(c) Medicaid Waiver to do all of the following:

"a. Maintain a local presence in order to respond to the unique needs and priorities of localities.

"b. Implement a process for feedback end exchange of information and ideas to ensure communication with consumers, families, providers, and stakeholders regarding disability-specific and general Waiver operations.

"c. Establish and maintain systems for ongoing communication and coordination regarding the care of individuals with mental illness, intellectual and developmental disabilities, and substance abuse disorders with other organized systems such as local departments of social services, Community Care of North Carolina, hospitals, school systems, the Department of Juvenile Justice, and other community agencies.

"d. Comply with the following operational requirements:

"1. Maintain disability specific infrastructure and competency to address the clinical, treatment, rehabilitative, habilitative, and support needs of all disabilities covered by the 1915(b)/(c) Medicaid Waiver.

"2. Maintain administrative and clinical functions, including requirements for customer service, quality management, due process, provider network development, information systems, financial reporting, and staffing.

"3. Maintain full accountability for all aspects of Waiver operations and for meeting all contract requirements specified by the Department. The Department shall not require LMEs to subcontract any managed care functions or nonservice activities to other entities. However, LMEs that choose to subcontract managed care functions to other entities will be limited to the following:

"I. Information systems.

"II. Customer service (including call center) operations.

"III. Claims processing.

"IV. Provider, enrollment, credentialing, and monitoring.

"V. Professional services.

"VI. Treatment Plan development.

"VII. Referral to services.

"(b) By August 1, 2011, the Department shall select LMEs that have been assessed to meet minimum criteria for Waiver operations according to the requirements of RFA #2011-261 issued on April 1, 2011.

"(c) The Department shall require LMEs that have not been approved by the Department to operate a 1915(b)/(c) Medicaid Waiver by January 1, 2013, to merge with or be aligned through an interlocal agreement with an LME that has been approved by the Department to operate a 1915(b)/(c) Medicaid Waiver. If any LME fails to comply with this requirement, or fails to meet performance requirements of an approved contract with the Department to operate a 1915(b)/(c) Medicaid Waiver, the Department shall assign responsibility for management of the 1915(b)/(c) Medicaid Waiver on behalf of the noncompliant LME to an LME that is successfully operating the Waiver and successfully meeting performance requirements of the contract with the Department. Those LMEs approved to operate the 1915(b)/(c) Medicaid Waiver under an interlocal agreement must have a single LME entity designated as responsible for all aspects of Waiver operations and solely responsible for meeting contract requirements.

"(d) County governments are not financially liable for overspending or cost overruns associated with an area authority's operation of a 1915(b)/(c) Medicaid Waiver. County governments are not financially liable for overspending or cost overruns of Medicaid services associated with a county program or multicounty program's operation of a 1915(b)/(c) Medicaid Waiver beyond the county program or multicounty program's Medicaid risk reserve and Medicaid fund balance amounts.

"(e) Providers of targeted case management under the CAP-MR/DD Waiver are qualified to provide the 1915(c) service known as Community Guide under the Innovations Waiver. During the first year of assuming responsibility for Waiver operations, LMEs shall offer to contract with providers that were previously approved to provide targeted case management to individuals with intellectual and developmental disabilities under the CAP-MR/DD Waiver, for the provision of Community Guide services.

"(f) By December 31, 2011, the Department shall determine the feasibility of adding habilitation services to the State Medicaid Plan through the 1915(i) Option as a strategy to address the needs of Medicaid enrollees with IDD who are not enrolled in the Innovations Waiver and are not residing in an intermediate care facility for the mentally retarded (ICF-MR facility).

"(g) The Department shall consider the impact on ICF-MR facilities included in the 1915(b)/(c) Medicaid Waiver to determine and, to the extent possible, minimize potential inconsistencies with the requirements of G.S. 131E-176 and G.S. 131E-178 without negatively impacting the viability and success of the 1915(b)/(c) Medicaid Waiver programs.

"(h) The Department shall discontinue the pilot program to administer the Supports Intensity Scale to people with intellectual and developmental disabilities in non-Waiver LMEs.

"(i) The Department shall establish written policies ensuring alignment of objectives and operational coordination of the 1915(b)/(c) Medicaid Waiver and the care of individuals with mental illness, intellectual and developmental disabilities, and substance abuse disorders with other organized systems under the auspices of the Department, including Community Care of North Carolina.

"(j) In the development of the budget for the 2013-2015 fiscal biennium and subsequent biennia, the General Assembly shall consider a reinvestment of at least fifteen percent (15%) of the total projected State savings for that biennium from the operation of the 1915(b)/(c) Waiver, for the purpose of expanding the number of consumers served by the Innovations 1915(c) Medicaid Waiver, or for the purpose of expanding other services that are designed to meet the needs of individuals with intellectual and developmental disabilities.

"(k) By October 1, 2011, the Department, in coordination with the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the Division of Medical Assistance, LMEs, PBH, and with stakeholder input, shall submit to the appropriate Oversight Committee of the General Assembly a strategic plan delineating specific strategies and agency responsibilities for the achievement of the objectives and deadlines set forth in this Act.

"( l ) The Department shall submit status reports to the General Assembly on the restructuring and expansion authorized in this section on January 1, 2012, April 1, 2012, October 1, 2012, February 1, 2013, and October 1, 2013."

Session Laws 2014-100, s. 12H.5, provides: "The Department of Health and Human Services, Division of Medical Assistance, shall design and draft a 1915(c) wavier that meets the following requirements:

"(1) The waiver should create 1,000 new slots each year for 3 years, to serve a total of 3,000 additional adults with developmental disabilities from January 1, 2016, to June 30, 2019.

"(2) The budget for each slot should be capped at twenty thousand dollars ($20,000) per plan year per beneficiary, and slots will target individuals on the registry of unmet needs.

"(3) The slots should be managed as part of the LME/MCO managed care system.

"The Department shall report the draft waiver, other findings, and any other options or recommendations to best serve the additional adults with developmental disabilities on the registry of unmet needs to the House Appropriations Subcommittee on Health and Human Services and the Senate Appropriations Committee on Health and Human Services by March 1, 2015. The Department may submit drafts of the waiver to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waiver for CMS approval until authorized by the General Assembly."

Traumatic Brain Injury Waiver. - Session Laws 2014-100, s. 12H.6, provides: "The Department of Health and Human Services, Division of Medical Assistance, and Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, in conjunction with the North Carolina Traumatic Brain Injury Advisory Council, shall design and draft a 1915(c) waiver to add a new service package for Medicaid eligibles with traumatic brain injury (TBI). This draft waiver may be based on an update to the 2010 report on a waiver to serve individuals with traumatic brain injury. The Department shall report the draft waiver, other findings, and any additional options to provide Medicaid services to those suffering from TBI to the House Appropriations Subcommittee on Health and Human Services and the Senate Appropriations Committee on Health and Human Services by February 1, 2015. The Department may submit drafts of the waiver to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waiver for CMS approval until authorized by the General Assembly."

Session Laws 2015-241, s. 12H.6(a), provides: "The Department of Health and Human Services, Division of Medical Assistance and Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (Department), shall submit to the Centers for Medicare and Medicaid Services a request for approval of the 1915(c) waiver for individuals with traumatic brain injury (TBI) that the Department designed pursuant to Section 12H.6 of S.L. 2014-100, which the Joint Legislative Oversight Committee on Health and Human Services recommended as part of its December 2014 report to the General Assembly, and which is further described in the Department's February 1, 2015, report to the General Assembly."

Session Laws 2015-241, s. 12H.6(b), provides: "The Department shall report to the Joint Legislative Oversight Committee on Health and Human Services on the status of the Medicaid TBI waiver request and the plan for implementation no later than December 1, 2015. The Department shall submit an updated report by March 1, 2016. Each report shall include the following:

"(1) The number of individuals who are being served under the waiver and the total number of individuals expected to be served.

"(2) The expenditures to date and a forecast of future expenditures.

"(3) Any recommendations regarding expansion of the waiver."

Session Laws 2015-241, s. 12H.6(d), provides: "The waiver and any State Plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed]."

Session Laws 2018-81, s. 1, provides: "Beginning October 1, 2018, the Department of Health and Human Services (DHHS) shall report quarterly to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, the Joint Legislative Oversight Committee on Health and Human Services, the chairs of the Senate Appropriations Committee on Health and Human Services, the chairs of the House of Representatives Appropriations Committee on Health and Human Services, and the Fiscal Research Division on the status and implementation of the 1915(c) waiver for individuals with traumatic brain injury (TBI) that has been submitted to the Centers for Medicare and Medicaid Services in accordance with Section 12H.6 of S.L. 2015-241.

"As part of the process of implementing the TBI waiver, DHHS shall adopt rules or medical coverage policies relating to service programs for individuals with traumatic brain injury, including setting standards that ensure that individuals with brain injuries who require residential treatment receive appropriate, effective, and high-quality treatment in community-based residential settings. Additionally, DHHS shall develop a best practice model system that includes a comprehensive continuum of care and an array of short-term and long-term treatments, rehabilitation options, and home and community support services as part of the TBI waiver. Finally, DHHS shall strive to maintain adequate reimbursement rates for residential and community-based care programs that serve individuals with traumatic brain injury, which will aid in attracting and retaining quality and highly specialized providers and programs into North Carolina."

Supplemental Payments to Eligible Medical Professional Providers. - Session Laws 2014-100, s. 12H.13(a)-(c), as amended by Session Laws 2020-88, s. 13(e), provides: "(a) Effective July 1, 2014, supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical providers described in the Medicaid State Plan, Attachment 4.19-B, Section 5, Pages 2 and 3, shall be modified as follows:

"(1) The number of eligible medical professional providers shall be limited as follows:

"a. 418 with the East Carolina University (ECU) Brody School of Medicine.

"b. 1,176 with the University of North Carolina at Chapel Hill (UNC) Faculty Physicians.

"c. 14 with the UNC Hospitals Pediatric Clinic.

"d. 75 with UNC Physicians Network.

"e. 18 with Chatham Hospital.

"(2) Supplemental payments shall not be made for services provided in Wake County.

"The Department of Health and Human Services shall not make any other modifications to the portion of the Medicaid State Plan referenced in this section, except as provided herein.

"(b) (Repealed effective July 1, 2021) Beginning on December 31, 2014, and annually thereafter, UNC and ECU shall submit an annual report based on their preceding fiscal year to the Joint Legislative Oversight Committee on Health and Human Services containing all of the following information for each individual provider for whom this supplemental payment is received:

"(1) For each service provided by the provider and for which the supplemental payment is received, the location where the service was provided, including county, municipality, and zip code.

"(2) The percentage of the provider's total time spent serving Medicaid recipients annually that is for services provided at locations other than the ECU Brody School of Medicine, the Firetower Medical Office, or the UNC School of Medicine.

"(3) The amount of Medicaid reimbursement for each service for which a supplemental payment was made for services provided by the provider.

"(4) On an annual basis, the percentage of the provider's time spent engaging in the following:

"a. Clinical patient care.

"b. Teaching.

"c. Research.

"d. Other activities.

"(c) Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed]."

Session Laws 2018-5, s. 11H.11(a), (b), provides: "(a) Effective July 1, 2018, supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical providers described in the Medicaid State Plan, Attachment 4.19-B, Section 5, Pages 2 and 3, shall be modified to increase the number of eligible medical professional providers listed in subdivision (1) of Section 12H.13(a) of S.L. 2014-100 by 60. The allocation of the increase among the listed entities shall be determined by the Department of Health and Human Services.

"(b) No later than October 1, 2018, the Department of Health and Human Services shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice regarding the allocation of the 60 additional medical professional providers eligible for supplemental payments, as required by subsection (a) of this section. This report shall also include a detailed analysis of how the increase in eligible medical professional providers will increase access to health care in rural areas of the State."

Session Laws 2020-88, s. 13(a)-(d), provides: "(a) The Department of Health and Human Services shall revise the supplemental payment program for eligible medical professional providers described in the Medicaid State Plan, Attachment 4.19-B, Section 5, Pages 2 and 3, as required by this section. This payment program shall be called the Average Commercial Rate Supplemental and Directed Payment Program. Effective July 1, 2021, the following two changes to the program shall be implemented:

"(1) The program shall no longer utilize a limit on the number of eligible medical professional providers that may be reimbursed through the program and instead shall utilize a limit on the total payments made under the program.

"(2) Payments under the program shall consist of two components: (i) supplemental payments that increase reimbursement to the average commercial rate under the State Plan and (ii) directed payments that increase reimbursement to the average commercial rate under the managed care system.

"(b) The limitation on total payments made under the Average Commercial Rate Supplemental and Directed Payment Program for eligible medical professional providers shall apply to the combined amount of payments made as supplemental payments under the State Plan and payments made as directed payments under the managed care system and shall be based on the amount of supplemental payments for services provided during the 2018-2019 fiscal year. For services provided on or after July 1, 2021, the total annual supplemental and directed payments made under the Average Commercial Rate Supplemental and Directed Payment Program shall not exceed one hundred percent (100%) of the gross supplemental payments for services provided by eligible medical providers during the 2018-2019 fiscal year, increased at the start of each State fiscal year by an inflation factor determined by the Department of Health and Human Services, Division of Health Benefits.

"(c) Consistent with the existing supplemental payment program for eligible medical professional providers, the Department of Health and Human Services shall limit the total amount of supplemental and directed payments that may be received by the eligible providers affiliated with the East Carolina University Brody School of Medicine and the University of North Carolina at Chapel Hill Health Care System. Average commercial rate supplemental payments and directed payments shall not be made for services provided in Wake County.

"(d) The Department of Health and Human Services is not authorized to make any modifications to the supplemental payment program for eligible medical professional providers, except as authorized by this section."

Department of Health and Human Services Waiver Application. - Session Laws 2011-398, s. 55.1, provides: "Pursuant to 31 U.S.C. § 6504, the Department of Health and Human Services shall request a waiver from the single State agency requirement contained in 42 C.F.R. § 432.10(e)(3) with regard to final decisions in administrative hearings. The waiver application shall include the following:

"(1) The waiver request is made at the direction of the North Carolina General Assembly, which is responsible for the organizational structure of State government.

"(2) The single State agency requirement prevents the establishment of the most effective and efficient arrangement for providing administrative hearings to claimants because it requires that after a hearing and decision by an administrative law judge, the case must be returned to the agency for a final decision. The return to the agency is an unnecessary, time-consuming, and costly additional step.

"(3) The use of another State administrative hearings arrangement will not endanger the objectives of the law authorizing the Medicaid program because the administrative law judges will abide by the properly adopted policies, rules, and regulations of the State Medicaid agency in making final decisions."

AIDS Drug Assistance Pilot Program. - Session Laws 2012-142, s. 10.16(a)-(c), provides: "(a) The Department of Health and Human Services, Division of Public Health, shall develop a pilot program to enroll individuals receiving services under the Aids Drug Assistance Program (ADAP) in Inclusive Health North Carolina. The Department shall not implement the pilot program until it obtains actuarial services to ensure the cost neutrality or cost savings of enrolling ADAP recipients in Inclusive Health North Carolina. If an actuary determines that implementation will be cost neutral or achieve savings, the Department shall implement the pilot program for the period commencing January 1, 2013, and terminating December 31, 2013. The purposes of the pilot are (i) to determine cost savings to ADAP through enrollment of ADAP recipients in a preexisting conditions insurance program (PCIP) and (ii) to inform the Department of best practices in transitioning ADAP recipients to Medicaid as they become eligible. The Department shall select up to three HIVIDS care provider agencies with the highest number of ADAP recipients to participate in the pilot. The Department shall ensure that the total number of ADAP recipients participating in the pilot meets all of the following requirements:

"(1) Participation does not exceed ten percent (10%) of the total number of ADAP recipients.

"(2) ADAP recipients shall be enrolled in Inclusive Health North Carolina only up to the point that enrollment remains cost neutral or achieves cost savings to ADAP, as determined by an actuary.

"(b) The Department may contract with a vendor to evaluate the results of the pilot program. By no later than April 1, 2014, the Department shall report to the Joint Legislative Oversight Committee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the House Appropriations Subcommittee on Health and Human Services on the results of the pilot program. The report shall include all of the following:

"(1) The number of pilot program participants.

"(2) A cost analysis for the pilot program, including a cost comparison between ADAP recipients who received services through Inclusive Health North Carolina and ADAP recipients who received services only through ADAP.

"(3) Feedback from pilot program participants.

"(4) Best practices identified by the Department for transitioning ADAP recipients to Medicaid as they become eligible.

"(5) Improved health outcomes.

"(c) The Department shall use funds appropriated to it to develop and implement the pilot program authorized by this section. The Division of Public Health shall manage the number of ADAP recipients enrolled in Inclusive Health North Carolina as part of the pilot program and the number of ADAP recipients receiving services only through ADAP in order to ensure that pilot program expenditures do not exceed available funds."

Session Laws 2015-241, s. 12E.2, provides: "The Department of Health and Human Services shall work with the Department of Public Safety (DPS) to use DPS funds to purchase pharmaceuticals for the treatment of individuals in the custody of DPS who have been diagnosed with Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (HIV/AIDS) in a manner that allows these funds to be accounted for as State matching funds in the Department of Health and Human Services drawdown of federal Ryan White funds earmarked for the AIDS Drug Assistance Program (ADAP)."

Critical Access Behavioral Health Agencies. - Session Laws 2012-171, ss. 1-3, provide: "SECTION 1. Qualified provider. - The Department of Health and Human Services (Department) shall ensure that Critical Access Behavioral Health Agencies (CABHAs) are the only providers of the following Medicaid services: (i) Community Support Team; (ii) Intensive In-Home; and (iii) Child and Adolescent Day Treatment. CABHAs shall provide these services in accordance with all of the following:

"(1) State statutory requirements regulating the provision of mental health and substance abuse services in Chapter 122C of the General Statutes.

"(2) Chapters 21 through 25 and Chapter 27 of Title 10A of the North Carolina Administrative Code.

"(3) Clinical policy requirements specified in Medicaid Clinical Coverage Policy, Section 8, and in the 1915(b) MH/DD/SAS Health Plan Waiver.

"(4) Federal Medicaid policy as outlined in 42 C.F.R. Chapter IV, Subchapter C.

"SECTION 2. Required services. - Each CABHA shall, at a minimum, provide comprehensive clinical assessment, medication management, outpatient therapy, and at least two of the following listed services within an age and disability-specific continuum:

"(1) Intensive In-Home.

"(2) Community Support Team.

"(3) Child and Adolescent Day Treatment.

"(4) Substance Abuse Intensive Outpatient Program.

"(5) Substance Abuse Comprehensive Outpatient Treatment.

"(6) Child and Adolescent Residential Treatment Level II - Family and Program Type, Level III, or Level IV (provision of multiple residential service levels counts as one service).

"(7) Psychosocial Rehabilitation.

"(8) Assertive Community Treatment Team.

"(9) Multi-Systemic Therapy.

"(10) Partial Hospitalization.

"(11) Substance Abuse Medically Monitored Community Residential Treatment.

"(12) Substance Abuse Non-Medical Community Residential Treatment.

"(13) Outpatient Opioid Treatment.

"(14) Any other mental health or substance abuse service required to be delivered by a CABHA as set forth in the North Carolina State Plan of Medical Assistance as approved by the Centers for Medicare and Medicaid Services (CMS) or in a waiver approved by CMS pursuant to 42 U.S.C. § 1915(b).

"SECTION 3. Staffing. - In accordance with the North Carolina State Plan of Medical Assistance, the Department shall ensure each CABHA meet the following staffing requirements:

"(1) A medical director who is a medical doctor licensed in North Carolina, enrolled as a provider, and in good standing with the Division of Medical Assistance. The medical director shall provide medical, clinical, and quality management oversight of the agency's CABHA services described in Section 2 of this act.

"(2) A clinical director who shall be one of the following licensed or certified providers:

"a. Licensed medical doctor.

"b. Licensed psychologist.

"c. Licensed clinical social worker.

"d. Licensed psychological associate.

"e. Licensed professional counselor.

"f. Licensed marriage and family therapist.

"g. Licensed nurse practitioner.

"h. Licensed clinical addiction specialist.

"i. Certified clinical supervisor.

"(3) A quality managementraining director who shall have any training or experience in quality management or training."

Ensure Adequate Funding in Medicaid Budget. - Session Laws 2012-2, s. 1, provides: "(a) In order to ensure that there is adequate funding in the Medicaid budget for the 2011-2012 fiscal year, the General Assembly directs the Director of the Budget, in conjunction with the State Controller and other necessary State officials, to effectuate the following extraordinary budget adjustments in an amount not to exceed two hundred five million five hundred thousand dollars ($205,500,000). These adjustments are set forth in priority order, and no adjustment shall be made until the preceding adjustment has been completely exhausted in the permissible amount. To the extent necessary to ensure payment to providers for the remainder of the 2011-2012 fiscal year, the following adjustments are authorized in priority order:

"(1) Transfer a minimum of twenty-nine million dollars ($29,000,000) of funds available within the Department of Health and Human Services. Neither the Director of the Budget nor any other State official, officer, or agency shall, pursuant to this subdivision, authorize any transfer of unearned or borrowed Medicaid Disproportionate Share Receipts or transfer of any funds if the action would create or increase a financial obligation in the 2012-2013 fiscal year or any subsequent fiscal year.

"(2) Transfer twenty-one million dollars ($21,000,000) in unanticipated federal Children's Health Insurance Program Reauthorization Act bonus funds to the State Controller to be deposited in Nontax Budget Code 19978 or the appropriate budget code as determined by the State Controller. These funds are hereby appropriated.

"(3) Transfer ten million five hundred thousand dollars ($10,500,000) currently allocated to the Department of Health and Human Services from Budget Code 19945, the Repairs and Renovations Reserve Account, to the State Controller to be deposited in Nontax Budget Code 19978 or the appropriate budget code as determined by the State Controller, notwithstanding G.S. 143C-4-3. If funds are transferred pursuant to this subdivision, then notwithstanding G.S. 143C-4-3, Section 30.5 of S.L. 2011-145, or any other provision of law, the Office of State Budget and Management shall not allocate or use funds in the Repairs and Renovations Reserve Account to replace those funds. These funds are hereby appropriated.

"(4) Transfer of projected 2011-2012 General Fund reversions from all State agencies and departments, including debt service reversions, in the amount of one hundred five million dollars ($105,000,000). Neither the Director of the Budget nor any other State official, officer, or agency shall authorize any such transfer that creates or increases a financial obligation in the 2012-2013 fiscal year or any subsequent fiscal year.

"(5) Transfer twenty million dollars ($20,000,000) currently allocated to the various State agencies from Budget Code 19945, the Repairs and Renovations Reserve Account, to the State Controller to be deposited in Nontax Budget Code 19978 or the appropriate budget code as determined by the State Controller. If funds are transferred pursuant to this subdivision, then notwithstanding G.S. 143C-4-3, Section 30.5 of S.L. 2011-145, or any other provision of law, the Office of State Budget and Management shall ensure priority is given to excluding from transfer those funds specifically allocated to State agencies to address health and safety projects. These funds are hereby appropriated.

"(6) Transfer of projected revenue overcollections for the 2011-2012 fiscal year in the amount up to twenty million dollars ($20,000,000). These funds are hereby appropriated.

"(b) Subsection (a) of this section applies only to funds required to cover the costs of paying Medicaid providers during the 2011-2012 fiscal year. Transfers under each subdivision of subsection (a) of this section shall be limited to the amounts actually required to pay providers through the end of the 2011-2012 fiscal year. To the extent that the full amount of any of these funds is not required to pay providers through the end of the 2011-2012 fiscal year, (i) the authority to transfer funds shall immediately lapse with respect to the unneeded portions and unneeded adjustments; and (ii) any excess funds transferred shall be transferred back to the source fund.

"(c) On or before October 1, 2012, the Office of State Budget and Management and the Department of Health and Human Services shall report on the measures taken pursuant to this section to the Appropriations•ase Budget Committee of the Senate, the Appropriations Committee of the House of Representatives, and the Joint Legislative Commission on Governmental Operations."

Session Laws 2012-57, s. 1, provides: "(a) In order to ensure that there is adequate funding in the Medicaid budget for the 2011-2012 fiscal year, the General Assembly directs the Director of the Budget, in conjunction with the State Controller and other necessary State officials, to effectuate the following extraordinary budget adjustment. To the extent necessary for this purpose, up to ninety-four million dollars ($94,000,000) in funds appropriated to the Repairs and Renovations Reserve Account for the 2011-2012 fiscal year and allocated to State agencies and The University of North Carolina shall be transferred to the State Controller, deposited in the appropriate budget code as determined by the State Controller, and used to ensure payment to Medicaid providers for the remainder of the 2011-2012 fiscal year.

"(b) Subsection (a) of this section applies only to funds required to cover the costs of paying Medicaid providers during the 2011-2012 fiscal year. Transfers under this section shall be limited to the amounts actually required to pay providers through the end of the 2011-2012 fiscal year. To the extent that the full amount of any of the funds transferred is not required to pay providers through the end of the 2011-2012 fiscal year, (i) the authority to transfer funds shall immediately lapse with respect to the unneeded portions and unneeded adjustments; and (ii) any excess funds transferred shall be transferred back to the Repairs and Renovations Reserve Account for reallocation to State agencies.

Session Laws 2012-142, s. 6.14, provides: "(a) The General Assembly finds that:

"(1) In recent fiscal years, Medicaid program costs have grown disproportionately more than the remainder of the State budget.

"(2) Addressing large and frequent Medicaid program shortfalls has required the reallocation of funds that could have been used for other purposes.

"(3) To cover an early draw down of Medicaid funds during the 2009-2010 fiscal year, the 2011 General Assembly was required to make an additional one hundred twenty-five million dollars ($125,000,000) available to the Medicaid program.

"(4) To cover a shortfall in the 2011-2012 Medicaid budget, the 2012 Session of the 2011 General Assembly was required to appropriate additional funds for the Medicaid program.

"(5) To ensure that adequate funds are available to cover any potential shortfall in the 2012-2013 Medicaid budget, it is necessary to implement management flexibility reductions across State government.

"(b) In order to provide adequate funds to cover any potential shortfall in the 2012-2013 Medicaid budget while minimizing the impact on State government services, the Director of the Budget shall ensure that cost savings required through the management flexibility reductions in this act are realized so that at least fifty percent (50%) of the cost savings are realized by December 31, 2012."

Session Laws 2012-142, s. 6.15, as added by Session Laws 2012-145, s. 1.2, provides: "Notwithstanding the provisions of Section 6.14 of this act and G.S. 143C-6-4, and unless otherwise specifically directed in this act or in S.L. 2011-145, additional funds appropriated for the 2012-2013 fiscal year to State agencies as defined by G.S. 143C-1-1(d)(24) shall not be used to offset management flexibility adjustments enacted in this act or in S.L. 2011-145."

Session Laws 2012-142, s. 10.9G, provides: "Notwithstanding any other provision of this act or any other provision of law, the Department of Health and Human Services shall not, under any circumstances, expend any of the funds appropriated in this act for the 2012-2013 fiscal year for the following purposes until January 1, 2013, pending a determination by the Office of State Budget and Management that there is adequate funding for the Medicaid budget for the 2012-2013 fiscal year:

"(1) Funds appropriated to the Division of Child Development and Early Education pursuant to Section 10.4 of this act for 'Read NC' Early Literacy Initiative, Development Officers, and assistance to rural partnerships.

"(2) Funds appropriated to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services for the following:

"a. Additional psychiatric care beds at Broughton Hospital.

"b. Additional local inpatient psychiatric beds or bed days available to local management entities or managed care organizations under the State-administered three-way contract pursuant to Section 10.10 of this act.

"(3) Funds appropriated to the Division of Public Health pursuant to Section 10.14(a)(5) of this act for local community health and wellness initiatives."

Medicaid Contingency Reserve. - Session Laws 2014-100, s. 12H.38(a)-(d), provides: "(a) There is established in the General Fund the Medicaid Contingency Reserve. The Office of the State Controller shall reserve from funds available in the General Fund the sum of one hundred eighty-six million three hundred seventy-two thousand six hundred seventy-three dollars ($186,372,673) in recurring funds to the Medicaid Contingency Reserve. Funds in the Medicaid Contingency Reserve shall be used only for budget shortfalls in the Medicaid Program that occur during the 2014-2015 fiscal year. These funds shall be available for expenditure only upon an appropriation by act of the General Assembly.

"(b) It is the intent of the General Assembly to appropriate funds from the Medicaid Contingency Reserve only if:

"(1) The Director of the Budget, after the State Controller has verified that receipts are being used appropriately, has found that additional funds are needed to cover a shortfall in the Medicaid budget for the State fiscal year.

"(2) The Department of Health and Human Services has submitted a State plan amendment to the Centers for Medicare and Medicaid Services to delink eligibility for Medicaid from eligibility for State-County Special Assistance, to be effective 90 days after the date of submission of the State plan amendment. At least 45 days prior to submitting that State plan amendment, the Department of Health and Human Services must have submitted a draft of that plan to the Joint Legislative Oversight Committee on Health and Human Services and, if the General Assembly was not in session, must have consulted with the Committee on that draft.

"(3) The Director of the Budget has reported immediately to the Fiscal Research Division on the amount of the shortfall found in accordance with subdivision (1) of this subsection. This report shall include an analysis of the causes of the shortfall, such as (i) unanticipated enrollment and mix of enrollment, (ii) unanticipated growth or utilization within particular service areas, (iii) errors in the data or analysis used to project the Medicaid budget, (iv) the failure of the program to achieve budgeted savings, (v) other factors and market trends that have impacted the price of or spending for services, (vi) variations in receipts from prior years or from assumptions used to prepare the Medicaid budget for the current fiscal year, or (vii) other factors. The report shall also include data in an electronic format that is adequate for the Fiscal Research Division to confirm the amount of the shortfall and its causes.

"(c) Effective 90 days after the State plan amendment is submitted to the Centers for Medicare and Medicaid Services (CMS) or when CMS approves the State plan amendment, whichever occurs later, eligibility for Medicaid coverage is delinked from eligibility for State-County Special Assistance and recipients of State-County Special Assistance no longer automatically qualify for Medicaid coverage solely because of their receipt of State-County Special Assistance.

"(d) Nothing in this section shall be construed to limit the authority of the Governor to carry out his duties under the Constitution."

Session Laws 2017-57, s. 11H.9(a), (b), provides: "(a) Funds in the Medicaid Contingency Reserve established by Section 12H.38 of S.L. 2014-100 shall be used only for budget shortfalls in the Medicaid Program. These funds shall be available for expenditure only upon an appropriation by act of the General Assembly. It is the intent of the General Assembly to appropriate funds from the Medicaid Contingency Reserve only if:

"(2) The Director of the Budget has reported immediately to the Fiscal Research Division on the amount of the shortfall found in accordance with subdivision (1) of this subsection. This report shall include an analysis of the causes of the shortfall, such as (i) unanticipated enrollment and mix of enrollment, (ii) unanticipated growth or utilization within particular service areas, (iii) errors in the data or analysis used to project the Medicaid budget, (iv) the failure of the program to achieve budgeted savings, (v) other factors and market trends that have impacted the price of or spending for services, (vi) variations in receipts from prior years or from assumptions used to prepare the Medicaid budget for the current fiscal year, or (vii) other factors. The report shall also include data in an electronic format that is adequate for the Fiscal Research Division to confirm the amount of the shortfall and its causes.

"(b) Nothing in this section shall be construed to limit the authority of the Governor to carry out his duties under the Constitution."

Session Laws 2015-241, s. 12H.28(a)-(c), provides: "(a) Funds in the Medicaid Contingency Reserve established by Section 12H.38 of S.L. 2014-100 shall be used only for budget shortfalls in the Medicaid Program that occur during the 2015-2016 fiscal year. These funds shall be available for expenditure only upon an appropriation by act of the General Assembly.

"(b) It is the intent of the General Assembly to appropriate funds from the Medicaid Contingency Reserve only if:

"(c) Nothing in this section shall be construed to limit the authority of the Governor to carry out his duties under the Constitution."

Rejection of Medicaid expansion under Affordable Care Act. - Session Laws 2013-5, s. 3, provides: "The State will not expand the State's Medicaid eligibility under the Medicaid expansion provided in the Affordable Care Act, P.L. 111-148, as amended, for which the enforcement was ruled unconstitutional by the U.S. Supreme Court in National Federation of Independent Business, et al. v. Sebelius, Secretary of Health and Human Services, et al., 132 S. Ct. 2566 (2012). No department, agency, or institution of this State shall attempt to expand the Medicaid eligibility standards provided in S.L. 2011-145, as amended, or elsewhere in State law, unless directed to do so by the General Assembly."

Session Laws 2012-142, s. 10.9F(c), as amended by Session Laws 2012-194, s. 70 and Session Laws 2013-306, s. 1, provides: "A Medicaid recipient who meets each of the following criteria is eligible for up to 80 hours of personal care services:

"(1) The recipient has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum, (i) three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; (ii) two ADLs, one of which requires extensive assistance; or (iii) two ADLs, one of which requires assistance at the full dependence level.

"(2) The recipient (i) resides in a private living arrangement, a residential facility licensed by the State of North Carolina as an adult care home, or a combination home as defined in G.S. 131E-101(1a); or (ii) resides in a group home licensed under Chapter 122C or the General Statutes and under 10A NCAC 27G.5601 as a supervised living facility for two or more adults whose primary diagnosis is mental illness, a developmental disability, or substance abuse dependency, and is eligible to receive personal care services under the Medicaid State Plan.

"The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility. For Medicaid recipients meeting the criteria above, personal care services shall be available in accordance with an assessment conducted under subsection (d) of this section and a plan of care developed by the service provider and approved by the Department of Health and Human Services, Division of Medical Assistance, or its designee.

"(3) A Medicaid recipient who meets the eligibility criteria provided in subdivisions (1) and (2) of this subsection and all of the criteria provided below is eligible for up to 50 additional hours of Medicaid Personal Care Services per month for a total of up to 130 hours per month in accordance with an assessment and a plan of care.

"a. The recipient requires an increased level of supervision.

"b. The recipient requires caregivers with training or experience in caring for individuals who have a degenerative disease, characterized by irreversible memory dysfunction, that attacks the brain and results in impaired memory, thinking, and behavior, including gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills.

"c. Regardless of setting, the recipient requires a physical environment that includes modifications and safety measures to safeguard the recipient because of the recipient's gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills.

"d. The recipient has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and an increased incidence of falls.

"Physician attestation. - A recipient must have a physician's attestation that the recipient meets each of the criteria in sub-subdivisions a. through d. of subdivision 3 of this subsection. A recipient is not required to have a new attestation if he or she is identified by the Department of Health and Human Services, Division of Medical Assistance, as having on record a physician's attestation that meets the requirements of this subdivision. A recipient is required to have a new attestation if one cannot be identified by the Division of Medical Assistance or if the one identified does not meet the requirements of this subdivision.

"Independent assessment. - Based on the physician's attestation, the Medicaid recipient must receive an independent assessment conducted by a trained professional who is qualified to assess and has experience assessing individuals with the needs for additional safeguards identified by this subdivision. The independent assessment shall be conducted in accordance with subsection (d) of this section and shall determine the number of hours of personal care services needed by the individual. In response to the assessment, a plan of care shall be developed by the service provider and approved by the Department of Health and Human Services, Division of Medical Assistance, or its designee.

"Personal care services shall not include nonmedical transportation; financial management; non-hands-on assistance such as cueing, prompting, guiding, coaching, or babysitting; and household chores not directly related to the qualifying ADLs."

Session Laws 2012-142, s. 10.9F(d), as amended by Session Laws 2012-194, s. 70 and Session Laws 2013-306, s. 1, provides: "All assessments for personal care services, continuation of service, and change of status reviews shall be performed by an independent assessment entity (IAE). The IAE shall not be an owner of a provider business or provider of personal care services of any type.

"A recipient shall be assessed by the IAE after the recipient's primary or attending physician provides written authorization for referral for the service and written attestation to the medical necessity for the service. The IAE shall determine and authorize the amount of service to be provided as determined by its review and findings of each recipient's degree of functional disability and level of unmet needs for personal care services in the five qualifying ADLs."

Session Laws 2013-306, s. 2, provides: "The Department of Health and Human Services shall reduce the rate for personal care services in order to fund the additional service hours authorized in Section 1 of this act and in order to remain within the budgeted amount of funds for personal care services."

Session Laws 2013-306, s. 3, provides: "On or before August 15, 2013, the Department of Health and Human Services shall submit to the Centers for Medicare and Medicaid Services a Medicaid State Plan Amendment necessary to implement this act. The State Plan Amendment shall include an effective date of July 1, 2013, or as soon after July 1, 2013, as allowed by the Centers for Medicare and Medicaid Services."

Session Laws 2013-306, s. 4(a), provides: "On or before August 1, 2013, the Department of Health and Human Services shall make an interim report on the implementation of this act to the Joint Legislative Oversight Committee on Health and Human Services and to the Fiscal Research Division. The report shall include the following: (i) an estimate of the number of Medicaid recipients that would be eligible for Medicaid Personal Care Services under this act, (ii) an estimate of the number of PCS hours potential recipients would need broken out in increments of 10 hours between 80 and 130 hours, (iii) a copy of the draft Medicaid State Plan Amendment (SPA), (iv) an estimated time line for approval of the SPA and a projected implementation date, and (v) the rate reductions necessary to implement this act."

Session Laws 2013-306, s. 4(b). provides: "On or before November 1, 2013, the Department of Health and Human Services shall report on the implementation of this act to the Joint Legislative Oversight Committee on Health and Human Services."

Medicaid Reform Proposal; Medicaid Reform Advisory Group. - Session Laws 2013-360, s. 12H.1(a)-(f), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, (Department), in consultation with the Medicaid Reform Advisory Group created by subsection (e) of this section, shall create a detailed plan for, but not implement, significant reforms to the State's Medicaid Program that shall accomplish the following:

"(1) Create a predictable and sustainable Medicaid program for North Carolina taxpayers.

"(2) Increase administrative ease and efficiency for North Carolina Medicaid providers.

"(3) Provide care for the whole person by uniting physical and behavioral health care.

"(b) The Department shall submit its detailed proposal of how to reform the State's Medicaid Program to the General Assembly. The report shall contain the following:

"(1) The details of the reform plan, including how the plan would accomplish the goals set out in subsection (a) of this section.

"(2) The Department's methodology for selecting the reform plan over alternatives.

"(3) Forecasts of the reform plan's potential to slow the growth of the costs of the Medicaid Program, including the assumptions and methodology used for the forecast, as well as an explanation of how the Department's forecast methodology has been improved to produce more accurate forecasting than in prior years.

"(4) The reform plan's impact, as compared to the existing Medicaid Program, on both providers and recipients in areas such as enrollment within the Medicaid system, access to services, quality of care, and payment methodologies, and any other areas of comparison to help the General Assembly evaluate the reform plan.

"(5) If regional demonstration projects, pilot projects, or similar projects will be used to test a proposal, how the Department will ensure that the test methodology is scientifically valid and consistent with social science research methods.

"(6) How financial risks will be allocated under the reform plan.

"(7) The mechanisms through which the Department and any contractors under the reform plan would be held accountable for the implementation and performance of the plan.

"(8) Short-term costs to implement the plan and expected long-term savings in future years from slowing the growth of costs.

"(9) A realistic time line for implementation.

"(10) Draft Medicaid State Plan Amendments, Medicaid waivers, amendments to State law, or other changes necessary to legally allow the Department to implement its reform plan.

"(11) Any other detailed information that would assist the General Assembly in evaluating the strength of the reform plan and the plan's ability to accomplish the goals set out in subsection (a) of this section.

"(c) The Department is encouraged to and may submit draft Medicaid State Plan amendments, draft waiver applications, or other documents to the federal government to solicit feedback on the Department's proposal prior to reporting to the General Assembly. The Department shall not, however, submit any documents to the federal government to implement the reform plan without legislation authorizing the Department to implement the Department's reform plan.

"(d) The Department shall submit its reform plan to the General Assembly no later than March 17, 2014, but is encouraged to submit its plan as early as it responsibly can.

"(e) Advisory Group. - There is established the North Carolina Medicaid Reform Advisory Group (Advisory Group) in order to advise the Department of Health and Human Services in its development of its detailed plan to reform Medicaid. The Advisory Group shall meet in order to (i) provide stakeholder input in a public forum and (ii) ensure the transparency of the process of developing the reform proposal. The Advisory Group shall meet at the call of the chair.

"The Advisory Group shall consist of the following five members, and the appointing officer shall fill vacancies:

"(1) A Representative appointed by the Speaker of the House of Representatives.

"(2) A Senator appointed by the President Pro Tempore of the Senate.

"(3) Three persons appointed by the Governor, one of whom shall be designated as the chair.

"Legislative members of the Advisory Group shall receive per diem, subsistence, and travel expenses as provided in G.S. 120-3.1. Non-legislative members of the Advisory Group shall receive per diem, subsistence, and travel expenses as allowed under G.S. 138-5 or, if the member is a State employee, lodging and travel expenses as allowed under G.S. 138-6.

"The Secretary of Health and Human Services shall ensure adequate staff representation and support from the Department of Health and Human Services.

"The Advisory Group shall terminate on July 1, 2014.

"(f) Eligibility of Legislation. - Legislation based on the Department's reform proposal and recommended by the Advisory Group shall be eligible for consideration when the 2013 General Assembly reconvenes in 2014, and G.S. 143C-5-2 does not apply to such legislation."

Behavioral Health Clinical Integration and Performance Monitoring. - Session Laws 2013-360, s. 12F.4A(a)-(e), as amended by Session Laws 2017-57, s. 11F.16, provides: "(a) The Department of Health and Human Services shall require local management entities, including local management entities that have been approved to operate the 1915(b)/(c) Medicaid Waiver (LME/MCOs), to implement clinical integration activities with Community Care of North Carolina (CCNC) through Total Care, a collaborative initiative designed to improve and minimize the cost of care for patients who suffer from comorbid mental health or substance abuse and primary care or other chronic conditions.

"(b) The Department shall ensure that, by no later than January 1, 2014, all LME/MCOs submit claims data, including to the extent practical, retrospective claims data and integrated payment and reporting system (IPRS) data, to the CCNC Informatics Center and to the Medicaid Management Information System. Upon receipt of this claims data, CCNC shall provide access to clinical data and care management information within the CCNC Informatics Center to LME/MCOs and authorized behavioral health providers to support (i) treatment, quality assessment, and improvement activities or (ii) coordination of appropriate and effective patient care, treatment, or habilitation.

"(c) The Department, in consultation with CCNC and the LME/MCOs, shall develop quality and performance statistics on the status of mental health, developmental disabilities, and substance abuse services, including, but not limited to, variations in total cost of care, clinical outcomes, and access to and utilization of services.

"(d) The Department shall, within available appropriations and as deemed necessary by the Department, expand or alter existing contracts by mutual agreement of all parties to the contract in order to implement the provisions of this section.

Session Laws 2013-363, s. 12H.3(b), provides: "The Department shall not take any actions that the Department determines would jeopardize the State's qualification to receive federal funds through the Medicaid Program."

Community Care of NC Cost-Effectiveness Study; Reporting. - Session Laws 2013-360, s. 12H.21(a), (b), provides: "(a) The Office of the State Auditor shall, as recommended in its January 2013 performance audit of the Medicaid Program, engage nationally recognized medical researchers to perform a scientifically valid study based upon actual data to determine whether the Community Care of North Carolina (CCNC) model saves money and improves health outcomes. This study shall begin during fiscal year 2013-2014 and shall, if possible, be completed by the end of that fiscal year. The Department of Health and Human Services shall, upon the direction of and in amounts specified by the Office of the State Auditor, make payments to the contractor hired by the Office of the State Auditor from the one hundred thousand dollars ($100,000) appropriated elsewhere in this budget for this study as well as from federal Medicaid matching funds available for this study.

"(b) North Carolina Community Care Networks, Inc. (NCCCN), shall report quarterly to the Department and to the Office of State Budget and Management (OSBM) on the development of the statewide Enhanced Primary Care Case Management System and its defined goals and deliverables as agreed upon in the contract. NCCCN shall submit biannual reports to the Secretary of Health and Human Services, OSBM, the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division on the progress and results of implementing the quantitative, analytical, utilization, quality, cost containment, and access goals and deliverables set out in the contract. NCCCN shall conduct its own analysis of the CCNC system to identify any variations from the development plan for the Enhanced Primary Care Case Management System and its defined goals and deliverables set out in the contract between the Department of Health and Human Services, Division of Medical Assistance (DMA), and NCCCN. Upon identifying any variations, NCCCN shall develop and implement a plan to address the variations. NCCCN shall report the plan to DMA within 30 days after taking any action to implement the plan."

Session Laws 2013-363, s. 12H.3(b) provides: "The Department shall not take any actions that the Department determines would jeopardize the State's qualification to receive federal funds through the Medicaid Program."

Per Member Per Month (PMPM) Payments for Community Care of NC Primary Care Providers. - Session Laws 2013-360, s. 12H.22(a)-(d), provides: "(a) The Department of Health and Human Services shall contract with Community Care Networks, Inc. (NCCCN), to administer and distribute the funds currently allocated to per member per month (PMPM) payments for Community Care of North Carolina (CCNC) primary care providers. NCCCN shall distribute one hundred percent (100%) of the funds allocated to PMPM payments to primary care providers on a care management performance basis using criteria developed by NCCCN. In developing its pay for performance model, NCCCN shall (i) ensure an adequate statewide network of participating CCNC primary care providers and (ii) adopt a payment level of zero dollars ($0.00) for providers who do not satisfactorily participate in CCNC care management initiatives. Performance-based payments shall begin on July 1, 2014.

"(b) PMPM payments from the Department to CCNC primary care providers shall continue until the implementation of the performance-based payment system.

"(c) The Department shall consult with the Joint Legislative Oversight Committee on Health and Human Services on the performance-based payment proposal from NCCCN to incentivize better care management from primary care providers. If the Department submits a report and requests a meeting for the consultation, but the Oversight Committee does not hear the consultation within 90 days of the request, then the consultation requirement shall be deemed waived by the Oversight Committee. The report submitted for consultation shall include the following:

"(1) Measureable elements that will be used to differentiate care management performance-based payments from the existing PMPM payments.

"(2) A comparison of the performance plan to other measures such as the Healthcare Effectiveness Data and Information Set (HEDIS) or other national performance or quality measures.

"(3) The specific structure of when payments would be made.

"(4) An impact calculation of prospective payments under the performance-based payment plan and the current PMPM rates.

"(d) Subsection (a) of this section is contingent upon both of the following:

"(1) The Department's successful renegotiation of and modification to the existing contract or entering into a new contract with NCCCN to administer and distribute performance-based payments, as provided in subsection (a) of this section.

"(2) The consultation required under subsection (c) of this section or an implied waiver of the consultation requirement, as provided in subsection (c) of this section."

Session Laws 2014-100, s. 12H.19, effective July 1, 2014, provides: "It is the intent of the General Assembly that the structure of per member per month (PMPM) payments or other payments to providers participating in Community Care of North Carolina (CCNC) programs be considered as a part of any Medicaid reform plan for the State. Therefore, Section 12H.22 of S.L. 2013-360 is repealed."

Transformation of Medicaid and NC Health Choice Programs. - Session Laws 2015-245, ss. 1-9A, as amended by Session Laws, 2016-121, s. 2(a)-(e1), Session Laws 2017-57, s. 11H.17(a), Session Laws 2017-186, s. 4, Session Laws 2018-5, s. 11H.10(c), (d), Session Laws 2018-48, s. 1, Session Laws 2018-49, ss. 4-7, Session Laws 2019-81, s. 12-14, and Session Laws 2020-88, s. 7(a), provides: "Section 1. Codified as G.S. 108D-30 by Session Laws 2019-81, s. 14(a)(1), effective October 1, 2019.

"Section 2. Role of the General Assembly. - The General Assembly shall have the following roles and responsibilities in Medicaid and NC Health Choice transformation and governance:

"(1) Define the overall goals of transformation and the structure of the delivery system for the programs.

"(2) Monitor the development of transformation plans and implementation through the Joint Legislative Oversight Committee on Medicaid and NC Health Choice.

"(3) Define and approve eligibility categories, resource limits, and income thresholds for the programs, including which populations will be covered by Prepaid Health Plans (PHPs).

"(4) Appropriate the annual budget for the Medicaid and NC Health Choice programs.

"(5) Confirm the Director of the Division of Health Benefits, as required by G.S. 143B-216.85, enacted by Section 12 of this act.

"Section 3. Time Line for Medicaid Transformation. - The following milestones for Medicaid transformation shall occur no later than the following dates:

"(1) When this act becomes law. -

"a. The Division of Health Benefits of the Department of Health and Human Services (DHHS) is created pursuant to Section 10 of this act.

"b. The Joint Legislative Oversight Committee on Medicaid and NC Health Choice is created pursuant to Section 15 of this act to oversee the Medicaid and NC Health Choice programs.

"c. DHHS shall begin development of the 1115 waiver and any other State Plan amendments and waiver amendments necessary to effectuate the Medicaid transformation required by this act.

"(2) March 1, 2016. - DHHS shall report its plans and progress on Medicaid transformation, including recommended statutory changes, to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, as required by subdivision (12) of Section 5 of this act.

"(3) On or before June 1, 2016. - DHHS shall submit the waivers and State Plan amendments required by this act to the Centers for Medicare & Medicaid Services (CMS).

"Not later than July 1, 2021. - Capitated contracts shall begin. DHHS may phase recipient enrollment on a regional basis, provided that initial recipient enrollment shall be complete no later than five months after the date capitated contracts begin.

"Section 4. Structure of Delivery System. - The transformed Medicaid and NC Health Choice programs described in Section 1 of this act [now G.S. 108D-30] shall be organized according to the following principles and parameters:

"(1) DHHS authority. - The Department of Health and Human Services (DHHS) shall have full authority to manage the State's Medicaid and NC Health Choice programs provided that the total expenditures, net of agency receipts, do not exceed the authorized budget for each program, except the General Assembly shall determine eligibility categories, resource limits, and income thresholds. DHHS shall be responsible for planning and implementing the Medicaid transformation required by this act.

"(2) Prepaid Health Plan. - For purposes of this act, a Prepaid Health Plan (PHP) shall be defined as an entity, which may be a commercial plan or provider-led entity, that operates or will operate a capitated contract for the delivery of services pursuant to subdivision (3) of this section, or a local management entity/managed care organization (LME/MCO) that operates or will operate a BH IDD Tailored Plan pursuant to subdivision (10) of this section [now G.S. 108D-60]. For purposes of this act, the terms "commercial plan" and "provider-led entity" are defined as follows:

"a. Commercial plan or CP. - Any person, entity, or organization, profit or nonprofit, that undertakes to provide or arrange for the delivery of health care services to enrollees on a prepaid basis except for enrollee responsibility for copayments and deductibles and holds a PHP license issued by the Department of Insurance.

"b. Provider-led entity or PLE. - An entity that meets all of the following criteria:

"1. A majority of the entity's ownership is held by an individual or entity that has as its primary business purpose the ownership or operation of one or more capitated contracts described in subdivision (3) of this section or Medicaid and NC Health Choice providers.

"2. A majority of the entity's governing body is composed of individuals who (i) are licensed in the State as physicians, physician assistants, nurse practitioners, or psychologists and (ii) have experience treating beneficiaries of the North Carolina Medicaid program.

"3. Holds a PHP license issued by the Department of Insurance.

"(3) Capitated contracts. - The Division of Health Benefits, created in Section 10 of this act, shall enter into capitated contracts with PHPs for the delivery of Medicaid and NC Health Choice services as specified in this act. All capitated contracts shall be the result of requests for proposals (RFPs) issued by the Division of Health Benefits and the submission of competitive bids by PHPs, pursuant to subdivision (6) of Section 5 of this act [Most of subdivision (6) was codified as G.S.108D-65].

"(4) Codified as G.S. 108D-35 by Session Laws 2019-81, s. 14(a)(2), effective October 1, 2019.

"(5) Codified as G.S. 108D-40(a) by Session Laws 2019-81, s. 14(a)(3), effective October 1, 2019.

"(5a) Codified as G.S. 108D-40(b) by Session Laws 2019-81, s. 14(a)(4), effective October 1, 2019.

"(6) Codified as G.S. 108D-45 by Session Laws 2019-81, s. 14(a)(5), effective October 1, 2019.

"(6a) The Department of Health and Human Services, Division of Health Benefits, and the Department of Insurance shall jointly review the applicability of provisions of Chapter 58 of the General Statutes to PHPs, and report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice by March 1, 2016, on the following:

"a. Proposed exceptions to the applicability of Chapter 58 of the General Statutes for PHPs.

"b. Recommendations for resolving conflicts between Chapter 58 of the General Statutes and the requirements of Medicaid federal law and regulations.

"c. Proposed statutory changes necessary to implement this subdivision.

"(7) Codified as G.S. 108D-50 by Session Laws 2019-81, s. 14(a)(6), effective October 1, 2019.

"(8) Codified as G.S. 108D-55 by Session Laws 2019-81, s. 14(a)(7), effective October 1, 2019.

"(9) Codified as G.S. 122C-115(e) by Session Laws 2019-81, s. 14(a)(8), effective October 1, 2019.

"(10) [Portions of this subdivision were codified as G.S. 108D-60 by Session Laws 2019-81, s. 14(a)(9), effective October 1, 2019] BH IDD Tailored Plans. - DHHS shall not begin any application process to implement, establish rules for, or begin any contracting or procurement process with respect to BH IDD Tailored Plans, as defined in this subdivision, until August 31, 2018, or until authorized to do so in a subsequent act of the General Assembly, whichever comes first. BH IDD Tailored Plans shall be defined as capitated PHP contracts that meet all requirements in this act pertaining to capitated PHP contracts, except as specifically provided in this subdivision. Capitated PHP contracts that are not BH IDD Tailored Plans shall be referred to as Standard Benefit Plans. With regard to BH IDD Tailored Plans, the following shall occur:

"a. DHHS shall create a detailed plan for implementation of BH IDD Tailored Plans under the 1115 Waiver in accordance with the following requirements:

"1. In the event of the discontinuation of the 1915(b)/(c) Waivers, the following essential components of the 1915(b)/(c) Waivers shall be included in the 1115 Waiver:

"I. Entities operating BH IDD Tailored Plans shall authorize, pay for, and manage services currently offered under the 1915(b)/(c) Waivers, including coverage of 1915(b)(3) services, within their capitation payments.

"II. Entities operating BH IDD Tailored Plans shall operate care coordination functions.

"III. Entities operating BH IDD Tailored Plans shall oversee home and community-based services.

"IV. Entities operating BH IDD Tailored Plans shall maintain closed provider networks for behavioral health, intellectual and developmental disability, and traumatic brain injury services and shall ensure network adequacy.

"V. Entities operating BH IDD Tailored Plans shall manage provider rates.

"VI. Entities operating BH IDD Tailored Plans shall provide Local Business Plans.

"VII. The State Consumer and Family Advisory Committees shall continue to operate and advise DHHS and entities operating the BH IDD Tailored Plans.

"2. During the contract term of the initial contracts for BH IDD Tailored Plans to begin one year after the implementation of the first contracts for Standard Benefit Plans and to last four years, an LME/MCO shall be the only entity that may operate a BH IDD Tailored Plan. LME/MCOs operating BH IDD Tailored Plans shall receive all capitation payments under the BH IDD Tailored Plan contracts. Entities operating BH IDD Tailored Plan contracts shall conduct care coordination administrative functions for all services offered through the BH IDD Tailored Plans, and shall bear all risk for service utilization. This sub-sub-subdivision shall not be construed to preclude an entity operating a BH IDD Tailored Plan from engaging in incentives, risk sharing, or other contractual arrangements.

"3. During the contract term of the initial contracts for BH IDD Tailored Plans to begin one year after the implementation of the first contracts for Standard Benefit Plans and to last four years, BH IDD Tailored Plans shall be operated only by LME/MCOs that meet certain criteria established by DHHS. Any LME/MCO desiring to operate a BH IDD Tailored Plan will make an application to DHHS in response to this set of criteria. Approval to operate a BH IDD Tailored Plan will be contingent upon a comprehensive readiness review. The constituent counties of the existing LME/MCOs may change, or existing LME/MCOs may merge or be acquired by another LME/MCO, as allowed under Chapter 122C of the General Statutes, prior to operating a BH IDD Tailored Plan, provided that DHHS ensures every county in the State is covered by an LME/MCO that operates a BH IDD Tailored Plan. DHHS shall issue no more than seven and no fewer than five regional BH IDD Tailored Plan contracts and shall not issue any statewide BH IDD Tailored Plan contracts.

"4. After the term of the initial contracts for BH IDD Tailored Plans to last four years, BH IDD Tailored Plan contracts will be the result of RFPs issued by DHHS and the submission of competitive bids from nonprofit PHPs and entities operating the initial BH IDD Tailored Plan contracts.

"5. LME/MCOs operating BH IDD Tailored Plans shall contract with an entity that holds a PHP license and that covers the services required to be covered under a Standard Benefit Plan contract.

"6. Entities operating BH IDD Tailored Plans shall utilize closed provider networks only for the provision of behavioral health, intellectual and developmental disability, and traumatic brain injury services, notwithstanding sub-subdivision d. of subdivision (6) of Section 5 of this act.

"7. Entities authorized to operate BH IDD Tailored Plans shall be in compliance with applicable State law, regulations, and policy and shall meet certain criteria established by DHHS. These criteria shall include the ability to coordinate activities with local governments, county departments of social services, the Division of Juvenile Justice of the Department of Public Safety, and other related agencies.

"8. BH IDD Tailored Plans shall cover the behavioral health, intellectual and developmental disability, and traumatic brain injury services excluded from Standard Benefit Plan coverage under sub-subdivision a. of subdivision (4) of this section, in addition to the services required to be covered by all PHPs under subdivision (4) of this section.

"9. Entities authorized to operate BH IDD Tailored Plans shall continue to manage non-Medicaid behavioral health services funded with federal, State, and local funding in accordance with Chapter 122C of the General Statutes and other applicable State and federal law, rules, and regulations.

"10. Recipients described in sub-subdivision l . of subdivision (5) of this section shall be automatically enrolled with an entity operating a BH IDD Tailored Plan and shall have the option to enroll with a PHP operating a Standard Benefit Plan, provided that a recipient electing to enroll with a PHP operating a Standard Benefit Plan would only have access to the behavioral health services covered by the Standard Benefit Plans and would no longer have access to the behavioral health services excluded from Standard Benefit Plan coverage under sub-subdivision a. of subdivision (4) of this section, and provided that the recipient's informed consent shall be required prior to the recipient's enrollment with a PHP operating a Standard Benefit Plan.

"b. No later than June 22, 2018, DHHS shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice with a plan for the implementation of BH IDD Tailored Plans. At a minimum, the report shall contain the following:

"1. The date when BH IDD Tailored Plans are planned to be operational.

"2. The proposed parameters for contracts between LME/MCOs and partnering entities to operate a BH IDD Tailored Plan, including, but not limited to, incentive arrangements for providing integrated care and for achieving measurable outcomes, and strategies to minimize cost-shifting between the LME/MCO and the partnering entity.

"3. Proposed language for any legislative changes needed to implement the plan.

"4. A detailed description of the process by which recipients will be able to transition between BH IDD Tailored Plans and Standard Benefit Plans. At a minimum, this process must include the following:

"I. The proposed definition for a qualifying event, after which a Standard Benefit Plan enrollee would be eligible to enroll with a BH IDD Tailored Plan, and the proposed process for rapid enrollment in a BH IDD Tailored Plan after a qualifying event.

"II. A process for the periodic evaluation of BH IDD Tailored Plan enrollees with criteria to determine whether enrollees continue to require the comprehensive services managed by the BH IDD Tailored Plans or whether their needs can be adequately met through coverage by a Standard Benefit Plan.

"III. A detailed description of the process and criteria to be used for the assessments that are required under sub-subdivision l . of subdivision (5) of this section [now G.S. 108D-40(a)(12)] of individuals after their second visit to an emergency department for a psychiatric problem within the prior 18 months or after their second episode using behavioral health crisis services within the prior 18 months.

"IV. The manner by which a recipient's continuation of care shall be ensured when the recipient transitions between BH IDD Tailored Plans and Standard Benefit Plans or between Standard Benefit Plans and BH IDD Tailored Plans. This process should include a consideration of the maintenance of the recipient's care providers as well as any prior authorization approvals existing prior to the recipient transitioning between these two plans.

"5. An estimate of State spending under the 1115 Waiver if BH IDD Tailored Plans are implemented compared to an estimate of State spending under the 1115 Waiver if BH IDD Tailored Plans are not implemented.

"6. Specific measureable outcomes, along with a time frame for the achievement of each measureable outcome, to be included in the capitated PHP contracts for BH IDD Tailored Plans.

"7. A description of the solvency requirements for LME/MCOs operating BH IDD Tailored Plans describing how the solvency requirements relate to the solvency standards for PHPs set by the Department of Insurance under Section 6 of this act and how they relate to the solvency standards for LME/MCOs.

"8. Any anticipated barriers to the ability of BH IDD Tailored Plans to meet the standardized contract terms described in subdivision (6) of Section 5 of this act [much of subdivision (6) is now codified as G.S. 108D-65].

"9. Justification and proposed guidelines for the management of the closed provider networks utilized by the BH IDD Tailored Plans as required by sub-sub-subdivision 6. of sub-subdivision a. of this subdivision.

"10. A plan for adding recipients who are being served through the CAP/C program to the populations covered by BH IDD Tailored Plans.

"11. A plan for transitioning children aged zero to three years old with, or at risk for, developmental delay or disability.

"12. A plan for adding coverage, under BH IDD Tailored Plans or another specialty plan, of all recipients who are enrolled in the foster care system, who are enrolled in Medicaid under the former foster care eligibility category, who receive Title IV-E Adoption Assistance, or who are under the age of 26 and formerly received Title IV-E Adoption Assistance. This plan shall include assurances that these recipients will be supported in instances when they have a change in residence.

"c. After receiving the report required by sub-subdivision b. of this subdivision, the Joint Legislative Oversight Committee on Medicaid and NC Health Choice may recommend that the General Assembly consider proposed legislation during the 2018 Regular Session containing any modifications to the law that are necessary to implement BH IDD Tailored Plans.

"d. Beginning August 31, 2018, or when authorized by a subsequent act of the General Assembly, whichever comes first, DHHS is authorized to take any actions necessary to implement BH IDD Tailored Plans in accordance with all the requirements in this act, including all the requirements enumerated under sub-subdivision a. of this subdivision."

"Section 5. Codified as G.S. 108D-65 by Session Laws 2019-81, s. 14(a)(10), effective October 1, 2019, except: [Sub-subdivision d. of subdivision (6) and subdivisions (10), (11), (12), and (13), as set out below, were not codified.]

"d. A requirement that PHPs develop and maintain provider networks that meet access to care requirements for their enrollees. PHPs may not exclude providers from their networks except for failure to meet objective quality standards or refusal to accept network rates. Notwithstanding the previous sentence, PHPs must include all providers in their geographical coverage area that are designated essential providers by DHHS pursuant to subdivision (13) of this section, unless DHHS approves an alternative arrangement for securing the types of services offered by the essential providers.

"(10) Require all PHPs and Medicaid and NC Health Choice providers to submit data through the Health Information Exchange Network, as required by Section 12A.5 of House Bill 97, 2015 Regular Session, in order to ensure effective systems and connectivity to support clinical coordination of care, the exchange of information, and the availability of data to DHHS and the Division of Health Benefits to manage the Medicaid and NC Health Choice programs for the State.

"(11) Develop a Dual Eligibles Advisory Committee, which must include at least a reasonably representative sample of the populations receiving long-term services and supports covered by Medicaid. DHHS upon the advice of the Dual Eligibles Advisory Committee, shall develop a long-term strategy to cover dual eligibles through capitated PHP contracts and report the strategy to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice by January 31, 2017.

"(12) Report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice by March 1, 2016. At a minimum, this report shall include:

"a. The proposed waiver application.

"b. The expected time frame for the submission of the proposed waiver to CMS.

"c. Proposed statutory changes required.

"d. Status of staffing of the Division of Health Benefits, including a description of staff's key competencies and expertise.

"e. Anticipated distribution of regional capitated PHP contracts.

"f. Plans for recipient enrollment.

"g. Recipient access standards.

"h. Performance measures.

"i. A plan for the proposed inclusion of the following features as part of Medicaid and NC Health Choice transformation:

"1. Rate floors in addition to those required by subdivision (5) of Section 5 of this act [see now G.S. 108D-65].

"2. Antitrust policies.

"3. Protections against the exclusion of certain provider types.

"4. Prompt pay requirements.

"5. Uniform credentialing requirements.

"6. Good-faith negotiations.

"j. Time line for issuance of RFP and solicitation of bids.

"k. Measures for sustainability of the transformed system.

" l . A plan for transition of features of the contract with the North Carolina Community Care Network, Inc., (NCCCN) to the new delivery system, including a plan for utilizing, at the appropriate time, the Health Information Exchange Network to perform certain functions presently being performed by NCCCN's Informatics Center in conjunction with the primary care case management program.

"m. A plan to stabilize the Division of Medical Assistance during the transition of the Medicaid and NC Health Choice programs to the Division of Health Benefits.

"n. A plan that will ensure continuity of services for individuals in foster care and adoptive placements in the transformed Medicaid and NC Health Choice programs.

"(13) Designate Medicaid and NC Health Choice providers as essential providers if the provider either offers services that are not available from any other provider within a reasonable access standard or provides a substantial share of the total units of a particular service utilized by Medicaid and NC Health Choice recipients within the region during the last three years, and the combined capacity of other service providers in the region is insufficient to meet the total needs of the Medicaid and NC Health Choice enrollees. DHHS shall not classify physicians and other practitioners as essential providers. At a minimum, providers in the following categories shall be designated essential providers:

"a. Federally qualified health centers.

"b. Rural health centers.

"c. Free clinics.

"d. Local health departments.

"e. State Veterans Home.

"Section 6. Role of the Department of Insurance. - The transformed Medicaid and NC Health Choice system shall include the licensing of PHPs, as required by subdivision (2) of Section 4 of this act, based on solvency requirements established and implemented by the Department of Insurance. The Commissioner of Insurance, in consultation with the Director of the Division of Health Benefits, shall develop recommended solvency requirements that are similar to the solvency requirements for similarly situated regulated entities and recommended licensing procedures that include an annual review by the Commissioner and reporting of changes in licensure to the Division of Health Benefits. The Commissioner shall report the recommendations as well as proposed fees to offset the cost of licensure and any necessary statutory changes to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice by March 1, 2016.

"Section 7. Primary Care Case Management. - By July 1, 2016, DHHS will renegotiate its contract with North Carolina Community Care Networks, Inc., (NCCCN) to reduce per member per month payments to NCCCN for administration, including informatics, by fifteen percent (15%) from the amount of per member per month payments NCCCN received for January 2015. The renegotiated contract shall provide for greater efficiencies and facilitate a smooth transition of features of the enhanced primary care case management program, including case management, informatics center operations, and practice supports, to the primary care medical home model or other care management model that will be utilized by PHPs, consistent with the plan reported to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice pursuant to subdivision (12) of Section 5 of this act. The renegotiated contract shall also include performance measures and consequences for failing to meet those performance measures. DHHS shall continue to utilize NCCCN to perform existing functions until capitated PHP contracts begin as required by this act. When capitated PHP contracts begin, any contract with NCCCN existing on that date shall terminate. Funds equal to the amount of any savings achieved on or after August 1, 2015, by the Division of Medical Assistance as a result of the contract renegotiation required by this section shall be transferred to the Division of Health Benefits to be used for the transition to capitated PHP contracts.

"Section 7A. Codified as G.S. 108D-70 by Session Laws 2019-81, s. 14(a)(11), effective October 1, 2019.

"Section 8. Innovations Center. - DHHS shall submit a program design and budget proposal no later than May 1, 2016, to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice that will create a Medicaid and NC Health Choice Transformation Innovations Center with the purpose of assisting Medicaid and NC Health Choice providers in achieving the ultimate goals of better health, better care, and lower costs for North Carolinians. The center should be designed to support providers through technical assistance and learning collaboratives that foster peer-to-peer sharing of best practices. DHHS shall use the Oregon Health Authority's Transformation Center as a design model and shall consider at least the following features:

"(1) Learning collaboratives, peer-to-peer networks.

"(2) Clinical standards and supports.

"(3) Innovator agents.

"(4) Council of Clinical Innovators.

"(5) Community and stakeholder engagement.

"(6) Conferences and workshops.

"(7) Technical assistance.

"(8) Infrastructure support.

"Section 9. Maintain Funding Mechanisms. - In developing the waivers and State Plan amendments necessary to implement this act, DHHS shall work with the Centers for Medicare & Medicaid Services (CMS) to attempt to preserve existing levels of funding generated from Medicaid-specific funding streams, such as assessments, to the extent that the levels of funding may be preserved. If such Medicaid-specific funding cannot be maintained as currently implemented, then DHHS shall advise the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, created in Section 15 of this act, of any modifications necessary to maintain as much revenue as possible within the context of Medicaid transformation. If such Medicaid-specific funding streams cannot be preserved through the transformation process or if revenue would decrease, it is the intent of the General Assembly to modify such funding streams so that any supplemental payments to providers are more closely aligned to improving health outcomes and achieving overall Medicaid goals.

"Section 9A. Eligibility for Parents of Children in Foster Care. - DHHS is authorized to seek approval from CMS through the 1115 waiver required by subdivision (1) of Section 5 of this act [see now G.S. 108D-65(1)] to allow parents to retain Medicaid eligibility while their child is being served temporarily by the foster care program. It is the intent of the General Assembly to expand Medicaid eligibility to cover this population upon implementation of the 1115 waiver, if CMS approves this coverage in the waiver."

Session Laws 2018-49, s. 8(a)-(c), provides: "(a) It is the intent of the General Assembly to enact legislation, no later than March 15, 2019, that will ensure that the premium tax levied under G.S. 105-228.5 applies to capitation payments received by Prepaid Health Plans, as defined in G.S. 58-93-2, in the same manner in which the tax is applied to the gross premiums from business done in this State for all other health care plans and contracts of insurance provided by insurers or health maintenance organizations subject to the tax.

"(b) Until March 15, 2019, or such earlier date as the legislation described in subsection (a) of this section is enacted, the Department of Health and Human Services shall plan for the implementation of Medicaid transformation with the assumption that such legislation will be enacted. If the General Assembly has not ratified the legislation described in subsection (a) of this section by March 15, 2019, then the Department of Health and Human Services shall plan for the implementation of Medicaid transformation with the assumption that such legislation will be not enacted, and the Department shall correct all actions taken in reliance on the previous assumption, including the reissuance of the requests for proposals for capitated PHP contracts, if necessary.

"(c) By October 1, 2018, the Department of Health and Human Services, in consultation with the Department of Revenue, shall submit a report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice containing proposed legislative changes necessary to accomplish the intent set forth in subsection (a) of this section. The report shall include the following:

"(1) Assurances that the proposed legislative changes do not violate federal Medicaid laws or regulations.

"(2) An estimate of the amount of increase in revenue that is anticipated as a result of the proposed legislative changes, and any proposed uses for the increase in revenue."

Session Laws 2018-49, s. 10, provides: "The time frame within which the Department of Health and Human Services shall issue the requests for proposals required by subdivision (6) of Section 5 of S.L. 2015-245, as amended by Section 2(c) of S.L. 2016-121 and Section 6(b) of this act, shall be as follows:

"(1) If the 1115 demonstration waiver request submitted as required by this act on June 1, 2016, as amended, is not approved before the expiration of the 60 days after this act becomes law, then within 60 days after this act becomes law.

"(2) If the 1115 demonstration waiver request submitted as required by this act on June 1, 2016, as amended, is approved before the expiration of the 60 days after this act becomes law, then within 60 days after this act becomes law, or 30 days after the date of the waiver approval, whichever is later."

Session Laws 2020-88, s. 7(b), (c), provides: "(b) The Department of Health and Human Services (DHHS) shall amend the statewide and regional standard benefit plan prepaid health plan capitated contracts awarded as of June 1, 2020, so that the contract covers four contract year terms, instead of three, with the option to extend the contract for up to one successive contract year or a shorter period as required by DHHS.

"(c) If any prepaid health plan declines in writing to DHHS the contract amendment required under subsection (b) of this section, then that contract amendment shall not be required and the contract terms shall remain as in effect on June 1, 2020, until and unless amended by a future agreement."

Adult and Pediatric Traumatic Brain Injury Pilot Program. - Session Laws 2017-57, s. 11F.9(a)-(d), as amended by Session Laws 2017-212, s. 3.3, provides: "(a) The Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall establish an adult and pediatric traumatic brain injury pilot program, to be conducted at not less than three and not more than five trauma hospitals licensed in this State. The purpose of the pilot program is to increase compliance with internationally approved evidence-based treatment guidelines for severe adult and pediatric traumatic brain injury in order to reduce patient mortality, improve patient level of recovery, and reduce long-term care costs.

"(b) Of the funds appropriated in this act to the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, the sum of one hundred fifty thousand dollars ($150,000) in nonrecurring funds for the 2017-2018 fiscal year and the sum of three hundred thousand dollars ($300,000) in nonrecurring funds for the 2018-2019 fiscal year shall be used to enter into a contract with an independent entity to operate the pilot program authorized by this section. In so doing, the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, shall select an independent entity that has (i) developed software for an interactive quality assessment and quality assurance clinical decision support tool that provides real-time, evidence-based medical care guidance for intensive care unit patients with severe adult or pediatric traumatic brain injury and (ii) prior experience assisting trauma hospitals in other states in implementing this software. In consideration for payments made to the independent entity under the contract, the independent entity shall assume responsibility for all of the following:

"(1) Initiating and operating the pilot program, including the selection of not less than three and not more than five trauma hospitals licensed in this State to serve as pilot program sites.

"(2) Assisting participating trauma hospitals in implementing the software developed by the independent entity for use as an interactive quality assessment and quality assurance clinical decision support tool to provide real-time, evidence-based medical care guidance for intensive care unit patients with severe adult or pediatric traumatic brain injury. In providing such implementation assistance, the independent entity shall utilize the treatment guidelines and practice recommendations that have been peer reviewed and approved by the American Association of Neurological Surgeons and are recognized as the current standard of care for individuals with severe traumatic brain injury.

"(c) By February 1, 2018, the Department of Health and Human Services shall submit a progress report on the development and implementation of the pilot program authorized by this section to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division."

Medicaid Coverage for Nurse Family Partnership Model Pilot. - Session Laws 2017-57, s. 11H.14(a), (b), provides: "(a) It is the intent of the General Assembly to provide Medicaid and NC Health Choice coverage for evidence-based home visits for pregnant women and families with young children designed to improve maternal and child health, prevent child abuse and neglect, encourage positive parenting, and promote child development and school readiness that are consistent with the model used by Nurse-Family Partnership. No later than July 1, 2018, the Department of Health and Human Services, Division of Medical Assistance (Department), shall begin providing Medicaid and NC Health Choice coverage for home visits statewide or through a pilot program.

"The Department shall develop a plan to implement changes necessary to provide Medicaid and NC Health Choice coverage for home visits statewide or through a pilot program; however, consistent with G.S. 108A-54(e)(4), the Department is not authorized to make any changes to eligibility for the Medicaid or NC Health Choice programs. The plan shall detail the design and scope of coverage for the home visits for pregnant women and families with young children and include the identification of any State Plan Amendments or waivers that may be necessary to submit to the Centers for Medicare and Medicaid Services.

"(b) No later than November 1, 2017, the Department shall submit to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division a report containing the following information:

"(1) As required by subsection (a) of this section, a copy of the plan to provide, no later than July 1, 2018, Medicaid and NC Health Choice coverage for home visits statewide or through a pilot program.

"(2) A detailed description of the coverage to be provided, including the proposed service definition, the home visit schedule, the scope of the covered service, and the anticipated reimbursement rate to be paid.

"(3) An analysis of the total fiscal impact of adding Medicaid and NC Health Choice coverage for the home visits for pregnant women and families with young children. This shall include an outline of both costs and savings to the Medicaid and NC Health Choice programs, as well as any savings to other programs provided by the State.

"(4) A description of how the Department intends to leverage any private funding that may be currently utilized to provide coverage for evidence-based home visits for pregnant women and families with young children.

"(5) Whether the Department intends to add this coverage pursuant to its authority under G.S. 108A-54(e) or whether additional appropriations are required.

"(6) Any plans to include pay-for-success initiatives as part of the Medicaid and NC Health Choice funding for the covered service.

"(7) An anticipated time line for the implementation of the Department's plan and the submission of any necessary State Plan Amendments or waivers to the Centers for Medicare and Medicaid Services."

Session Laws 2018-5, s. 11H.3(a), (b), provides: "(a) No later than August 1, 2018, the Department of Health and Human Services (DHHS) shall submit to the Centers for Medicare and Medicaid Services any State Plan amendments or waivers necessary to draw down a Medicaid federal match for coverage of the services provided under the County Pilot A design contained in the DHHS report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice dated January 24, 2018, entitled "Plan to Implement Coverage for Home Visits for Pregnant Women and Families with Young Children." Coverage of the services provided under the County Pilot A design shall be expanded statewide upon the conclusion of the pilot. The State Plan amendment or waivers submitted under this section shall provide for the Medicaid federal match effective July 1, 2018, as well as for the future statewide implementation.

"(b) No later than November 1, 2018, the Department of Health and Human Services (DHHS) shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice on the expected savings associated with the County Pilot A design contained in the DHHS report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice dated January 24, 2018, entitled "Plan to Implement Coverage for Home Visits for Pregnant Women and Families with Young Children." The report shall also include an expected time line for statewide implementation and expected outcomes and savings associated with the statewide expansion.

"No later than six months after the conclusion of the County Pilot A program, DHHS shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on the actual outcomes and savings achieved through the County Pilot A program.

"For the purposes of this subsection, the term "savings" shall include, but is not limited to, savings based on outcomes related to the health status of pregnant women and babies, the utilization of services based on cost, savings generated due to a decline in hospitalizations, and savings associated with future health care costs of the mother and child."

Establish Medicaid Coverage for Ambulance Transports to Alternative Appropriate Care Locations - Session Laws 2017-57, s. 11H.14A(a), (b), provides: "(a) It is the intent of the General Assembly to provide opportunities to divert individuals in behavioral health crisis from hospital emergency departments to alternative appropriate care locations. Consistent with Option 1 outlined in the Department of Health and Human Services' (Department) March 1, 2015, legislative report entitled 'Ambulance Transports to Crisis Centers,' the Department shall design a plan for adding Medicaid coverage for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations. The plan shall ensure the following:

"(1) Medicaid reimbursement is contingent upon an Emergency Medical Services (EMS) System's ability to demonstrate its EMS providers have received appropriate education in caring for individuals in behavioral health crisis and that the EMS System has at least one partnership with a receiving facility that is able to provide care appropriate for those individuals.

"(2) An EMS System shall be required to include in its EMS System Plan a report on patient experiences and outcomes in accordance with rules adopted by the Department of Health and Human Services, Division of Health Regulation, Office of Emergency Medical Services.

"(b) No later than December 1, 2017, the Department shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice on the plan for adding Medicaid coverage for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations. The report shall include the following:

"(1) The proposed reimbursement methodology to be utilized.

"(2) An analysis of the financial impact of adding the coverage, including any anticipated costs to the Medicaid program.

"(3) Whether the Department intends to add this coverage pursuant to its authority under G.S. 108A-54(e) or whether additional appropriations are required.

"(4) If the Department intends to add this coverage pursuant to its authority under G.S. 108A-54(e), a time line for submission of any State Plan amendments or any waivers necessary for implementation and expected implementation date."

Session Laws 2018-5, s. 11H.4(a), (b), provides: "(a) No later than November 1, 2018, the Department of Health and Human Services shall submit to the Centers for Medicare and Medicaid Services (CMS) any State Plan amendments or any waivers necessary to establish Medicaid reimbursement for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations. Coverage under this section shall begin July 1, 2019, or upon CMS approval of any submitted State Plan amendments or waiver, whichever date is later.

"Coverage under this section shall meet the following requirements:

"Medicaid reimbursement for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations shall not be implemented until CMS approval of any submitted State Plan amendments or waivers has been received.

"(b) No later than December 1, 2018, the Department of Health and Human Services shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on the following:

"(1) As required by subsection (a) of this section, a copy of the State Plan amendment or waiver to establish Medicaid reimbursement for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations to begin July 1, 2019, including the proposed reimbursement methodology to be utilized.

"(2) Expected costs to the State associated with the establishment of Medicaid reimbursement for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations.

"(3) Expected outcomes and savings associated with the establishment of Medicaid reimbursement for ambulance transports of Medicaid recipients in behavioral health crisis to behavioral health clinics or other alternative appropriate care locations. Expected outcomes shall include an analysis of a reduction of transfers from hospital settings, an improvement in referral to and coordination of follow-up care, and general health status outcomes that result when a recipient is transported to an alternative appropriate care setting. Expected savings shall include an analysis of the cost difference of treatment in the alternative appropriate care location instead of a hospital emergency room setting.

"(4) Whether this coverage shall be included in the capitated Prepaid Health Plan contracts required by S.L. 2015-245, the capitated contracts with LME/MCOs, as defined in G.S. 122C-3, or both."

Editor's Note. - Session Laws 2000-67, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2000."'

Session Laws 2000-67, s. 28.2, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2000-2001 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2000-2001 fiscal year."

Session Laws 2000-67, s. 28.4, contains a severability clause.

Session Laws 2004-124, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2004'."

Session Laws 2004-124, s. 33.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2004-2005 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2004-2005 fiscal year."

Session Laws 2004-124, s. 33.5, contains a severability clause.

Session Laws 2005-276, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2005'."

Session Laws 2005-276, s. 46.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2005-2007 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2005-2007 fiscal biennium."

Session Laws 2005-276, s. 46.5 is a severability clause.

Laws 2006-66, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2006'."

Session Laws 2006-66, s. 28.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2006-2007 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2006-2007 fiscal year."

Session Laws 2006-66, s. 28.6 is a severability clause.

Session Laws 2007-323, s. 31.16.1(a), effective October 1, 2007, and applicable to Medicaid claims paid by the State on or after that date, provides: "Effective October 1, 2007, twenty-five percent (25%) of the nonfederal share of Medical Assistance Program costs and Medicare Part D clawback payments borne by the counties, excluding administrative costs, shall be borne by the State."

Session Laws 2007-323, s. 31.16.1(b), effective June 1, 2008, and applicable to Medicaid claims paid by the State on or after that date and ends with claims paid by the State through May 31, 2009, provides: "Effective July 1, 2008, fifty percent (50%) of the nonfederal share of Medical Assistance Program costs and Medicare Part D clawback payments borne by the counties, excluding administrative costs, shall be borne by the State."

Session Laws 2007-323, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2007'."

Session Laws 2007-323, s. 31.16.1(c), amends this section. According to the introductory language in s. 31.16.1(c), the amendment is effective July 1, 2009, whereas Session Laws 2007-323, s. 31.16.1(d), made the 2007 amendment effective June 1, 2009, and applicable to Medicaid claims paid on or after that date. Session Laws 2008-107, s. 10.10(c), amended Session Laws 2007-323, s. 31.16.1(d), to remove the effective date language and make the 2007 amendment applicable to Medicaid claims paid by the State on and after that date. The version of G.S. 108A-54 set out above contains amendments made by Session Laws 2007-323, s. 31.16.1(c).

Session Laws 2007-323, s. 32.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2007-2009 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2007-2009 fiscal biennium."

Session Laws 2007-323, s. 32.5 is a severability clause.

Session Laws 2008-107, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2008'."

Session Laws 2008-107, s. 30.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2008-2009 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2008-2009 fiscal year."

Session Laws 2008-107, s. 30.5 is a severability clause.

Session Laws 2009-451, s. 10.68, provides: "Consistent with Sections 31.16.1(c) and (d) of S.L. 2007-323 that require the State to assume responsibility for the nonfederal share of the costs of medical services provided under the Medicaid Program starting June 1, 2009, the counties shall neither bear any responsibility for settlement payments to providers nor refunds of expenditures for program service claims paid on or before June 1, 2009. Counties will continue to participate in their share of administrative costs."

Session Laws 2009-451, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2009'."

Session Laws 2009-451, s. 28.5 is a severability clause.

Session Laws 2011-145, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2011.'"

Session Laws 2011-145, s. 32.5 is a severability clause.

Session Laws 2011-375, s. 2, provides: "Notwithstanding 10A NCAC 22F.0402, a provider shall submit to the Division of Medical Assistance a written request for a Reconsideration Review within 30 working days from the date of the receipt of notice of tentative decision. Failure to request a Reconsideration Review in the specified time shall result in the implementation of the tentative decision as the Division's final decision. Any provider who had received notice of a tentative decision under 10A NCAC 22F.0402 on or after March 1, 2011, shall be eligible to resubmit a written request for Reconsideration Review within 30 working days of this act becoming law. The Department of Health and Human Services shall amend any rule in conflict with this provision."

Session Laws 2012-142, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2012.'"

Session Laws 2012-142, s. 27.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2012-2013 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2012-2013 fiscal year."

Session Laws 2012-142, s. 27.7 is a severability clause.

Session Laws 2013-5, s. 2, provides in part: "Such Medicaid funding for NC FAST obtained during fiscal year 2012-2013 is hereby appropriated to the Department for fiscal year 2012-2013 to develop NC FAST's ability to provide Medicaid eligibility determinations for the federally facilitated Health Benefit Exchange."

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Session Laws 2015-241, s. 12A.6(b), as amended by Session Laws 2016-94, s. 12A.2, provides: "Beginning on November 15, 2015, and monthly thereafter, the Department of Health and Human Services shall submit a report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division on the status of the implementation of ICD-10. The Department shall continue to submit the report by the 15th of each month until three consecutive months have passed in which the Department did not issue any hardship advances and until the new Department of Information Technology (DIT), created by this act, can assume this function. Thereafter, the Department or DIT, as appropriate, shall submit this report upon request of the Joint Legislative Oversight Committee on Health and Human Services. The report shall include all of the following items:

Session Laws 2015-245, s. 22A(a), (b), as added by Session Laws 2016-121, s. 2(j), provides: "(a) Notwithstanding any provision of S.L. 2015-241, as amended by S.L. 2015-263, S.L. 2015-264, S.L. 2015-267, S.L. 2015-268, S.L. 2015-276, S.L. 2015-286, and S.L. 2016-5, that requires a reduction within the Division of Medical Assistance, the Department of Health and Human Services (DHHS), is authorized to establish, maintain, or adjust all Medicaid program components, except for eligibility categories and income thresholds, within the appropriated and allocated budget for the Medicaid program, provided that the total Medicaid expenditures, net of agency receipts, do not exceed the authorized budget for the Medicaid program, in accordance with G.S. 108A-54(e).

"(b) If DHHS intends to maintain any program components as authorized by subsection (a) of this section, then no later than 60 calendar days after Senate Bill 838, 2015 Regular Session, becomes law, DHHS shall request that the Office of State Budget and Management (OSBM) certify that there are sufficient recurring Medicaid funds to maintain the program component. Within 30 calendar days after receiving DHHS's request, OBSM must respond to the request. If OSBM does not certify by the end of the 30-day period that there are sufficient recurring Medicaid funds to maintain the program component, then DHHS shall implement the reduction required by S.L. 2015-241, as amended by S.L. 2015-263, S.L. 2015-264, S.L. 2015-267, S.L. 2015-268, S.L. 2015-276, S.L. 2015-286, and S.L. 2016-5."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 11E.9, provides: "Beginning January 1, 2018, the Department of Health and Human Services shall implement the use of the Modified Adjusted Gross Income formula in the calculation of income for the purpose of determining eligibility for the AIDS Drug Assistance Program in order to ensure consistency in the Department's methods of determining eligibility for other benefit programs."

Session Laws 2017-57, s. 11H.15(a), provides: "The Department of Health and Human Services (Department) shall enhance the capability of the NC Tracks Medicaid Management Information System (MMIS) to include the ability to detect and prevent fraud, waste, and abuse prior to the payment of claims. Program changes shall be made to MMIS to prevent claims payment to providers when fraud, waste, or abuse is identified. The new capability required by this subsection shall utilize publicly available data regarding Medicaid providers and recipients. For this new capability, the Department shall establish criteria for the identification of suspicious claims, suspicious patterns of activity, or both without preselecting providers or recipients for review. Claims or patterns of activity identified by this new capability shall be evaluated utilizing a combination of automated and manual processes to determine the validity of the suspected fraud, waste, or abuse prior to the issuance of any payment to the provider for the suspicious claims.

"The new capability required by this subsection shall be implemented utilizing existing MMIS contracts no later than 150 days after this section becomes effective [June 28, 2017]. Nothing in this section shall be construed to change or limit any current laws or rules regarding prompt payment to providers or provider prepayment claims review."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 11H.9, provides: "By November 1, 2018, the Department of Health and Human Services shall submit to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division a detailed seven-year forecast for Medicaid Transformation, as required by S.L. 2015-245, as amended. The seven-year period for this forecast should include an annual budget detailing anticipated requirements, receipts, and appropriations for each fiscal year beginning with fiscal year 2018-2019 and ending with fiscal year 2024-2025. At a minimum, the following information for each fiscal year shall be addressed in the detailed seven-year forecast:

"(1) Forecasted enrollment by program aid category and the assumptions used in each forecast.

"(2) Forecasted claims run-out, and associated costs, for populations transitioning from a fee-for-service system to a managed care system and the assumptions used in developing this forecast.

"(3) Assumed capitation rates and fee-for-service per member per month costs, including at least all of the following components of those assumed rates and costs:

"a. Changes in utilization by service type for each program aid category compared to fiscal year 2017-2018, including what assumptions were used to forecast those changes.

"b. New programs or changes to existing programs.

"c. Any new reimbursement rates or methodologies proposed as part of Medicaid Transformation.

"(4) The assumed Federal Medical Assistance Program (FMAP) percentage.

"(5) Additions, changes, consolidations, and eliminations of administrative staff, Department functions, or contracts that occur as a result of Medicaid Transformation.

"(6) All anticipated infrastructure funding needed, including IT funding, and the FMAP assumptions and time line for receipt of funds from an enhanced FMAP rate associated with those needs.

"(7) A forecast of expenditures and receipts from cost settlements, program integrity, rebates, supplemental payments, Disproportionate Share Hospital (DSH) payments, intergovernmental transfers, assessments, and fees.

"(8) By line item or category, any recurring or nonrecurring Medicaid Transformation transition cost that is not otherwise addressed under this section, including costs associated with the elimination of the Division of Medical Assistance.

"(9) Any savings anticipated as a result of the transition from a fee-for-service system to a managed care system and the source or reason for the identified savings."

Session Laws 2018-5, s. 11H.13(b), as added by Session Laws 2018-97, s. 3.13, provides: "Notwithstanding any provision of this act, the Committee Report described in Section 39.2 of this act, any provision of S.L. 2017-57, as amended, or the Committee Report described in Section 39.2 of S.L. 2017-57 to the contrary, there is appropriated the sum of five million five hundred thousand dollars ($5,500,000) in recurring funds for fiscal year 2018-2019 to be used to increase the rate to no more than three dollars and ninety cents ($3.90) paid per 15-minute billing unit for in-home aide services provided under the Community Alternatives Program for Disabled Adults (CAP-DA) waiver pursuant to Clinical Coverage Policy 3K-2, effective January 1, 2019. Notwithstanding G.S. 108A-54(e), the rate paid per 15-minute billing unit for in-home aide services provided under the CAP-DA waiver pursuant to Clinical Coverage Policy 3K-2 shall not exceed three dollars and ninety cents ($3.90)."

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Session Laws 2018-136, 3rd Ex. Sess., s. 5.4(a)-(c), provides: "(a) The following definitions apply in this section:

"(1) DMH/DD/SAS. - The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services within the Department of Health and Human Services.

"(2) Federally declared disaster area. - Any county designated under a major disaster declaration by the President of the United States under the Stafford Act (P.L. 93-288) as a result of Hurricane Florence.

"(3) LME/MCO. - As defined in G.S. 122C-3.

"(4) Qualifying LME/MCO. - An LME/MCO with a catchment area that includes at least one federally declared disaster area.

"(b) It is the intent of the General Assembly to support individuals and families experiencing distress as a result of Hurricane Florence by meeting the increased demand for behavioral health services in the counties most impacted by Hurricane Florence. To that end, funds allocated in this act from the Hurricane Florence Disaster Recovery Fund to the Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, to increase single-stream funding, shall be allocated by DMH/DD/SAS among LME/MCOs with a catchment area that includes at least one federally declared disaster area. DMH/DD/SAS shall determine the basis for allocating these funds among qualifying LME/MCOs. Qualifying LME/MCOs shall not use these allocated funds for any purpose other than to fund mental health, developmental disabilities, and substance use disorder services that are (i) for individuals residing in a federally declared disaster area who have been determined by the LME/MCO to be in need of these services as a result of Hurricane Florence, and (ii) not reimbursable under the Medicaid program. Each qualifying LME/MCO shall offer at least the same level of single-stream service utilization required by Section 11F.2(b) of S.L. 2017-57, as amended, increased proportionately by the amount of single-stream funding allocated to the LME/MCO pursuant to this section.

"(c) Pursuant to its authority under G.S. 108A-54(e), the Department of Health and Human Services shall manage, within the Medicaid budget, any increased demand for behavioral health services reimbursable under the Medicaid program for individuals residing in a federally declared disaster area."

"(b) Counties that were phased-in the NC FAST Child Welfare System after January 1, 2019, may elect to opt out of the utilization of the Intake and Assessment functionality of the NC FAST system.

"(e) This section is effective when it becomes law."

Session Laws 2020-4, s. 1.1, provides: "This act shall be known as the '2020 COVID-19 Recovery Act.'"

Session Laws 2020-4, s. 1.2, provides: "Except as otherwise provided, the following definitions apply in this act:

"(1) CDC. - The federal Centers for Disease Control and Prevention.

"(2) Coronavirus or COVID-19. - The coronavirus disease 2019.

"(3) COVID-19 emergency. - The period beginning March 10, 2020, and ending on the date the Governor signs an executive order rescinding Executive Order No. 116 (2020), Declaration of a State of Emergency to Coordinate Response and Protective Actions to Prevent the Spread of COVID-19.

"(4) COVID-19 Recovery Legislation. - The following legislation enacted by Congress:

"a. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, P.L. 116-136.

"b. The Families First Coronavirus Response Act, P.L. 116-127.

"c. The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, P.L. 116-123.

"d. Paycheck Protection Program and Health Care Enhancement Act, P.L. 116-139."

Session Laws 2020-4, s. 1.3, provides: "The General Assembly finds that State government must serve as a facilitator in assisting local governments, communities, families, workers and other individuals, and businesses in accessing federal relief and recovery funds related to the COVID-19 pandemic. The purpose of this act is to fulfill the General Assembly's constitutional duty to appropriate all funds, including federal funds appropriated or otherwise made available under the COVID-19 Recovery Legislation, and to direct the use of those funds in a manner that is consistent with the authorizing federal legislation and that responsibly provides for the public health and economic well-being of the State."

Session Laws 2020-4, s. 4.5, as amended by Session Laws 2021-62, s. 1.1(a), provides: "The Department of Health and Human Services, Division of Health Benefits (DHB), is authorized to provide the Medicaid coverage described in 42 U.S.C.A. § 1396a(a)(10)(A)(ii)(XXIII), which covers COVID-19 testing for certain uninsured individuals during the period in which there is a declared nationwide public health emergency as a result of the 2019 novel coronavirus, and for which the federal medical assistance percentage is one hundred percent (100%). DHB is authorized to provide this medical assistance retroactively to the earliest date allowable. Notwithstanding G.S. 108D-40, individuals receiving this Medicaid coverage shall not be covered by capitated prepaid health plan contracts under Article 4 of Chapter 108D of the General Statutes."

Session Laws 2020-4, s. 4.6, as amended by Session Laws 2021-3, s. 2.1, provides: "In addition to the five percent (5%) rate increases already requested by the Department of Health and Human Services (DHHS) in the 1135 Medicaid disaster State Plan amendment (SPA) submitted to the Centers for Medicare and Medicaid Services on April 8, 2020, for certain provider types, DHHS shall increase the fee-for-service Medicaid rates paid directly by the Division of Health Benefits for all remaining provider types by five percent (5%). The rate increases authorized under this section shall be effective March 1, 2020. Any rate increases authorized under this section shall expire on the earlier of the following dates:

"(1) The date the declared nationwide public health emergency as a result of the 2019 novel coronavirus expires.

"(2) The date Executive Order No. 116, Declaration of a State of Emergency to Coordinate Response and Protective Actions to Prevent the Spread of COVID-19 expires or is rescinded.

"(3) June 30, 2021."

Session Laws 2020-4, s. 4.8, provides: "Effective no later than June 1, 2020, the eligibility requirements for the Disabled Adult Child Passalong authorized under section 1634 of the Social Security Act for the Medicaid program shall consist of only the following four requirements:

"(1) The adult is currently entitled to and receives federal Retirement, Survivors, and Disability Insurance (RSDI) benefits as a disabled adult child on a parent's record due to the retirement, death, or disability of a parent.

"(2) The adult is blind or has a disability that began before age 22.

"(3) The adult would currently be eligible for Supplemental Security Income (SSI) or State-County Special Assistance if the current RSDI benefit is disregarded.

"(4) For eligibility that is based on former receipt of State-County Special Assistance and not SSI, the adult must currently reside in an adult care home."

Session Laws 2020-4, s. 5.2, is a severability clause.

Session Laws 2020-78, s. 4D.2, provides: "The Department of Health and Human Services (Department) shall issue Medicaid identification cards to recipients on an annual basis with updates as needed. The Department shall adopt rules, or amend any current rules relating to Medicaid identification cards, to implement this section. No later than February 1, 2021, the Department shall submit a report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice confirming the adoption or amendment of rules in accordance with this section."

Session Laws 2020-78, s. 4D.3, provides: "The Department of Health and Human Services, Division of Health Benefits, may, subject to the approval of a change in the State Medicaid Plan, contract for services, medical equipment, supplies, and appliances by implementation of volume purchase plans, single source procurement, or other contracting processes in order to improve cost containment."

Session Laws 2020-78, s. 22.3, is a severability clause.

Session Laws 2020-88, s. 6(a)-(e), provides: "(a) County departments of social services shall do all of the following:

"(1) Resume Medicaid eligibility redeterminations for beneficiaries whose annual or other periodic renewal of Medicaid eligibility is due on or after September 1, 2020.

"(2) Resume requesting post-eligibility verification information for Medicaid applications received on or after September 1, 2020.

Effect of Amendments. - Session Laws 2007-323, s. 31.16.1(c), rewrote the section. For effective date, see the Editor's note.

Session Laws 2011-399, s. 5, effective July 25, 2011, added the subsection (a) designation; and added subsection (b).

Session Laws 2013-5, s. 2, effective March 6, 2013, added subsection (d).

Session Laws 2013-360, s. 12H.3, as amended by Session Laws 2013-363, s. 4.9(a), effective July 1, 2013, added the fourth sentence in subsection (a); and added subsection (c).

Session Laws 2013-360, s. 12H.9(a), effective July 1, 2013, recodified former subsection (b) as G.S. 108A-54.1B(a).

Session Laws 2015-245, s. 13, effective September 23, 2015, added subsections (e) through (g).

Session Laws 2016-94, s. 12H.4, effective July 1, 2016, deleted "through the Division of Health Benefits" following "Department of Health and Human Services" in the introductory language of subsection (e); and substituted "the Medicaid program and NC Health Choice program" for "each program" at the end of the first sentence in subdivision (e)(1).

Session Laws 2016-121, s. 2(h), effective June 1, 2016, rewrote the introductory language of subsection (e); substituted "the Medicaid program and NC Health Choice program" for "each program" at the end of the first sentence in subdivision (e)(1); deleted "through the Division of Health Benefits" following "Services" near the middle of subsection (f); and deleted former subsection (g).

Session Laws 2018-5, s. 11H.10(a), (b), effective July 1, 2018, in subdivision (e)(4) and subsection (f), substituted "categories, resource limits, and income" for "categories and income."

CASE NOTES

North Carolina Department of Health and Human Services is the agency responsible for operating the state's Medicaid plan. A local political subdivision of the State under G.S. 122C-116(a), is one which has contracted with the NCDHHS to operate a managed care Medicaid program on the state's behalf. K.C. v. Shipman, 716 F.3d 107 (4th Cir. 2013).

ALJ and trial court had jurisdiction to hear a Medicaid provider's contest to the North Carolina Department of Health and Human Services' (DHHS) decision that the provider received an overpayment, despite the provider's failure to appeal that decision within 60 days of receiving a private contractor's tentative notice of overpayment (TNO), because the TNO did not begin the time for appealing an administrative decision as DHHS could not delegate the discretionary authority to decide how to dispose of the issue to the private contractor as (1) DHHS was the state's single state agency authorized to make such decisions, and (2) the TNO stated a "final decision" would be reached in the future, so the TNO did not inform the provider of DHHS's final decision on the matter, which initiated the appeal time. N.C. HHS v. Parker Home Care, LLC, 246 N.C. App. 551, 784 S.E.2d 552 (2016), review denied, mot. dismissed, stay denied, 793 S.E.2d 690, 2016 N.C. LEXIS 988 (2016); mot. dismissed, as moot, 793 S.E.2d 688, 2016 N.C. LEXIS 1013 (2016).

Cited in Charlotte-Mecklenburg Hosp. Auth. v. N.C. HHS, 201 N.C. App. 70, 685 S.E.2d 562 (2009), review denied 363 N.C. 854, 694 S.E.2d 201, 2010 N.C. LEXIS 224 (2010); Cloninger v. N.C. HHS, 203 N.C. App. 345, 691 S.E.2d 127 (2010), review denied 364 N.C. 324, 2010 N.C. LEXIS 1083 (2010).

§ 108A-54.1: Recodified as G.S. 108A-66.1 by Session Laws 2013-360, s. 12H.10(f), effective July 1, 2013.

§ 108A-54.1A. Amendments to Medicaid State Plan and Medicaid Waivers.

The Department of Health and Human Services is expressly authorized and required to take any and all necessary action to amend the State Plan and waivers in order to keep the program within the certified budget, except as provided in G.S. 108A-54(f). For purposes of this section, the term "amendments to the State Plan" includes State Plan amendments, Waivers, and Waiver amendments.
, (c) Repealed by Session Laws 2015-245, s. 18, effective September 23, 2015.
No fewer than 10 days prior to submitting an amendment to the State Plan to the federal government, the Department shall post the amendment on its Web site and notify the members of the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division that the amendment has been posted. For any amendments to the State Plan that add or eliminate an optional service, the notice required by this subsection shall be 90 days. This notice requirement shall not apply to draft or proposed amendments submitted to the federal government for comments but not submitted for approval.
Repealed by Session Laws 2015-245, s. 18, effective September 23, 2015.
Any public notice required under 42 C.F.R. 447.205 shall, in addition to any other posting requirements under federal law, be posted on the Department's Web site. Upon posting such a public notice, the Department shall notify the members of the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division that the public notice has been posted. Public notices shall remain posted on the Department's Web site.

History

(2013-360, s. 12H.2(a); 2014-100, s. 12H.21(a); 2015-245, s. 18.)

Primary Care Case Management for Dual Eligibles. - Session Laws 2014-100, s. 12H.20(a), provides: "The Department of Health and Human Services, Division of Medical Assistance, shall draft one or more waivers that would expand primary care case management and that are designed to accomplish the following:

"(1) Medicare and Medicaid dual eligibles shall be required to enroll in primary care case management to the maximum extent allowed by the Centers for Medicare and Medicaid Services (CMS).

"(2) Primary care case management shall be provided for enrolled dual eligibles.

"(3) Primary care case management for dual eligibles with a primary diagnosis of mental illness or intellectual or developmental disability may be administered by the LME/MCOs.

"The Department may submit drafts of the waivers to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waivers for CMS approval until authorized by the General Assembly."

Session Laws 2014-100, s. 12H.20(b), provides: "No later than March 1, 2015, the Department shall submit to the House Appropriations Subcommittee on Health and Human Services and the Senate Appropriations Committee on Health and Human Services a copy of the draft waivers and a report, which shall include the following:

"(1) The anticipated increase in number of dual eligibles that will enroll in primary care case management.

"(2) The costs associated with serving the increased number of enrolled dual eligibles.

"(3) The anticipated savings to the Medicaid program."

Drug Ingredient Pricing Methodology. - Session Laws 2014-100, s. 12H.8(a)-(c), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall adopt an average acquisition cost methodology for brand and generic drug ingredient pricing to be effective beginning on January 1, 2015. The drug ingredient pricing methodology shall be consistent with new federal requirements or, if the new federal requirements have not yet been finalized by October 1, 2014, consistent with the draft federal requirements. In adopting a new drug ingredient pricing methodology, the Department shall also do all of the following:

"(1) Raise dispensing fees so that the average acquisition cost ingredient pricing plus the dispensing fees, net of any drug rebates, generates nine hundred seventy-five thousand dollars ($975,000) in savings in General Fund appropriations.

"(2) Maintain a distinction between the dispensing fees for preferred and brand drugs.

"(3) Ensure that ingredient prices are updated at least monthly.

"(b) The Department of Health and Human Services, Division of Medical Assistance, shall issue a request for proposals (RFP) for a contractor to perform a statewide drug dispensing fee study to begin on March 1, 2015. The Department shall use the one hundred thousand dollars ($100,000) appropriated in this budget for this study as the State share to draw down additional federal Medicaid funds for this study.

"(c) The Department of Health and Human Services, Division of Medical Assistance, shall follow the procedures in G.S. 108A-54.1A in submitting the State plan amendment required to implement this section."

Session Laws 2015-241, s. 12H.19(a), (b), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, (Department) shall adopt an average acquisition cost methodology for brand and generic drug ingredient pricing to be effective beginning on January 1, 2016. The drug ingredient pricing methodology shall be consistent with new federal requirements or, if the new federal requirements have not yet been finalized by July 1, 2015, consistent with the most recent draft federal requirements. In adopting a new drug ingredient pricing methodology, the Department shall also do all of the following:

"(1) Raise the average dispensing fee to a weighted average amount that does not exceed twelve dollars and forty cents ($12.40).

"(2) Set actual dispensing fees that maintain a higher dispensing fee for preferred and generic drugs and a lower dispensing fee for brand and nonpreferred drugs.

"(3) Ensure that ingredient prices are updated at least monthly.

"(b) In order to implement this section, the Department shall either amend the State plan amendment request submitted to the Centers for Medicare and Medicaid Services (CMS) pursuant to Section 12H.8 of S.L. 2014-100 so that it conforms with the requirements of this section or shall withdraw that State plan amendment and submit a new State plan amendment request to CMS that conforms with the requirements of this section. Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed] but shall be submitted by January 1, 2016."

Graduate Medical Education. - Session Laws 2015-241, s. 12H.23(a)-(d), as amended by Session Laws 2015-264, s. 88, provides: "(a) The Department of Health and Human Services shall submit a State Plan amendment to modify Section 4.19-A of the Medicaid State Plan, such that, effective January 1, 2016, no Medicaid provider may receive reimbursement for Graduate Medical Education (GME) in addition to their DRG Unit Value (Base) rate under the methodology as defined in the current Medicaid State Plan.

"(b) The modification to the Medicaid State Plan required by subsection (a) of this section shall be implemented upon approval by the Centers for Medicare & Medicaid Services (CMS).

"(c) The Department of Health and Human Services, Division of Medical Assistance, shall be exempt from the 90-day prior submission requirement in G.S. 108A-54.1A(e) [repealed] in order to submit to CMS the State Plan amendment required to implement this section but shall submit the State Plan amendment by January 1, 2016.

"(d) The Department of Health and Human Services, Division of Medical Assistance, shall submit a report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division by March 1, 2016, identifying options for alternative funding streams to replace the GME reimbursement eliminated by this section."

Session Laws 2020-88, s. 9, repealed Session Laws 2015-241, s. 12H.23(a)-(d), as amended by Session Laws 2015-264, s. 88, effective July 2, 2020.

Editor's Note. - Session Laws 2013-360, s. 12H.2(c), provides: "The Department of Health and Human Services shall take any and all action necessary to amend the Medicaid State Plan, Attachment 4.19-B, Section 5, Page 2, which pertains to supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical professional providers, in order to limit the definition of eligible medical professional providers to only physicians employed by the East Carolina University School of Medicine or the University of North Carolina at Chapel Hill School of Medicine as academic faculty. The supplemental payments shall be made only for services provided at these schools of medicine."

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Session Laws 2013-363, s. 4.14(a), provides: "The Department of Health and Human Services shall take any and all action necessary to amend the Medicaid State Plan, Attachment 4.19-B, Section 5, Page 2, which pertains to supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical professional providers, in order to limit the definition of eligible medical professional providers to only eligible medical professional providers who were receiving such supplemental payments as of May 22, 2013."

Session Laws 2014-100, s. 12H.21(c), provides: "By repealing language in subsection (b) of this section related to giving to the General Assembly notice of a public notice, it is not the intent of the General Assembly to remove the required notice of the changes to reimbursement amounts for services, equipment, or supplies. Rather, it is the intent that those notices be given pursuant to G.S. 108A-54.1A(f), rather than pursuant to both G.S. 108A-54.1A(f) and G.S. 108A-55(c)."

Session Laws 2014-100, s. 12H.21(d), made the amendment to subsection (e) by Session Laws 2014-100, s. 12H.21(a), applicable to State Plan Amendments with effective dates on or after December 1, 2014.

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Session Laws 2015-241, s. 12H.20(a), (b), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall submit a State Plan amendment request to the Centers for Medicare and Medicaid Services to assure that all State-operated dental schools receive the same reimbursement for dental services provided to North Carolina Medicaid beneficiaries.

"(b) The State Plan amendment required by this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed]."

Session Laws 2015-241, s. 12H.22(a), (b), provides: "(a) Effective January 1, 2016, the Department of Health and Human Services, Division of Medical Assistance, shall increase by ten percent (10%) the rate paid for private duty nursing services provided pursuant to Clinical Coverage Policy 3G.

"(b) Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed] but shall be submitted by January 1, 2016."

Session Laws 2015-241, s. 12H.26(c), provides: "Any State Plan amendments required to implement this section shall not be subject to the 90-day prior submission requirements of G.S. 108A-54.1A(e) [repealed] and G.S. 108A-70.25(b)."

Session Laws 2015-241, s. 12H.27(a), (b), provides: "(a) Notwithstanding any other provision of law, the Department of Health and Human Services, Division of Medical Assistance, (Department) is authorized to use any reimbursement methodology or arrangement to provide Medicaid coverage for blood glucose testing equipment and supplies, provided that the Department's total requirements, net of rebates, for providing blood glucose testing equipment and supplies does not exceed one million nine hundred thirty-three thousand three hundred fifty-seven dollars ($1,933,357) in fiscal year 2015-2016 and two million twenty thousand nine hundred seventy-four dollars ($2,020,974) in fiscal year 2016-2017.

"(b) Any state plan amendment submitted to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed]."

Session Laws 2015-241, s. 12H.30, as added by Session Laws 2015-264, s. 89, provides: "The Department of Health and Human Services, Division of Medical Assistance, shall submit a Medicaid State Plan amendment request to the Centers for Medicare and Medicaid Services (CMS) to amend the annual cost settlement methodology for local health departments, as defined in Article 2 of Chapter 130A of the General Statutes. The State Plan amendment shall provide a methodology that maximizes identification of allowable Medicaid costs in order to assure that North Carolina is receiving the maximum federal reimbursement for local health departments' treatment of Medicaid-eligible patients consistent with Medicare reimbursement principles. The State Plan amendment required by this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1A(e) [repealed] but shall be submitted by February 15, 2016 and shall apply to cost reports with a fiscal year beginning July 1, 2016 and thereafter. This section shall not be construed to require the Department to submit to CMS a State Plan amendment that increases State funding requirements."

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 12H.12, provides: "It is the intent of the General Assembly to explore all possible funding options to maintain or expand reimbursement for Graduate Medical Education."

Session Laws 2016-94, s. 39.7, is a severability clause.

Session Laws 2017-57, s. 11H.13(a)-(c), provides: "(a) For the period of July 1, 2017, through June 30, 2019, the Department of Health and Human Services, Division of Medical Assistance (DMA), shall no longer be required to implement the prohibitions on reimbursement for Graduate Medical Education (GME) payments required by Section 12H.23 of S.L. 2015-241, as amended by Section 88 of S.L. 2015-264.

"(b) It is the intent of the General Assembly to continue to appropriate funds to the Department of Health and Human Services in years beyond this fiscal biennium in order to maintain the GME add-on to the DRG Unit Value (Base) rate as part of Medicaid Transformation, as described in S.L. 2015-241.

"(c) No later than January 1, 2018, DMA shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on all of the following:

"(1) The actual and forecasted total requirements less receipts for payments made for the GME add-on to the DRG Unit Value (Base) rate.

"(2) The actual and forecasted total requirements less receipts for all Medicaid spending.

"(3) Any specific actions the Department of Health and Human Services has taken or proposes to take to maintain total Medicaid spending within the amounts appropriated for the Medicaid program."

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Effect of Amendments. - Session Laws 2014-100, s. 12H.21(a), effective September 1, 2014, inserted the third sentence in subsection (d); added the last sentence in subsection (e); and added subsection (f). See Editor's note for applicability.

Session Laws 2015-245, s. 18, effective September 23, 2015, rewrote the first sentence of subsection (a), which formerly read: "No provision in the Medicaid State Plan or in a Medicaid Waiver may expand or otherwise alter the scope or purpose of the Medicaid program from that authorized by law enacted by the General Assembly"; deleted subsections (b) and (c); in subsection (d), substituted "Medicaid and NC Health Choice" for "Health and Human Services" in the first sentence, inserted the second sentence, inserted "notice" in the present third sentence, and deleted the former last two sentences; and deleted subsection (e).

§ 108A-54.1B. Adoption of rules; State Plans, including amendments and waivers to State Plans, have effect of rules.

The Department is expressly authorized to adopt temporary and permanent rules to implement or define the federal laws and regulations, the North Carolina State Plan of Medical Assistance, and the North Carolina State Plan of the Health Insurance Program for Children, the terms and conditions of eligibility for applicants and recipients of the Medical Assistance Program and the Health Insurance Program for Children, audits and program integrity, the services, goods, supplies, or merchandise made available to recipients of the Medical Assistance Program and the Health Insurance Program for Children, and reimbursement for the services, goods, supplies, or merchandise made available to recipients of the Medical Assistance Program and the Health Insurance Program for Children.
Rule-making authority granted under this section for particular circumstances or programs is in addition to any other rule-making authority granted to the Department under Chapter 150B of the General Statutes.
Prior to filing a temporary rule authorized under G.S. 150B-21.1(a)(17) with the Rules Review Commission and the Office of Administrative Hearings, the Department shall consult with the Office of State Budget and Management on the possible fiscal impact of the temporary rule and its effect on State appropriations and local governments.
State Plans, State Plan Amendments, and Waivers approved by the Centers for Medicare and Medicaid Services (CMS) for the North Carolina Medicaid Program and the NC Health Choice program shall have the force and effect of rules adopted pursuant to Article 2A of Chapter 150B of the General Statutes.

History

(2013-360, s. 12H.9(a), (b).)

Effect of Amendments. - Session Laws 2013-360, s. 12H.9(a), effective July 1, 2013, recodified former G.S. 108A-54(b) as subsection (a).

Session Laws 2013-360, s. 12H.9(b), effective July 1, 2013, added the section heading and subsections (b), (c), and (d).

§ 108A-54.2. Procedures for changing medical policy.

The Department shall adopt rules to develop, amend, and adopt medical coverage policy for Medicaid and NC Health Choice in accordance with this section.
Medical coverage policy is defined as those policies, definitions, or guidelines utilized to evaluate, treat, or support the health or developmental conditions of a recipient so as to determine eligibility, authorization or continued authorization, medical necessity, course of treatment and supports, clinical outcomes, and clinical supports treatment practices for a covered procedure, product, or service. Medical coverage policy is subject to the following:
1. During the development of new medical coverage policy or amendment to existing medical coverage policy, the Department shall consult with and seek the advice of the Physician Advisory Group and other organizations the Secretary deems appropriate. The Secretary shall also consult with and seek the advice of officials of the professional societies or associations representing providers who are affected by the new medical coverage policy or amendments to existing medical coverage policy.
2. At least 45 days prior to the adoption of new or amended medical coverage policy, the Department shall:
  1. Publish the proposed new or amended medical coverage policy on the Department's Web site;
  2. Notify all Medicaid and NC Health Choice providers of the proposed, new, or amended policy; and
  3. Upon request, provide persons copies of the proposed medical coverage policy.
3. During the 45-day period immediately following publication of the proposed new or amended medical coverage policy, the Department shall accept oral and written comments on the proposed new or amended policy.
4. If, following the comment period, the proposed new or amended medical coverage policy is modified, then the Department shall, at least 15 days prior to its adoption:
  1. Notify all Medicaid and NC Health Choice providers of the proposed policy;
  2. Upon request, provide persons notice of amendments to the proposed policy; and
  3. Accept additional oral or written comments during this 15-day period.
If the adoption of new or amended medical coverage policies is necessitated by an act of the General Assembly or a change in federal law, then the 45- and 15-day time periods specified in subsection (b) of this section shall instead be 30- and 10-day time periods.
Repealed by Session Laws 2015-245, s. 19, effective September 23, 2015.

History

(2006-66, s. 10.4; 2009-451, s. 10.68A(b); 2011-399, s. 4; 2013-360, s. 12H.6(a); 2015-245, s. 19.)

Cross References. - As to Medicaid and Health Choice provider requirements, see Chapter 108C, G.S. 108C-1 et seq.

NC Health Choice Medical Policy. - Session Laws 2011-145, s. 10.27, provides: "Unless required for compliance with federal law, the Department shall not change medical policy affecting the amount, sufficiency, duration, and scope of NC Health Choice health care services and who may provide services until the Division of Medical Assistance has prepared a five-year fiscal analysis documenting the increased cost of the proposed change in medical policy and submitted it for departmental review. If the fiscal impact indicated by the fiscal analysis for any proposed medical policy change exceeds one million dollars ($1,000,000) in total requirements for a given fiscal year, then the Department shall submit the proposed medical policy change with the fiscal analysis to the Office of State Budget and Management and the Fiscal Research Division. The Department shall not implement any proposed medical policy change exceeding one million dollars ($1,000,000) in total requirements for a given fiscal year unless the source of State funding is identified and approved by the Office of State Budget and Management. For medical policy changes exceeding one million dollars ($1,000,000) in total requirements for a given fiscal year that are required for compliance with federal law, the Department shall submit the proposed medical policy or policy interpretation change with a five-year fiscal analysis to the Office of State Budget and Management prior to implementing the change. The Department shall provide the Office of State Budget and Management and the Fiscal Research Division a quarterly report itemizing all medical policy changes with total requirements of less than one million dollars ($1,000,000)."

For prior similar provisions, see Session Laws 2009-451, s. 10.33.

Editor's Note. - Session Laws 2011-399, s. 6, made the amendment to this section by Session Laws 2011-399, s. 4, applicable to medical coverage policies entered into or amended on or January 1, 2012.

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Effect of Amendments. - Session Laws 2009-451, s. 10.68A(b), effective July 1, 2009, deleted "of the North Carolina Medical Society" following "Physician Advisory Group" in the first sentence of subdivision (1).

Session Laws 2011-399, s. 4, effective January 1, 2012, and applicable to medical coverage policies entered into or amended on or after that date, added the subsection (a) designation, and therein inserted "adopt rules to" and substituted "with this section" for "with the following"; and added the subsection (b) designation, and therein added the introductory paragraph.

Session Laws 2013-360, s. 12H.6(a), effective July 1, 2013, added "for Medicaid and NC Health Choice" in subsection (a); added the last sentence in subsection (b); added "the Department shall" in subdivisions (b)(1) and (b)(3); added "and NC Health Choice" in sub-subdivisions (b)(2)b. and (b)(4)a.; added subsections (c) and (d).

Session Laws 2015-245, s. 19, effective September 23, 2015, deleted subsection (d).

§ 108A-54.3: Repealed by Session Laws 2013-360, s. 12H.6(b), effective July 26, 2013.

History

(2009-451, s. 10.32; 2011-145, s. 10.41(a); repealed by 2013-360, s. 12H.6(b), effective July 26, 2013.)

Cross References. - As to Medicaid and Health Choice provider requirements, see Chapter 108C, G.S. 108C-1 et seq.

Editor's Note. - Former G.S. 108A-54.3 pertained to procedures for changing medical policy.

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

§ 108A-54.3A. Eligibility categories and income thresholds.

The Department shall provide Medicaid coverage for individuals in accordance with federal statutes and regulations and specifically shall provide coverage for the following populations:

Families, children under the age of 21, pregnant women, and individuals who are aged, blind, or disabled, who are medically needy, subject to the following annual income levels after meeting the applicable deductible:
Families and children under the age of 21, subject to the following annual income levels:
Children under the age of 6 with family incomes equal to or less than two hundred ten percent (210%) of the federal poverty guidelines.
Children aged 6 through 18 with family incomes equal to or less than one hundred thirty-three percent (133%) of the federal poverty guidelines.
Children under the age of 21 who are receiving foster care or adoption assistance under Title IV-E of the Social Security Act, without regard to income.
Children in the legal custody of State-sponsored foster care who are under the age of 21 and ineligible for Title IV-E assistance, without regard to income.
Independent foster care adolescents ages 18, 19, and 20, as defined in 42 U.S.C. § 1396d(w)(1), without regard to income.
Former foster care children under the age of 26 in accordance with 42 U.S.C. § 1396a(a)(10)(A)(i)(IX), without regard to income.
Adoptive children with special or rehabilitative needs, regardless of the adoptive family's income.
Pregnant women with incomes equal to or less than one hundred ninety-six percent (196%) of the federal poverty guidelines. Coverage for pregnant women eligible under this subdivision include only services related to pregnancy and to other conditions determined by the Department as conditions that may complicate pregnancy.
Men and women of childbearing age with family incomes equal to or less than one hundred ninety-five percent (195%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to coverage for family planning services.
Women who need treatment for breast or cervical cancer and who are defined in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XVIII).
Aged, blind, or disabled individuals, as defined in Subpart F of Part 435 of Subchapter C of Chapter IV of Title 42 of the Code of Federal Regulations, with incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines.
Beneficiaries receiving supplemental security income under Title XVI of the Social Security Act.
Workers with disabilities, as provided in G.S. 108A-66.1.
Qualified working disabled individuals, as provided in G.S. 108A-67.
Qualified Medicare beneficiaries with incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare premiums and deductibles and coinsurance for Medicare-covered services.
Specified low-income Medicare beneficiaries with incomes equal to or less than one hundred twenty percent (120%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare Part B premiums.
Qualifying individuals who are Medicare beneficiaries and who have incomes equal to or less than one hundred thirty-five percent (135%) of the federal poverty guidelines may be covered within funds available for the Limited Medicare-Aid Capped Enrollment program. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare Part B premiums.
Recipients of an optional State supplementation program provided in accordance with 42 U.S.C. § 1382e.
Individuals who meet eligibility criteria under a Medicaid waiver approved by the Centers for Medicare and Medicaid Services and authorized by an act of the General Assembly, within funds available for the waiver.
Refugees, in accordance with 8 U.S.C. § 1522.
Qualified aliens subject to the five-year bar for means tested public assistance under 8 U.S.C. § 1613 and undocumented aliens, only for emergency services under 8 U.S.C. § 1611.

Family Size Income Level 1 $2,904 2 3,804 3 4,404 4 4,800 5 5,196 6 5,604 7 6,000 8 6,300 9 6,504 10 6,900 11 7,200 12 7,596 13 8,004 14 8,400 each additional family member add $396

Family Size Income Level 1 $5,208 2 6,828 3 8,004 4 8,928 5 9,888 6 10,812 7 11,700 8 12,432 9 13,152 10 14,028 each additional family member add $936

History

(2020-78, s. 4D.1; 2021-62, s. 4.3.)

Editor's Note. - Session Laws 2020-78, s. 22.1, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2019-2021 fiscal biennium, the textual provisions of this act apply only to the 2019-2021 fiscal biennium."

Session Laws 2020-78, s. 22.3, is a severability clause.

Session Laws 2020-78, s. 22.4 made this section effective July 1, 2020.

Effect of Amendments. - Session Laws 2021-62, s. 4.3, effective June 29, 2021, substituted "age of 21” for "age of 19” in subdivision (5).

§ 108A-54.4. Income disregard for federal cost-of-living adjustments.

An increase in a Medical Assistance Program recipient's income due solely to a cost-of-living adjustment to federal Social Security and Railroad Retirement payments shall be disregarded when determining income eligibility for the Medical Assistance Program. This section shall not be deemed to render a recipient eligible for the Medical Assistance Program if all other eligibility requirements are not met.

History

(2012-142, s. 10.6(a); 2016-94, s. 12H.7.)

Editor's Note. - Session Laws 2012-142, s. 10.6(c), as amended by Session Laws 2016-94, s. 12H.7, made this section effective January 1, 2013.

Session Laws 2012-142, s. 10.6(b), provides: "The Department of Health and Human Services shall apply to the Centers for Medicare and Medicaid Services for any necessary approvals to implement the income disregard required in subsection (a) of this section."

Session Laws 2012-142, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2012.'"

Session Laws 2012-142, s. 27.7 is a severability clause.

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

§ 108A-54.5. Maintenance of waivers for dependents of members of Armed Forces.

The Department of Health and Human Services shall ensure that the eligibility criteria for Medicaid home- and community-based waivers allow the dependent of a member of the Armed Forces of the United States to maintain the dependent's waiver status upon the transfer of the service member to an assignment outside of North Carolina, so long as the service member maintains the State of North Carolina as the legal residence to which the service member intends to return following completion of military service and the dependent meets Medicaid eligibility criteria and all other waiver eligibility criteria upon returning to North Carolina. Consequently, a dependent who is on the waiting list for a waiver slot shall maintain the dependent's position on the waiting list. A dependent who was receiving waiver services prior to the service member's transfer, upon the dependent's return to North Carolina, shall be reinstated to the dependent's waiver slot, if the slot remains available, or shall receive a priority position on the waiting list for the next available waiver slot. This section shall not be construed to authorize the provision of waiver services outside of North Carolina.

History

(2016-71, s. 1.)

Editor's Note. - Session Laws 2016-71, s. 3, made this section effective January 1, 2017.

Session Laws 2016-71, s. 2, provides: "The Department of Health and Human Services shall submit any Medicaid State Plan Amendments or waiver amendments necessary to accomplish the requirements in Section 1 of this act."

§ 108A-55. Payments.

The Department may authorize, within appropriations made for this purpose, payments of all or part of the cost of medical and other remedial care for any eligible person when it is essential to the health and welfare of such person that such care be provided, and when the total resources of such person are not sufficient to provide the necessary care. When determining whether a person has sufficient resources to provide necessary medical care, there shall be excluded from consideration the person's primary place of residence and the land on which it is situated, and in addition there shall be excluded real property contiguous with the person's primary place of residence in which the property tax value is less than twelve thousand dollars ($12,000).
Payments shall be made only to intermediate care facilities, hospitals and nursing homes licensed and approved under the laws of the State of North Carolina or under the laws of another state, or to pharmacies, physicians, dentists, optometrists or other providers of health-related services authorized by the Department. Payments may also be made to such fiscal intermediaries and to the capitation or prepaid health service contractors as may be authorized by the Department. Arrangements under which payments are made to capitation or prepaid health services contracts are not subject to the provisions of Chapter 58 of the General Statutes or of Article 3 of Chapter 143 of the General Statutes. However, the Department shall: (i) submit all proposed contracts for supplies, materials, printing, equipment, and contractual services that exceed one million dollars ($1,000,000) authorized by this subsection to the Attorney General or the Attorney General's designee for review as provided in G.S. 114-8.3; and (ii) include in all agreements or contracts to be awarded by the Department under this subsection a standard clause which provides that the State Auditor and internal auditors of the Department may audit the records of the contractor during and after the term of the contract to verify accounts and data affecting fees and performance. The Department shall not award a cost plus percentage of cost agreement or contract for any purpose.
The Department shall reimburse providers of services, equipment, or supplies under the Medical Assistance Program in the following amounts:
1. The amount approved by the Centers for Medicare & Medicaid Services (CMS) of the United States Department of Health and Human Services, if CMS approves an exact reimbursement amount.
2. The amount determined by application of a method approved by the Centers for Medicare & Medicaid Services (CMS) of the United States Department of Health and Human Services, if CMS approves the method by which a reimbursement amount is determined, and not the exact amount.
No payments shall be made for the care of any person in a nursing home or intermediate care home which is owned or operated in whole or in part by a member of the Social Services Commission, of any county board of social services, or of any board of county commissioners, or by an official or employee of the Department or of any county department of social services or by a spouse of any such person.
Medicaid is a secondary payor of claims. The Department shall apply Medicaid medical policy to recipients who have primary insurance other than Medicare, Medicare Advantage, and Medicaid. For recipients who have primary insurance other than Medicare, Medicare Advantage, or Medicaid, the Department shall pay the lesser of the Medicaid Allowable Amount or an amount up to the actual coinsurance or deductible or both of the primary payor, in accordance with the State Plan, as approved by the Department of Health and Human Services. The Department may disregard application of this policy in cases where application of the policy would adversely affect patient care.
For payments made in fiscal year 2013-2014 and for subsequent fiscal years, the Department of Health and Human Services, Division of Health Benefits, shall publish on its Web site comprehensive information on Medicaid payments made to providers. The information shall be updated annually within three months of the close of a State fiscal year to include payments for that fiscal year. The information published shall include all of the following for each individual providing Medicaid services:
1. Name of the individual providing the service.
2. Location of service provider's principal place of business.
3. Location of provided services, listed with both municipality and county. If an individual provides services in multiple locations, then those shall be specified and the items in subdivisions (6) through (10) of this subsection shall be provided for each location.
4. Practice name, hospital name, or other business name with which the individual providing service is affiliated.
5. Type of service provider and practice area.
6. Number of Medicaid patients seen.
7. Number of visits with Medicaid patients.
8. Number of procedures performed or items furnished for Medicaid patients.
9. Amount of Medicaid service payments received.
10. Amount of Medicaid supplemental payments received.
11. Amount of Medicaid settlement payments received.
12. Amount of Medicaid recoupments.

The Department shall establish the methods by which reimbursement amounts are determined in accordance with Chapter 150B of the General Statutes. A change in a reimbursement amount becomes effective as of the date for which the change is approved by the Centers for Medicare & Medicaid Services (CMS) of the United States Department of Health and Human Services.

The information shall be published in a character-separated values (CSV) plain text format or other file format that may easily be imported into software used for spreadsheets, databases, and data analytics. The Department shall ensure that no protected patient information be published.

History

(1965, c. 1173, s. 1; 1969, c. 546, s. 1; 1971, c. 435; 1973, c. 476, s. 138; c. 644; 1975, c. 123, ss. 1, 2; 1977, 2nd Sess., c. 1219, c. 25; 1979, c. 702, s. 7; 1981, c. 275, s. 1; c. 849, s. 2; 1991, c. 388, s. 1; 1993, c. 529, s. 7.3; 1998-212, s. 12.12B(c); 2010-194, s. 15; 2011-291, s. 2.22; 2011-326, s. 15(o); 2013-360, s. 12H.4; 2014-100, ss. 12H.15(a), 12H.21(b); 2019-81, s. 15(a).)

Editor's Note. - Session Laws 2009-451, s. 10.58A, provides: "Effective September 1, 2009, the Department of Health and Human Services, Division of Medical Assistance, shall charge an enrollment fee of one hundred dollars ($100.00) to each provider enrolling in the Medicaid program for the first time. The fee shall be charged to all providers at recredentialling every three years."

Session Laws 2009-451, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2009'."

Session Laws 2009-451, s. 28.5 is a severability clause.

Session Laws 2010-31, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2010'."

Session Laws 2010-31, s. 32.6 is a severability clause.

Session Laws 2011-145, s. 10.31A, as amended by Session Laws 2011-315, s. 1.1, and as amended by Session Laws 2011-391, s. 24, provides: "The Secretary of Health and Human Services may implement a Medicaid assessment program for any willing provider category allowed under federal regulations up to the maximum percentage allowed by federal regulation. The Department may retain up to sixty-five percent (65%) of the amount from an assessment program, except for the hospital assessment program authorized in Session Law 2011-11, implemented after December 31, 2010, except for the hospital assessment program authorized in S.L. 2011-11, that can be used by the Department to support Medicaid expenditures. Any assessment funds not retained by the Department shall be used to draw federal Medicaid matching funds for implementing increased rates or new reimbursement plans for each provider category being assessed.

"Receipts from the assessment program are hereby appropriated for the 2011-2012 fiscal year and the 2012-2013 fiscal year for the purposes set out in this section."

Session Laws 2011-145, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2011.'"

Session Laws 2011-145, s. 32.5 is a severability clause.

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Session Laws 2014-100, s. 12H.15(a), effective July 1, 2014, has been codified as subsection (f) of this section at the direction of the Revisor of Statutes.

Session Laws 2014-100, s. 12H.15(b), provides: "The Department of Health and Human Services, Division of Medical Assistance, shall begin discussions with the UNC School of Public Health or any other appropriate party of an educational or nonprofit nature to perform analytics on the information or to generate an interactive Web site to access the information contained within the data required to be reported under subsection (a) of this section. Such a Web site should be designed to exceed the functionality of South Carolina's HealthViz Medicaid statistics Web site."

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Session Laws 2015-241, s. 12H.4, as amended by Session Laws 2015-264, s. 87.5, provides: "The Department of Health and Human Services, Division of Medical Assistance, shall charge an application fee of one hundred dollars ($100.00), and the amount federally required, to each provider enrolling in the Medicaid Program for the first time. The fee shall be charged to all providers at recredentialing every five years." For prior similar provisions, see Session Laws 2013-360, s. 12H.7.

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Effect of Amendments. - Session Laws 2011-291, s. 2.22, effective June 24, 2011, substituted "Joint Legislative Oversight Committee on Health and Human Services" for "Joint Legislative Commission on Health Care Oversight" in the last sentence of the last paragraph in subsection (c).

Session Laws 2011-326, s. 15(o), effective June 27, 2011, in the next-to-last sentence of subsection (b), deleted "statewide and agency term" following "proposed" and inserted "and after."

Session Laws 2013-360, s. 12H.4, effective July 1, 2013, added subsection (e).

Session Laws 2014-100, s. 12H.21(b), effective September 1, 2014, in subsection (c), substituted "Centers for Medicare & Medicaid Services (CMS)" for "Health Care Financing Administration" and "CMS" for "that Administration" throughout, and deleted the former last sentence in the last paragraph concerning reporting changes in reimbursement amounts to agencies.

Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" in subsection (f).

Legal Periodicals. - For survey of 1980 constitutional law, see 59 N.C.L. Rev. 1116 (1981).

CASE NOTES

Use of Resource Spend-Down Not Required. - The North Carolina Medicaid plan does not require the use of resource spend-down when evaluating Medicaid eligibility. Elliot ex rel. Casstevens v. Department of Human Resources, 115 N.C. App. 613, 446 S.E.2d 809, aff'd, 341 N.C. 191, 459 S.E.2d 273 (1995).

This section does not require that Medicaid applicants own their primary place of residence in order to exclude property they own contiguous to their residence from their assets for purposes of determining their eligibility for Medicaid benefits. Correll v. Division of Social Servs., 332 N.C. 141, 418 S.E.2d 232 (1992).

Medicaid applicants are not required to own their primary places of residence before being entitled to the benefit of the contiguous property exclusion. Correll v. Division of Social Servs., 332 N.C. 141, 418 S.E.2d 232 (1992).

Medically Unnecessary Abortions. - By no stretch of the imagination can medically unnecessary abortions be considered as "essential to the health and welfare" of the recipients. Stam v. State, 302 N.C. 357, 275 S.E.2d 439 (1981), decided under former Chapter 108.

The action of the General Assembly in placing severe restrictions on the funding of medically necessary abortions for indigent women is valid and does not violate Article I, Section 1; Article 1, Section 19; or Article XI, Section 4 of the Constitution of North Carolina. Rosie J. v. North Carolina Dep't of Human Resources, 347 N.C. 247, 491 S.E.2d 535 (1997).

Payment by tort-feasor of injured party's claim without notice of subrogee's interest is a complete defense to a subrogee's claim against the tort-feasor. Johnston County v. McCormick, 65 N.C. App. 63, 308 S.E.2d 872 (1983).

Applied in Kempson v. North Carolina Dep't of Human Resources, 100 N.C. App. 482, 397 S.E.2d 314 (1990).

Cited in In re Nantz, 177 N.C. App. 33, 627 S.E.2d 665 (2006).

§ 108A-55.1. Medicare enrollment required.

The Department shall require State Medical Assistance Program recipients who qualify for Medicare to enroll in Medicare, in accordance with Title XIX of the Social Security Act, in order to pay medical expenditures that qualify for payment under Medicare Parts B and D, except that enrollment in Part D is not required if the recipient has creditable prescription drug coverage as defined by federal law.

Failure to enroll in Medicare shall result in nonpayment of these expenditures under the State Medical Assistance Program. A provider may seek payment for services from Medicaid enrollees who are eligible for but not enrolled in Medicare Parts B and D.

History

(2003-284, s. 10.27; 2006-66, s. 10.6.)

Effect of Amendments. - Session Laws 2006-66, s. 10.6, effective July 1, 2006, substituted "Parts B and D, except that enrollment in Part D is not required if the recipient has creditable prescription drug coverage as defined by federal law" for "Part B" at the end of the first paragraph; and substituted "Parts B and D" for "Part B" at the end of the last sentence in the second paragraph.

§ 108A-55.2. Collaboration among agencies to ensure Medicaid-related services payments to eligible students with disabilities in public schools.

The Department shall work with the Department of Public Instruction and local education agencies to develop efficient, effective, and appropriate administrative procedures and guidelines to provide maximum funding for Medicaid-related services for Medicaid-eligible students with disabilities. The procedures and guidelines shall be streamlined to ensure that local education agencies receive Medicaid reimbursement in a timely manner for Medicaid-related services and administrative outreach to Medicaid-eligible students with disabilities.

History

(2003-284, s. 10.29A.)

Editor's Note. - This section was enacted as G.S. 108A-55.1 and was redesignated as G.S. 108A-55.2 at the direction of the Revisor of Statutes.

§ 108A-55.3. Verification of State residency required for medical assistance.

At the time of application for medical assistance benefits, the applicant shall provide satisfactory proof that the applicant is a resident of North Carolina and that the applicant is not maintaining a temporary residence or abode incident to receiving medical assistance under this Part.
An applicant may meet the requirements of subsection (a) of this section by providing at least two of the following documents:
1. A valid North Carolina drivers license or other identification card issued by the North Carolina Division of Motor Vehicles.
2. A current North Carolina rent or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant's legal spouse showing a North Carolina address.
3. A valid North Carolina motor vehicle registration in the applicant's name and showing the applicant's current address.
4. A document showing that the applicant is employed in this State.
5. One or more documents proving that the applicant's domicile in the applicant's prior state of domicile has ended, such as closing of a bank account, termination of employment, or sale of a home.
6. The tax records of the applicant or the applicant's legal spouse, showing a current North Carolina address.
7. A document showing that the applicant has registered with a public or private employment service in this State.
8. A document showing that the applicant has enrolled the applicant's children in a public or private school or child care facility located in this State.
9. A document showing that the applicant is receiving public assistance or other services requiring proof of domicile, other than medical assistance, in this State.
10. Records from a health department or other health care provider located in this State showing the applicant's current North Carolina address.
11. A written declaration made under penalty of perjury from a person who has a social, family, or economic relationship with the applicant and who has personal knowledge of the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.
12. Current North Carolina voter registration card.
13. A document from the U.S. Department of Veterans Affairs, U.S. Department of Defense, or the U.S. Department of Homeland Security verifying the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.
14. Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools, including secondary schools, community colleges, colleges, and universities verifying the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment.
15. Repealed by Session Laws 2015-294, s. 14, effective October 1, 2015, and applicable to contracts entered into on or after that date.
For applicants, including those who are homeless or migrant laborers, who declare under penalty of perjury that they do not have two of the verifying documents in subsection (b) of this section, any other evidence that verifies residence may be considered. However, except for applicants of emergency Medicaid, a declaration, affidavit, or other statement from the applicant or another person that the applicant meets the requirements of G.S. 108A-24(6) is insufficient in the absence of other credible evidence. For applicants of emergency Medicaid, a declaration, affidavit, or other statement from the applicant's employer, clergy, or other person with personal knowledge of the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment satisfies the requirements of this subsection.
The Division of Health Benefits shall not provide payment for medical assistance provided to an applicant unless or until the applicant has met the proof of residency requirements of this section.
Unless otherwise provided for under Title 19 of the Social Security Act, a child under age 18 is a resident of the state where the child's parent or legal guardian is domiciled.
This section does not apply to an applicant whose eligibility for medical assistance is excepted from State residency requirements under federal law.
Nothing in this section shall be construed to establish North Carolina residency for a nonqualified alien who is present in North Carolina for a temporary or unspecified period of time unless the applicant is legally admitted for employment purposes.

History

(2005-276, s. 10.21A(a); 2011-183, s. 74; 2015-294, s. 14; 2019-81, s. 15(a).)

Effect of Amendments. - Session Laws 2011-183, s. 74, effective June 20, 2011, substituted "U.S. Department of Defense" for "U.S. Military" in subdivision (b)(13).

Session Laws 2015-294, s. 14, effective October 1, 2015, deleted former subdivision (b)(15), which read: "A document issued by the Mexican consular or other foreign consulate verifying the applicant's intent to live in North Carolina permanently or for an indefinite period of time or that the applicant is residing in North Carolina to seek employment or with a job commitment." For applicability, see editor's note.

Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" in subsection (d).

§ 108A-55.4. Insurers to provide certain information to Department of Health and Human Services.

As used in this section, the terms:
1. "Applicant" means an applicant or former applicant of medical assistance benefits.
2. "Department" means the Department of Health and Human Services.
3. "Division" means the Division of Health Benefits of the Department of Health and Human Services.
4. "Health insurer" includes self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, [29 USC Section 1167(1)]), service benefit plans, managed care organizations, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service as a condition of doing business in the State.
5. "Medical assistance" means medical assistance benefits provided under the State Medical Assistance Plan.
6. , (6) Reserved for future codification.
Health insurers, and pharmacy benefit managers regulated as third-party administrators under Article 56 of Chapter 58 of the General Statutes, shall provide, with respect to a subscriber upon request of the Division or its authorized contractor, information to determine during what period the individual or the individual's spouse or dependents may be (or may have been) covered by a health insurer and the nature of the coverage that is or was provided by the health insurer (including the subscriber's name, address, identification number, social security number, date of birth and identifying number of the plan) in a manner prescribed by the Division or its authorized contractor. Notwithstanding any other provision of law, every health insurer shall provide, not more frequently than twelve times in a year and at no cost, to the Department of Health and Human Services, Division of Health Benefits, or the Department's or Division's authorized contractor, upon its request, information as necessary so that the Division may (i) identify applicants or recipients who may also be subscribers covered under the benefit plans of the health insurer; (ii) determine the period during which the individual, the individual's spouse, or the individual's dependents may be or may have been covered by the health benefit plan; and (iii) determine the nature of the coverage. To facilitate the Division or its authorized contractor in obtaining this and other related information, every health insurer shall:
1. Cooperate with the Division to determine whether a named individual who is a recipient of medical assistance may be covered under the insurer's health benefit plan and eligible to receive benefits under the health benefit plan for services provided under the State Medical Assistance Plan.
2. Respond to the request for payment within 90 working days after receipt of written proof of loss or claim for payment for health care services provided to a recipient of medical assistance who is covered by the benefit plan of the health insurer.
3. Accept the Division's right of recovery and the assignment to the Division of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the State Medical Assistance Plan.
4. Respond to any inquiry by the Division or its authorized contractor regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of the health care item or service.
5. Notwithstanding subsection (d) of this section, agree not to deny a claim submitted by the Division solely on the basis of the date of submission of the claim, the type of format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
  1. The claim is submitted by the Division within the three-year period beginning on the date on which the item or service was furnished; and
  2. Any action by the Division to enforce its rights with respect to such claim is commenced within six years of the Division's submission of the claim.
A health insurer that complies with this section shall not be liable on that account in any civil or criminal actions or proceedings.
A health insurer is obligated to reimburse the Department only if the insurer has a contractual obligation to make payment for the covered service or item.

(7) "Recipient" means a present or former recipient of medical assistance benefits.

(8) "Request" means any inquiry by the Department or Division for the purpose of determining the existence of insurance where the Department or Division may have expended public assistance benefits.

(9) "Subscriber" means the policyholder or covered person under the insurance policy.

History

(2006-66, s. 10.8; 2006-221, ss. 9(a)-(c); 2007-442, s. 2; 2019-81, s. 15(a).)

Editor's Note. - At the direction of the Revisor of Statutes, subdivisions (a)(5) and (6) as added by Session Laws 2007-442, s. 2, were redesignated as subdivisions (a)(9) and (a)(1), respectively, and former subdivision (a)(1) was redesignated as subdivision (a)(1a).

Session Laws 2006-66, s. 10.8, effective January 1, 2007, enacted this section as G.S. 58-50-46; it was recodified on the same date as G.S. 108A-55.4 by Session Laws 2006-221, s. 9(a).

Session Laws 2007-442, s. 3.6, provides: "Unless required by federal law, the Department of Health and Human Services, Division of Medical Assistance shall limit notification of estate recovery to the application process for Medicaid and to following the death of the recipient."

Effect of Amendments. - Session Laws 2006-221, s. 9(b), effective January 1, 2007, substituted "proper documentation" for "property documentation" in the introductory language of subdivision (b)(5).

Session Laws 2007-442, s. 2, effective August 23, 2007, added subdivisions (a)(5) through (a)(8); rewrote subsection (b); substituted "A health" for "An" in subsection (c); and added subsection (d).

Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" in subdivision (a)(2) and the introductory paragraph of subsection (b).

§ 108A-55.5. Eligibility monitoring for medical assistance.

On at least a quarterly basis, the Department shall review information concerning changes in circumstances that may affect medical assistance beneficiaries' eligibility to receive medical assistance benefits. The Department shall share the information directly with, or make the information available to, the county department of social services that determined the beneficiary's eligibility.
The information reviewed by the Department shall include all of the following:
1. Earned and unearned income.
2. Employment status and changes in employment.
3. Residency status.
4. Enrollment status in other State-administered public assistance programs.
5. Financial resources.
6. Incarceration status.
7. Death records.
8. Lottery winnings.
9. Enrollment status in public assistance programs outside of this State.
A county department of social services shall promptly review the information provided or made available by the Department in accordance with subsection (a) of this section to determine if the information indicates a change in circumstances that may affect a medical assistance beneficiary's eligibility to receive medical assistance benefits and take one of the following actions:
1. If a review of the information does not result in the county department of social services finding a discrepancy or change in a beneficiary's circumstances that may affect that beneficiary's eligibility to receive medical assistance benefits, the county department of social services shall take no further action.
2. If a review of the information does result in the county department of social services finding a discrepancy or change in a beneficiary's circumstances that may affect that beneficiary's eligibility for medical assistance benefits, the county department of social services shall provide written notice to the beneficiary that describes in sufficient detail the circumstances of the discrepancy or change in circumstances that would affect the beneficiary's eligibility for medical assistance benefits. The notice must include the following information:
  1. The beneficiary will have 12 calendar days from the time of mailing to respond.
  2. A response from the beneficiary must be in writing.
  3. Self-declarations made by the beneficiary will not be accepted as verification of information in the response.
  4. The consequences of taking no action.
After the expiration of 12 calendar days from the time of mailing the notice required under subsection (c) of this section, the county department of social services shall take one of the following actions:
1. If a beneficiary did not respond to the notice, the county department of social services shall redetermine the beneficiary's eligibility for medical assistance benefits and provide the beneficiary with proper notice under G.S. 108A-79.
2. If a beneficiary responds to the notice and disagrees with the information in the notice, the county department of social services shall reinvestigate the matter and take one of the following actions:
  1. If the county department of social services determines that there has been an error and the beneficiary's eligibility to receive medical assistance benefits is not affected, then no further action shall be taken.
  2. If the county department of social services determines that there is no error, the county department of social services shall redetermine the beneficiary's eligibility for medical assistance benefits and provide the beneficiary with proper notice under G.S. 108A-79.
3. If a beneficiary responds to the notice and confirms the information in the notice is correct, then the county department of social services shall redetermine the beneficiary's eligibility for medical assistance benefits and provide the beneficiary with proper notice under G.S. 108A-79.
Nothing in this section shall preclude the Department or any county department of social services from receiving or reviewing additional information related to a beneficiary's eligibility for medical assistance benefits that is obtained in a manner other than that provided for under this section.

If, at any time after receiving a beneficiary's response to the notice, the county department of social services determines that there is a risk of fraud or misrepresentation or inadequate documentation, then the county department of social services may request additional documentation from the beneficiary.

History

(2017-57, s. 11H.20(a).)

Editor's Note. - Session Laws 2017-57, s. 11H.20(b)-(d), provides: "(b) The Department of Health and Human Services may sign a memorandum of understanding with any department, agency, or division of the State to obtain information concerning individuals enrolled in Medicaid that indicates a change in circumstances that may affect the individuals' eligibility to receive Medicaid benefits under G.S. 108A-55.5(a).

"(c) The Department of Health and Human Services may contract with one or more vendors to provide information concerning individuals enrolled in Medicaid that indicates a change in circumstances that may affect the individuals' eligibility to receive Medicaid benefits under G.S. 108A-55.5(a). The quarterly cost, net of receipts, of a contract entered into under this subsection must be less than the cost of claims, net of receipts, for the preceding quarter for individuals identified.

"(d) The Department of Health and Human Services (Department) shall consider joining any multistate cooperative to identify individuals who are also enrolled in public assistance programs outside of this State, including the National Accuracy Clearinghouse. No later than October 1, 2017, the Department shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice findings that explain the reasons for joining or not joining any multistate cooperative, and, if a determination has been made to join the multistate cooperative, a date when membership is expected."

Session Laws 2017-57, s. 11H.20(e), made this section effective January 1, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-56. Acceptance of federal grants.

All of the provisions of the federal Social Security Act providing grants to the states for medical assistance are accepted and adopted, and the provisions of this Part shall be liberally construed to effectuate compliance with the act, except to the extent the applicability of federal law or rules have been waived by agreement between the State and the U.S. Department of Health and Human Services. Nothing in this Part or the regulations made under its authority shall be construed to deprive a recipient of assistance of the right to choose the licensed provider of the care or service made available under this Part within the provisions of the federal Social Security Act, or valid waiver agreement. This section shall not be construed to prohibit a PHP from (i) requiring its enrollees to obtain services from providers that are under contract with the PHP or (ii) imposing utilization management criteria to a request for services, to the extent these actions are not otherwise prohibited by State or federal law or regulation, or by the Department.

History

(1965, c. 1173, s. 1; 1969, c. 546, s. 1; 1981, c. 275, s. 1; 2019-81, s. 4.)

Effect of Amendments. - Session Laws 2019-81, s. 4, effective October 1, 2019, rewrote the first sentence, added "or valid waiver agreement" at the end of the second sentence and added the third sentence.

CASE NOTES

Compliance with Statutes and Regulations in Determining Eligibility Required. - A state agency designated by the legislature as being responsible for determining eligibility for medical assistance must comply with state and federal statutes and regulations in making such determinations. Lowe v. North Carolina Dep't of Human Resources, 72 N.C. App. 44, 323 S.E.2d 454 (1984).

North Carolina agencies making disability benefit determinations are required to comply with federal Medicaid statutes and regulations. Henderson v. North Carolina Dep't of Human Resources, 91 N.C. App. 527, 372 S.E.2d 887 (1988).

Cited in Lackey v. North Carolina Dep't of Human Resources, 306 N.C. 231, 293 S.E.2d 171 (1982); Forsyth County Bd. of Social Servs. v. Division of Social Servs., 317 N.C. 689, 346 S.E.2d 414 (1986); Payne ex rel. Rabil v. State, Dep't of Human Resources, 126 N.C. App. 672, 486 S.E.2d 469 (1997); N.C. HHS v. Parker Home Care, LLC, 246 N.C. App. 551, 784 S.E.2d 552 (2016), review denied, mot. dismissed, stay denied, 793 S.E.2d 690, 2016 N.C. LEXIS 988 (2016); mot. dismissed, as moot, 793 S.E.2d 688, 2016 N.C. LEXIS 1013 (2016); Williford v. N.C. HHS, 250 N.C. App. 491, 792 S.E.2d 843 (2016); Mills v. N.C. HHS, 251 N.C. App. 182, 794 S.E.2d 566 (2016).

§ 108A-57. Subrogation rights; withholding of information a misdemeanor.

As used in this section, the term "beneficiary" means (i) the beneficiary of medical assistance, including a minor beneficiary, (ii) the medical assistance beneficiary's parent, legal guardian, or personal representative, (iii) the medical assistance beneficiary's heirs, and (iv) the administrator or executor of the medical assistance beneficiary's estate.
If the amount of the Medicaid claim does not exceed one-third of the medical assistance beneficiary's gross recovery, it is presumed that the gross recovery includes compensation for the full amount of the Medicaid claim. If the amount of the Medicaid claim exceeds one-third of the medical assistance beneficiary's gross recovery, it is presumed that one-third of the gross recovery represents compensation for the Medicaid claim
A medical assistance beneficiary may dispute the presumptions established in subsection (a1) of this section by applying to the court in which the medical assistance beneficiary's claim against the third party is pending, or if there is none, then to a court of competent jurisdiction in this State, for a determination of the portion of the beneficiary's gross recovery that represents compensation for the Medicaid claim. An application under this subsection shall be filed with the court and served on the Department pursuant to the Rules of Civil Procedure no later than 30 days after the date that the settlement agreement is executed by all parties and, if required, approved by the court, or in cases in which judgment has been entered, no later than 30 days after the date of entry of judgment. The court shall hold an evidentiary hearing no sooner than 60 days after the date the action was filed. All of the following shall apply to the court's determination under this subsection:
1. The medical assistance beneficiary has the burden of proving by clear and convincing evidence that the portion of the beneficiary's gross recovery that represents compensation for the Medicaid claim is less than the portion presumed under subsection (a1) of this section.
2. The presumption arising under subsection (a1) of this section is not rebutted solely by the fact that the medical assistance beneficiary was not able to recover the full amount of all claims.
3. If the beneficiary meets its burden of rebutting the presumption arising under subsection (a1) of this section, then the court shall determine the portion of the recovery that represents compensation for the Medicaid claim and shall order the beneficiary to pay the amount so determined to the Department in accordance with subsection (a5) of this section. In making this determination, the court may consider any factors that it deems just and reasonable.
4. If the beneficiary fails to rebut the presumption arising under subsection (a1) of this section, then the court shall order the beneficiary to pay the amount presumed pursuant to subsection (a1) of this section to the Department in accordance with subsection (a5) of this section.
Notwithstanding the presumption arising pursuant to subsection (a1) of this section, the medical assistance beneficiary and the Department may reach an agreement on the portion of the recovery that represents compensation for the Medicaid claim. If such an agreement is reached after an application has been filed pursuant to subsection (a2) of this section, a stipulation of dismissal of the application signed by both parties shall be filed with the court.
Within 30 days of receipt of the proceeds of a settlement or judgment related to a claim described in subsection (a) of this section, the medical assistance beneficiary or any attorney retained by the beneficiary shall notify the Department of the receipt of the proceeds.
The medical assistance beneficiary or any attorney retained by the beneficiary shall, out of the proceeds obtained by or on behalf of the beneficiary by settlement with, judgment against, or otherwise from a third party by reason of injury or death, distribute to the Department the amount due pursuant to this section as follows:
1. If, upon the expiration of the time for filing an application pursuant subsection (a2) of this section, no application has been filed, then the amount presumed pursuant to subsection (a1) of this section, as prorated with the claims of all others having medical subrogation rights or medical liens against the amount received or recovered, shall be paid to the Department within 30 days of the beneficiary's receipt of the proceeds, in the absence of an agreement pursuant to subsection (a3) of this section.
2. If an application has been filed pursuant to subsection (a2) of this section and no agreement has been reached pursuant to subsection (a3) of this section, then the Department shall be paid as follows:
  1. If the beneficiary rebuts the presumption arising under subsection (a1) of this section, then the amount determined by the court pursuant to subsection (a2) of this section, as prorated with the claims of all others having medical subrogation rights or medical liens against the amount received or recovered, shall be paid to the Department within 30 days of the entry of the court's order.
  2. If the beneficiary fails to rebut the presumption arising under subsection (a1) of this section, then the amount presumed pursuant to subsection (a1) of this section, as prorated with the claims of all others having medical subrogation rights or medical liens against the amount received or recovered, shall be paid to the Department within 30 days of the entry of the court's order.
3. If an agreement has been reached pursuant to subsection (a3) of this section, then the agreed amount, as prorated with the claims of all others having medical subrogation rights or medical liens against the amount received or recovered, shall be paid to the Department within 30 days of the execution of the agreement by the medical assistance beneficiary and the Department.
The United States and the State of North Carolina shall be entitled to shares in each net recovery by the Department under this section. Their shares shall be promptly paid under this section and their proportionate parts of such sum shall be determined in accordance with the matching formulas in use during the period for which assistance was paid to the recipient.
It is a Class 1 misdemeanor for any person seeking or having obtained assistance under this Part for himself or another to willfully fail to disclose to the county department of social services or its attorney and to the Department the identity of any person or organization against whom the recipient of assistance has a right of recovery, contractual or otherwise.
This section applies to the administration of and claims payments under the NC Health Choice Program established under Part 8 of this Article.
As required to ensure compliance with this section, the Department may apply to the court in which the medical assistance beneficiary's claim against the third party is pending, or if there is none, then to a court of competent jurisdiction in this State for enforcement of this section.

Notwithstanding any other provisions of the law, to the extent of payments under this Part, the State shall be subrogated to all rights of recovery, contractual or otherwise, of a beneficiary against any person. Any claim brought by a medical assistance beneficiary against a third party shall include a claim for all medical assistance payments for health care items or services furnished to the medical assistance beneficiary as a result of the injury or action, hereinafter referred to as the "Medicaid claim." Any claim brought by a medical assistance beneficiary against a third party that does not state the Medicaid claim shall be deemed to include the Medicaid claim. If the beneficiary has claims against more than one third party related to the same injury, then any amount received in payment of the Medicaid claim related to that injury shall reduce the total balance of the Medicaid claim applicable to subsequent recoveries related to that injury.

History

(1973, c. 476, s. 138; c. 1031, s. 1; 1979, 2nd Sess., c. 1312, ss. 1, 2; 1981, c. 275, s. 1; 1987 (Reg. Sess., 1988), c. 1022; 1993, c. 539, s. 815; 1994, Ex. Sess., c. 24, s. 14(c); 1996, 2nd Ex. Sess., c. 18, s. 24.2(a); 2009-16, s. 4(c); 2013-274, s. 1; 2017-57, s. 11H.23; 2018-5, s. 11H.6(a); 2019-240, s. 11(a).)

Editor's Note. - Session Laws 2009-16, s. 4(a), (b) provides: "Over-the-Counter Medications. - Coverage of over-the-counter medication authorized under G.S. 108A-70.21(d) for the NC Health Choice Program shall become effective on the later of July 1, 2010, or the date upon which the Department of Health and Human Services assumes full responsibility for administration and processing of claims under the NC Health Choice Program.

"Subrogation. - For the period authorized under subsection (a) of this section, the right of subrogation under G.S. 108A-57 applies to the State Health Plan for payments made by the Plan under the NC Health Choice Program. This subsection expires on the later of July 1, 2010, or the date upon which the Department of Health and Human Services assumes full responsibility for administration, processing, and payment of claims under the NC Health Choice Program."

Session Laws 2013-274, s. 2, made the revision of this section by Session Laws 2013-274, s. 1, applicable (i) to Medicaid claims that arise on or after July 18, 2013 and (ii) to Medicaid claims arising prior to July 18, 2013 for which the Department has not been paid in full. For Medicaid claims that arose prior to July 18, 2013 for which the Department has not been paid in full, the medical assistance beneficiary shall have 90 days from July 18, 2013 within which to apply to the court pursuant to G.S. 108A-57(a2).

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 11H.6(a), effective retroactively to July 1, 2017, repealed Session Laws 2017-57, s. 11H.23, which had rewritten the section. The 2018 amendment restored this section to the version prior to the 2017 rewrite.

Session Laws 2018-5, s. 11H.6(b), (c), provides: "(b) For Medicaid claims for which a settlement agreement was executed or a judgment was entered between the dates of October 1, 2017, and the date this section becomes law [July 1, 2018], the medical assistance beneficiary shall have 30 days from the date this section becomes law [July 1, 2018] within which to dispute the presumption established under G.S. 108A-57(a1), as amended by subsection (a) of this section, by applying to the court pursuant to G.S. 108A-57(a2), as amended by subsection (a) of this section, for a determination of the portion of the beneficiary's gross recovery that represented compensation for the Medicaid claim and, in cases where a distribution to the Department of Health and Human Services has been made, a determination of any erroneous distribution to the Department."

"(c) If any medical assistance beneficiary or any attorney retained by a medical assistance beneficiary has reason to believe that a Medicaid claim for which a distribution was made to the Department of Health and Human Services between the dates of October 1, 2017, and the date this section becomes law [July 1, 2018] resulted in a distribution that is in excess of what is required under G.S. 108A-57, as amended by subsection (a) of this section, but does not dispute the presumption established under G.S. 108A-57(a1), as amended by subsection (a) of this section, then the beneficiary shall have 30 days from the date this section becomes law [July 1, 2018] within which to apply to a court of competent jurisdiction for a determination of any erroneous distribution to the Department."

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Session Laws 2019-240, s. 11(b), made the amendment of subsections (a), (a2), (c), and (d) by Session Laws 2019-240, s. 11(a), effective November 6, 2019, and applicable to claims brought by medical assistance beneficiaries against third parties on or after that date.

Effect of Amendments. - Session Laws 2009-16, s. 4(c), effective April 23, 2009, added subsection (c).

Session Laws 2013-274, s. 1, effective July 18, 2013, rewrote the section. For applicability, see editor's note.

Session Laws 2017-57, s. 11H.23, effective July 1, 2017, rewrote the section.

Session Laws 2018-5, s. 11H.6(a) rewrote the section. See editor's note for effective date.

Session Laws 2019-240, s. 11(a), rewrote subsection (a); in subsection (a1), inserted "in this State" in the first sentence and substituted "60" for "30" in the third sentence; deleted "made by the Department of Health and Human Services" following "payments" in subsection (c); and inserted "in this State" in subsection (d). For effective date and applicability, see editor's note.

Legal Periodicals. - For comment, "Orders From On High: The Current Struggle over Medicaid Third Party Recovery Between North Carolina and the Supreme Court of the United States," see 30 Campbell L. Rev. 471 (2008).

CASE NOTES

Who May Bring Action. - Where a cause of action is created by statute and the statute also provides who is to bring the action, the person or persons so designated, and, ordinarily, only such persons, may sue. Malloy v. Durham County Dep't of Social Servs., 58 N.C. App. 61, 293 S.E.2d 285 (1982), decided under former G.S. 108-61.2

Relationship to Federal Law. - G.S. 108A-57 and G.S. 108A-59 comported with federal law because if a Medicaid recipient in North Carolina obtains a third-party lump-sum settlement, which did not allocate a specific portion to recovery for medical costs, G.S. 108A-57(a) controlled, and the State would be reimbursed the lesser of the State's past medical expenditures or one-third of the plaintiff's total recovery; by limiting the state's subrogation right to one-third of a Medicaid recipient's recovery, the scheme protected a plaintiff's interests while promoting efficiency in Medicaid reimbursement cases throughout North Carolina. Armstrong v. Cansler, 722 F. Supp. 2d 653 (W.D.N.C. June 28, 2010), vacated 674 F.3d 290, 2012 U.S. App. LEXIS 5996 (4th Cir. N.C. 2012).

Unrebuttable presumption inherent in the one-third cap on the state's recovery imposed by the North Carolina Medicaid third-party liability statutes, G.S. 108A-57 and G.S. 108A-59, is in fatal conflict with federal law, which limits a state's third-party recovery to settlement proceeds representing payment for medical expenses. In the event of a lump-sum settlement, the sum certain allocable to medical expenses must be determined, in the absence of a stipulation by the affected parties, by judicial determination or some similar adversarial process. E.M.A. v. Cansler, 674 F.3d 290 (4th Cir. 2012).

G.S. 108A-57(a) was preempted by the anti-lien provision of the Medicaid statute, 42 U.S.C.S. § 1396p(a)(1), to the extent it created an irrebuttable presumption that one-third of a tort recovery was attributable to a Medicaid beneficiary's medical expenses, because it allowed the State to take money that was not designated as a payment for medical care. Wos v. E.M.A., 568 U.S. 627, 133 S. Ct. 1391, 185 L. Ed. 2d 471 (2013).

Subdivision of County May Not Be Subrogated to Its Rights. - A county department of social services may not recover by subrogation under this section, since that right inheres only in the county involved, not such county department. Malloy v. Durham County Dep't of Social Servs., 58 N.C. App. 61, 293 S.E.2d 285 (1982), decided under former G.S. 108-61.2

Evidence of a Collateral Benefit. - In tort actions, evidence of a collateral benefit is improper when the plaintiff will not receive a double recovery. Because Medicaid provides for a right of subrogation in the State to recover sums paid to plaintiffs, this principle is applicable thereto. Cates v. Wilson, 321 N.C. 1, 361 S.E.2d 734 (1987).

Subrogation Rights. - The plain language of this section does not provide that the State is subrogated to all rights of recovery to the extent of all money a medical assistance beneficiary receives, only that the State is subrogated to all rights of recovery of the beneficiary of medical assistance to the extent of payments under the entitled Medical Assistance Program. North Carolina Dep't of Human Resources v. Weaver, 121 N.C. App. 517, 466 S.E.2d 717, cert. denied, 342 N.C. 896, 467 S.E.2d 905 (1996).

When a minor recipient of Medicaid benefits settled medical negligence claims with health care providers, equitable subrogation principles did not apply to the right of the Department of Health and Human Services, Division of Medical Assistance, to a share of the settlement, because G.S. 108A-57(a) specifically provided that the State "shall be subrogated to all rights of recovery," "notwithstanding any other provisions of the law." Ezell v. Grace Hosp., Inc., 175 N.C. App. 56, 623 S.E.2d 79 (2005), rev'd, remanded, 360 N.C. 529,631 S.E.2d 131 (2006).

Trial court properly granted reimbursement to a payor who paid a Medicaid recipient's medical expenses, pursuant to G.S. 108A-57, and did not err in subrogating the settlements subject to the one-third limitation outlined within the statute; moreover, the payor's claim was properly characterized as a lien, and although the trial court improperly labelled the payor as a "beneficiary," that was harmless error. Andrews v. Haygood, 188 N.C. App. 244, 655 S.E.2d 440 (2008), aff'd, review improvidently allowed, in part, 362 N.C. 599, 669 S.E.2d 310 (2008).

North Carolina Division of Medical Assistance had subrogation rights to the entire amount of a settlement, limited by the statutory provision of G.S. 108A-57(a) that only one-third of a recovery was subject to subrogation, because G.S. 108A-57(a) was a reasonable framework that comported with the requirements of federal Medicaid law under 42 U.S.C.S. § 1396a(a)(25). Andrews v. Haygood, 362 N.C. 599, 669 S.E.2d 310 (2008), cert. denied, - U.S. - 129 S. Ct. 2792 (2009).

Subrogation Rights - Similarities Between This Section And the FMCRA. - The Federal Medical Care Recovery Act (FMCRA), 42 U.S.C.A. § 2651-2653, like this section, provides for a right of subrogation by the United States, which right the government may abandon, although not to the benefit of the defendant tortfeasor. Kaminsky v. Sebile, 140 N.C. App. 71, 535 S.E.2d 109 (2000).

Minor Qualified As "Beneficiary". - Where the North Carolina Department of Human Resources, Division of Medical Assistance (DMA), expended Medicaid funds to pay medical care providers for services to an injured party, the injured party qualified as a "beneficiary" of medical assistance benefits within the meaning of G.S. 108A-57 for purposes of the DMA's right of subrogation to the injured party's settlement from a tortfeasor even though the injured party was a minor at the time that the benefits were paid; under the statute's plain meaning, a "beneficiary" includes one who receives benefits and there is no requirement that a "beneficiary" has to be one who has received a direct cash payment or relief from debt, or one who has the legal right to sue for medical benefits. Campbell v. N.C. Dep't of Human Res., 153 N.C. App. 305, 569 S.E.2d 670 (2002).

With respect to a minor who is both a "recipient" and a "beneficiary" of medical assistance, the North Carolina third-party liability statutes, G.S. 108A-57(a) and G.S. 108A-59(a), by their plain language abrogate the common law rule that a minor cannot recover for medical expenses. A minor's share of the proceeds of a malpractice settlement therefore was not shielded from the state's reimbursement claim by virtue of minority. E.M.A. v. Cansler, 674 F.3d 290 (4th Cir. 2012).

Action Subject to Abatement. - Because a family's federal lawsuit seeking a determination that the State department of health and human services was not entitled to a lien on the proceeds of the family's medical malpractice settlement against various defendants involved the same parties, issues, and remedies as the department's action against the family, the trial court erred in denying the family's motion to abate the department's state court action. State HHS v. Armstrong, 203 N.C. App. 116, 690 S.E.2d 293 (2010).

Attorney's Fees. - This section does not govern a private attorney's fee arrangement with his client. The section regulates the amount of the attorney's fee only as it relates to the amount of the "medicaid lien" payable to plaintiff. North Carolina Dep't of Human Resources v. Weaver, 121 N.C. App. 517, 466 S.E.2d 717, cert. denied, 342 N.C. 896, 467 S.E.2d 905 (1996).

Cited in Strawser v. Atkins, 290 F.3d 720 (4th Cir. 2002); Lewis v. W. Va. Dep't of Health & Human Res. (In re E.B.), 229 W. Va. 435, 729 S.E.2d 270 (2012).

§ 108A-57.1. Rules governing transfer of medical assistance benefits between counties.

Any recipient of medical assistance who moves from one county to another county of this State shall continue to receive medical assistance if eligible. The county director of social services of the county from which the recipient has moved shall transfer all necessary records relating to the recipient to the county director of social services of the county to which the recipient has moved. The county from which the recipient has moved shall pay the county portion of the nonfederal share of medical assistance payments paid for services provided to the recipient during the month following the recipient's move. Thereafter, the county to which the recipient has moved shall pay the county portion of the nonfederal share of medical assistance payments paid for the services provided to the recipient.

History

(1998-212, s. 12.6.)

§ 108A-58: Repealed by Session Laws 2006-66, s. 10.5(a), effective July 1, 2006.

§ 108A-58.1. Ineligibility for medical assistance based on transferring assets for less than fair market value.

General Rule. - Except as otherwise provided herein, an individual who is otherwise eligible to receive medical assistance under this Part is ineligible for Medicaid coverage and payment for the services specified in subsection (d) during the period specified in subsection (c) if the individual or the individual's spouse transfers an asset for less than fair market value on or after the "lookback date" specified in subsection (b).
Lookback Date. -
1. Except as otherwise provided herein, the lookback date is the date specified in 42 U.S.C. § 1396p(c)(1)(B).
2. Notwithstanding subdivision (1), the lookback date with respect to the medical services specified in subdivision (d)(2) is the date specified in 42 U.S.C. § 1396p(c)(1)(B) or February 1, 2003, whichever is later.
Penalty Period. - The penalty period for the transfer of assets for less than fair market value is the period specified in 42 U.S.C. § 1396p(c)(1)(D), (E), and (H).
Medical Services. -
1. In the case of an institutionalized individual, the transfer of assets penalty applies with respect to nursing facility services, a level of care in any institution equivalent to that of nursing facility services, and to home- or community-based services furnished under the State's Community Alternatives Program waiver pursuant to 42 U.S.C. § 1396n(c) or (d), and pursuant to the hardship waiver under subsection (k) of this section.
2. In the case of a noninstitutionalized individual, the transfer of assets penalty applies with respect to home health services and personal care services as defined in 42 U.S.C. § 1396d(a)(7) and (24) and, to the extent permitted by federal law, such other long-term care services specified by rules adopted by the Department of Health and Human Services pursuant to subsection (k) of this section.
Assets. - Assets are the income and resources of an individual or the individual's spouse (including the individual's or spouse's home) as defined in 42 U.S.C. § 1396p(h) and 42 U.S.C. § 1396p(c)(1)(G), (I), and (J).
Fair Market Value and Uncompensated Value. -
1. The fair market value of an asset is the value (minus any valid and legally enforceable liens, mortgages, and encumbrances against the asset) that would have been received if the asset had been sold for good and valuable consideration at the prevailing market price at the time the asset was transferred. In the case of real or personal property that is taxable under Subchapter II of Chapter 105 of the General Statutes, there is a rebuttable presumption that the fair market value of the property is its most recent value as ascertained under Subchapter II of Chapter 105 of the General Statutes (minus any valid and legally enforceable liens, mortgages, and encumbrances against the property).
2. The uncompensated value of an asset is its fair market value minus the amount of good and valuable consideration received in exchange for the asset's transfer.
Individual. - An individual is a person who applies for or is receiving medical assistance under this Part regardless of whether the person was, at the time an asset was transferred, a Medicaid applicant or recipient. The term "individual" also includes an individual's legal representative, anyone acting at the individual's direction or request, and any person, agency, or court acting lawfully on behalf of the individual.
Institutionalized and Noninstitutionalized Individuals. -
1. An institutionalized individual is an individual who meets the criteria set forth in 42 U.S.C. § 1396p(h)(3), regardless of whether the individual was institutionalized at the time an asset was transferred.
2. A noninstitutionalized individual is any individual who (i) is not an institutionalized individual, (ii) is an aged, blind, or disabled person who is categorically or medically needy pursuant to 42 C.F.R. § 120 Subpart B, C, or D or a qualified Medicare beneficiary as defined in 42 U.S.C. § 1396d(p)(1), and (iii) is not eligible for medical assistance under this Part based on his or her eligibility for an optional State supplement pursuant to 42 C.F.R. § 435.232.
Exceptions. -
1. This section does not apply if an individual establishes by the greater weight of the evidence that the transfer was exclusively for some purpose other than establishing or retaining eligibility for medical assistance under this Part.
2. This section does not apply to any transfer specified in 42 U.S.C. § 1396p(c)(2)(A), (B), (C)(i), or (C)(iii).
Application to Life Estates and Income Producing Real Property. - The Department of Health and Human Services may apply federal transfer of assets policies in accordance with this section to (i) life estates purchased by or on behalf of the recipient, and (ii) to real property excluded as "income producing", tenancy-in-common, or as nonhomesite property made "income producing." The Department shall exclude from countable resources any life estate in real property that is in the recipient's home and is measured by the recipient's life. Federal transfer of assets policies applied to income producing real property shall become effective not earlier than October 1, 2001. Federal transfer of assets policies applied to real property excluded as tenancy-in-common, or as nonhomesite property made income producing in accordance with this subsection, shall become effective not earlier than October 1, 2005.
Hardship Waiver. - The Department of Health and Human Services shall waive a transfer of assets penalty that has been imposed or is imposable under this section if the Department determines that imposition of the penalty would create an undue hardship.
Rules and Compliance with Federal Law. -
1. This section shall be interpreted and administered consistently with governing federal law, including 42 U.S.C. § 1396p(c).
2. The Department of Health and Human Services shall determine and publish at least annually the average monthly cost of nursing facility services for private patients that will be used in determining the length of a penalty period under this section.
3. The Department of Health and Human Services shall provide for a hardship waiver process in accordance with 42 U.S.C. § 1396p(c)(2)(D).
4. The Department of Health and Human Services may adopt administrative rules that are necessary and appropriate to implement this section or the requirements of 42 U.S.C. § 1396p(c) or other federal laws governing the transfer of assets and Medicaid eligibility.

History

(2006-66, s. 10.5(b); 2006-221, ss. 8(a)-(c).)

Effect of Amendments. - Session Laws 2006-221, S. 8(a)-(c), effective July 1, 2006, added "and pursuant to the hardship waiver under subsection (k) of this section" at the end of subdivision (b)(1); in subdivision (h)(2), inserted "Subpart B, C, or D" near the middle, and deleted "(3)" preceding "(iii) is not eligible"' and deleted the former second sentence of subsection (j), which read: "The transfer of assets policy shall apply only to an institutionalized individual or the individual's spouse, as defined in subsection (h) of this section."

CASE NOTES

Transfer of Assets. - Wife's transfer of the title to her residence through the execution of deeds of trust for the purpose of securing notes payable to her husband constituted the "disposal" of an asset for purposes of 42 U.S.C.S. § 1396p and the "transfer" of an asset for purposes of G.S. 108A-58.1; the trial court erred by concluding otherwise. Joyner v. N.C. HHS, 214 N.C. App. 278, 715 S.E.2d 498 (2011).

Cited in Williford v. N.C. HHS, 250 N.C. App. 491, 792 S.E.2d 843 (2016).

§ 108A-58.2. Waiver of transfer of assets penalty due to undue hardship.

Prior to imposition of a period of ineligibility for long-term care services because of an asset transfer, also known as a penalty period, the county department of social services shall notify the individual of the individual's right to request a waiver of the penalty period because it will cause an undue hardship to the individual. The director of the county department of social services, or the director's designee shall grant a waiver of the penalty period due to undue hardship if the individual meets the conditions set forth in subsection (e) of this section. As used in this section, "long term care services" are those services described in 42 U.S.C. § 1396p(c)(1)(C)(i) and (ii).
When a Medicaid applicant who is requesting Medicaid to pay for institutional care requests a waiver of a penalty period due to undue hardship, the determination of whether to waive the penalty period shall be processed as part of the Medicaid application and is subject to the application processing standards set forth in 10A NCAC 23C.0201.
When an ongoing Medicaid recipient applies for institutional care or is receiving Medicaid payment for institutional care receives the notice described in subsection (a) of this section, the recipient has 12 calendar days from the date of the notice to request a waiver of the penalty due to undue hardship. The following are the procedures for processing the waiver request:
1. Within five work days of receipt of a request for a waiver of the transfer of assets penalty, the county department of social services shall notify the individual in writing of the information and documentation necessary to determine if the requirements for approving the undue hardship waiver are met.
2. The individual shall have 12 calendar days from the date of the notice specified in subdivision (1) of this subsection to provide the necessary information and documentation to establish the undue hardship.
3. If at the end of the first 12 calendar day period the necessary information and documentation has not been received by the county department of social services, the county department of social services shall again notify the individual of the necessary information and documentation. The individual shall be given an additional 12 calendar days to provide the information and documentation.
4. If the individual fails to request the undue hardship waiver within 12 calendar days from the date of the notice described in subsection (a) of this section, the county department of social services shall impose the transfer of assets penalty in accordance with notice requirements in G.S. 108A-79.
5. If by the end of the 12 calendar days from the notice described in subdivision (3) of this subsection, the necessary information and documentation has not been received by the county department of social services, the county department of social services shall deny the request for waiver of the penalty for undue hardship and notify the individual of the denial in accordance with G.S. 108A-79.
6. If by the end of the time allowed under subdivisions (2) and (3) of this subsection the county department of social services has received the necessary information and documentation, the county department of social services shall make a determination of whether the imposition of the penalty period would cause an undue hardship to the individual. The county department of social services shall complete the determination and notify the individual, pursuant to subsection (g) of this section, of whether the imposition of the penalty period will be waived due to undue hardship within 12 calendar days of the receipt of the necessary information and documentation.
7. If as part of the determination described in subdivision (6) of this subsection the county department of social services identifies the need for additional information and documentation, it shall notify the individual in writing of that information and documentation. This notice shall initiate a new period of time for the individual to provide the information and documentation as set forth in subdivisions (2) and (3) of this subsection. Within 12 calendar days of the receipt of the additional information and documentation, the county department of social services shall complete the determination and notify the individual, pursuant to subsection (g) of this section, of whether the imposition of the penalty period will be waived due to undue hardship.
As required by 42 U.S.C. § 1396p(c)(2)(D), the facility in which an institutionalized individual is residing may request an undue hardship waiver on behalf of the institutionalized individual with the written consent of the individual or the personal representative of the individual. A facility applying for a waiver for an individual residing in the facility shall adhere to the requirements of this section but is not required to advance the costs of acquiring an attorney to aid the institutionalized individual.
Except as provided for in subsection (f) of this section, undue hardship exists if the imposition of the penalty period would deprive the individual of medical care, such that the individual's health or life would be endangered, or of food, clothing, shelter, or other necessities of life. The individual must provide the information and documentation necessary to demonstrate to the director of the county department of social services or the director's designee all of the following:
1. The individual currently has no alternative income or resources available to provide the medical care or food, clothing, shelter, or other necessities of life that the individual would be deprived of due to the imposition of the penalty.
2. The individual or some other person acting on the individual's behalf is making a good faith effort to pursue all reasonable means to recover the transferred asset or the fair market value of the transferred asset, including any of the following:
  1. Seeking the advice of an attorney and pursuing legal or equitable remedies such as asset freezing, assignment, or injunction.
  2. Cooperating with any attempt to recover the transferred asset or the fair market value of the transferred asset.
3. The following definitions apply in this subsection:
  1. Health or life would be endangered. - A medical doctor with knowledge of the individual's medical condition certifies in writing that in his or her professional opinion, the individual will be in danger of death or the individual's health will suffer irreparable harm if a penalty period is imposed.
  2. Recodified as sub-subdivision (e )(3)c1. of this section by Session Laws 2021-88, s. 9(a).
  3. Income. - All income of the individual and the community spouse less a protected amount for the community spouse equal to the minimum monthly maintenance needs allowance as determined under 42 U.S.C. § 1396r-5(d), including in all circumstances the excess shelter allowance described under 42 U.S.C. § 1396r-5(d)(3)(A)(ii), without regard to any adjustment that would be made under 42 U.S.C. § 1396r-5(e), plus fifty percent (50%) of the income in excess of the protected amount.
  4. Resources. - All resources of the individual and of the community spouse except the homesite in which the individual or community spouse has an equity interest not exceeding five hundred thousand dollars ($500,000), a motor vehicle in which the individual or community spouse has an equity interest not exceeding thirty thousand dollars ($30,000), personal property, and, in the case of a community spouse, a portion of such other resources in an amount equal to the community spouse resource allowance as defined by 42 U.S.C. § 1396r-5(f)(2), so long as the amount does not exceed sixty percent (60%) of the maximum community spouse resource allowance as defined by 42 U.S.C. § 1396r-5(f)(2)(A)(ii). For purposes of this sub-subdivision, "homesite" means the principal place of residence of the individual or the community spouse in which the individual or community spouse has an equity interest.
An undue hardship does not exist when the application of a transfer of assets penalty merely causes the individual an inconvenience or restricts the individual's lifestyle.
If the director of the county department of social services or the director's designee determines that:
1. An undue hardship exists, the county department of social services shall waive the penalty period and notify the individual of approval of the waiver of the penalty in accordance with G.S. 108A-79.
2. An undue hardship does not exist, the county department of social services shall deny the request for the waiver of the penalty and notify the individual of denial of the waiver request in accordance with G.S. 108A-79.
During a penalty period that has been waived because of undue hardship, acquisition by the individual of new or increased income or resources shall be treated as a change in situation and evaluated pursuant to the rules adopted by the Department of Health and Human Services.
While the determination on a request for a waiver of the penalty period due to undue hardship is pending, Medicaid shall not make payments for services in a nursing facility or in an intermediate care facility for individuals with intellectual disabilities to hold a bed for the individual, as described in 42 U.S.C. § 1396p(c)(2)(D). However, if the individual is institutionalized and receiving Medicaid payment for services, Medicaid will maintain the same level of services until the last day of the month after the latter of the following:
1. Expiration of the 10 workday period following the notice required by G.S. 108A-79.
2. The date of the decision of a local appeal hearing described in G.S. 108A-79 is issued if the individual requests an appeal of the imposition of a transfer of assets penalty period within the 10 workday period described in subdivision (1) of subsection (i) of this section.

a1. Seeking modification, avoidance, or nullification of a financial instrument, promissory note, loan, mortgage or other property agreement, or other similar transfer agreement.

c1. Other necessities of life. - Includes basic, life sustaining utilities, including water, heat, electricity, phone, and other items or activities that without which the individual's health or life would be endangered.

History

(2007-442, s. 3(a); 2021-62, s. 4.1; 2021-88, ss. 9(a), (b).)

Editor's Note. - Session Laws 2007-442, s. 3.6, provides: "Unless required by federal law, the Department of Health and Human Services, Division of Medical Assistance shall limit notification of estate recovery to the application process for Medicaid and to following the death of the recipient."

Effect of Amendments. - Session Laws 2021-88, ss. 9(a), (b), effective July 22, 2021, recodified sub-subdivision (e)(3)b. as sub-subdivision (e)(3)c1; substituted "10A NCAC 23C .0201” for "10A NCAC 21B.0203” in subsection (b); substituted "is not required” for "shall not be required” in subsection (d); rewrote subsection (e); substituted "does not exist” for "shall not exist” in subsection (f); and rewrote subsection (i).

§ 108A-59. Acceptance of medical assistance constitutes assignment to the State of right to third party benefits; recovery procedure.

Notwithstanding any other provisions of the law, by accepting medical assistance, the recipient shall be deemed to have made an assignment to the State of the right to third party benefits, contractual or otherwise, to which he may be entitled.
The responsible State agency will establish a third party resources collection unit that is adequate to assure maximum collection of third party resources.
Notwithstanding any other law to the contrary, in all actions brought pursuant to subsection (a) of this section to obtain reimbursement for payments for medical services, liability shall be determined on the basis of the same laws and standards, including bases for liability and applicable defenses, as would be applicable if the action were brought by the individual on whose behalf the medical services were rendered.

It shall be the responsibility of the county attorney of the county from which the medical assistance benefits are received or an attorney retained by that county and/or the State to enforce this subsection, and said attorney shall be compensated for his services in accordance with the attorneys' fee arrangements approved by the Department of Health and Human Services.

History

(1977, c. 664; 1979, 2nd Sess., c. 1312, ss. 3-5; 1981, c. 275, s. 1; 1995, c. 508, s. 2; 1997-443, s. 11A.118(a).)

CASE NOTES

Medicaid Benefits Protected. - Subsection (a) of this section does not remove Medicaid benefits from the protection of the collateral source rule. Availability of public assistance should not operate to reduce a tortfeasor's legal liability. Cates v. Wilson, 83 N.C. App. 448, 350 S.E.2d 898 (1986), modified, 321 N.C. 1, 361 S.E.2d 734 (1987).

Relationship to Federal Law. - G.S. 108A-57 and G.S. 108A-59 comported with federal law because if a Medicaid recipient in North Carolina obtains a third-party lump-sum settlement, which did not allocate a specific portion to recovery for medical costs, G.S. 108A-57(a) controlled, and the State would be reimbursed the lesser of the state's past medical expenditures or one-third of the plaintiff's total recovery; by limiting the state's subrogation right to one-third of a Medicaid recipient's recovery, the scheme protected a plaintiff's interests while promoting efficiency in Medicaid reimbursement cases throughout North Carolina. Armstrong v. Cansler, 722 F. Supp. 2d 653 (W.D.N.C. June 28, 2010), vacated 674 F.3d 290, 2012 U.S. App. LEXIS 5996 (4th Cir. N.C. 2012).

Injured Party Was a "Recipient" of Medical Assistance Despite Being a Minor When Benefits Were Paid. - Where the North Carolina Department of Human Resources, Division of Medical Assistance, expended Medicaid funds to pay certain medical care providers for services that they had rendered to an injured party, the injured party qualified as a "recipient" of medical assistance benefits within the meaning of G.S. 108A-24(5) and G.S. 108A-59 even though the injured party was a minor at the time that the benefits were paid; there was no requirement that a "recipient" had to be one who had received a direct cash payment or relief from debt, or one who had the legal right to sue for medical benefits. Campbell v. N.C. Dep't of Human Res., 153 N.C. App. 305, 569 S.E.2d 670 (2002).

Subrogation Rights in State's Favor Properly Recognized. - Trial court properly granted reimbursement to a payor who paid a Medicaid recipient's medical expenses, pursuant to G.S. 108A-57, and did not err in subrogating the settlements subject to the one-third limitation outlined within the statute; moreover, the payor's claim was properly characterized as a lien, and although the trial court improperly labelled the payor as a "beneficiary," that was harmless error. Andrews v. Haygood, 188 N.C. App. 244, 655 S.E.2d 440 (2008), aff'd, review improvidently allowed, in part, 362 N.C. 599, 669 S.E.2d 310 (2008).

Cited in Payne ex rel. Rabil v. State, Dep't of Human Resources, 126 N.C. App. 672, 486 S.E.2d 469 (1997); Strawser v. Atkins, 290 F.3d 720 (4th Cir. 2002); Lewis v. W. Va. Dep't of Health & Human Res. (In re E.B.), 229 W. Va. 435, 729 S.E.2d 270 (2012).

§ 108A-60. Protection of patient property.

It shall be unlawful for any person:
1. To willfully commingle or cause or solicit the commingling of the personal funds or moneys of a recipient resident of a provider health care facility with the funds or moneys of such facility; or
2. To willfully embezzle, convert, or appropriate or cause or solicit the embezzlement, conversion or appropriation of recipient personal funds or property to his own use or to the use of any provider or other person or entity.
A violation of subdivision (a)(1) of this section shall be a Class 1 misdemeanor. A violation of subdivision (a)(2) of this section shall be a Class H felony.
For purposes of this section:
1. "Health care facility" shall include skilled nursing facilities, intermediate care facilities, rest homes, or any other residential health care facility; and
2. "Person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization; and
3. "Recipient" shall include current resident recipients, deceased recipients and recipients who no longer reside at such facility.

History

(1979, c. 510, s. 1; 1981, c. 275, s. 1; 1993, c. 539, ss. 816, 1300; 1994, Ex. Sess., c. 24, s. 14(c).)

Editor's Note. - Session Laws 2020-78, s. 4D.4(a)-(f), provides: "(a) Effective until coverage under tailored plans described under G.S. 108D-60 begins, the Department of Health and Human Services shall ensure that local management entities/managed care organizations (LME/MCOs) utilize out-of-network agreements between a single provider of behavioral health or intellectual and developmental disability (IDD) services and the LME/MCO to ensure access to care in accordance with 42 C.F.R. § 438.206(b)(4). These out-of-network agreements shall contain standardized elements developed in consultation with all LME/MCOs, reduce administrative burden on providers of behavioral health and IDD services, and comply with all requirements of State and federal laws.

"(b) LME/MCOs shall use an out-of-network agreement in lieu of a comprehensive provider contract when all of the following conditions are met:

"(1) The services requested are medically necessary and cannot be provided by a provider in the LME/MCO's closed provider network.

"(2) The behavioral health or IDD services provider's site of service delivery is located outside of the geographical catchment area of the LME/MCO, and either (i) the LME/MCO is not accepting applications for membership into its closed provider network or (ii) the provider does not wish to apply for membership in the LME/MCO's closed provider network.

"(3) The behavioral health or IDD services provider is not excluded from participation in the Medicaid program, the NC Health Choice program, or any other State or federal health care program.

"(4) The behavioral health or IDD provider is serving no more than two enrollees of the LME/MCO.

"(c) An LME/MCO shall not restrict its number of out-of-network agreements to provide inpatient hospitalization services unless the services could be provided by a provider in the LME/MCO's closed provider network and the out-of-network provider is unwilling to enter into a network agreement with the LME/MCO.

"(d) An LME/MCO shall not restrict its number of out-of-network agreements for other behavioral health and IDD services to foster children and "independent foster care adolescents," ages 18, 19, and 20, as defined in 42 U.S.C. § 1396d(w)(1) if the person is already receiving such services from such provider, though the services could be provided by a provider in the LME/MCO's closed provider network.

"(e) Any provider enrolled in the North Carolina Medicaid program that provides services pursuant to an out-of-network agreement shall be considered a network provider for purposes of Chapter 108D of the General Statutes only as it relates to enrollee grievances and appeals for those services.

"(f) This section is effective when it becomes law."

Session Laws 2020-78, s. 22.3, is a severability clause.

§ 108A-61: Repealed by Session Laws 1989, c. 701.

§ 108A-61.1. Financial responsibility of a parent for a child under age 21 in a medical institution.

Notwithstanding any other provisions of the law, for the purpose of determining eligibility for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., the income and financial resources of the natural or adoptive parents of a person who is under the age of 21 and who requires Medicaid covered services in a medical institution shall not be counted if the patient's physician certifies, and the Division of Health Benefits or its agents approve, that continuous care and treatment are expected to exceed 12 months. For purposes of this subsection, "medical institution" means licensed acute care inpatient medical facilities providing medical, surgical, and psychiatric or substance abuse treatment, or facilities providing skilled or intermediate care, including intermediate care for individuals with intellectual disabilities.

History

(1993, c. 386, s. 1; 2019-81, s. 15(a); 2021-62, s. 4.1; 2021-88, s. 9(c).)

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance."

Session Laws 2021-88, s. 9(c), effective July 22, 2021, substituted "individuals with intellectual disabilities” for "the mentally retarded.”

§ 108A-62. Therapeutic leave for medical assistance patients.

A medical assistance beneficiary at an intermediate care facility or skilled nursing facility may take therapeutic leave in accordance with this section without the facility losing reimbursement under the medical assistance program.
The maximum amount of therapeutic leave days that may be taken in a calendar year by a medical assistance beneficiary are as follows:
1. Ninety days for a beneficiary in an intermediate care facility.
2. Sixty days for a beneficiary in a skilled nursing facility.
No more than 15 consecutive days of therapeutic leave may be taken by a medical assistance beneficiary without the approval of one of the following:
1. The Division of Health Benefits of the Department.
2. The local management entity/managed care organization with which the beneficiary is enrolled under Chapter 122C of the General Statutes.
3. The prepaid health plan with which the beneficiary is enrolled under Chapter 108D of the General Statutes.

History

(1979, c. 925; 1981, c. 275, s. 1; 1985 (Reg. Sess., 1986), c. 1014, s. 120; 1991, c. 126, s. 1; 1997-443, s. 11A.118(a); 2019-81, s. 15(a); 2021-62, s. 3.1(a).)

Editor's Note. - Session Laws 2021-62, s. 3.1(b), made the rewriting of this section by Session Laws 2021-62, s. 3.1(a), effective June 29, 2021, and individuals who had exhausted the amount of therapeutic leave prior to that date shall be entitled to any additional leave for the calendar year allowed under G.S. 108A-62, as amended by this section.

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance."

Session Laws 2021-62, s. 3.1(a), rewrote the section. For effective date and applicability, see editor's note.

§ 108A-63. Medical assistance provider fraud.

It shall be unlawful for any provider of medical assistance under this Part to knowingly and willfully make or cause to be made any false statement or representation of a material fact:
1. In any application for payment under this Part, or for use in determining entitlement to such payment; or
2. With respect to the conditions or operation of a provider or facility in order that such provider or facility may qualify or remain qualified to provide assistance under this Part.
It shall be unlawful for any provider of medical assistance to knowingly and willfully conceal or fail to disclose any fact or event affecting:
1. His initial or continued entitlement to payment under this Part; or
2. The amount of payment to which such person is or may be entitled.
Except as otherwise provided in subsection (e) of this section, any person who violates a provision of this section shall be guilty of a Class I felony.
"Provider" shall include any person who provides goods or services under this Part and any other person acting as an employee, representative or agent of such person.
In connection with the delivery of or payment for benefits, items, or services under this Part, it shall be unlawful for any provider of medical assistance under this Part to knowingly and willfully execute, or attempt to execute, a scheme or artifice to:
1. Defraud the Medical Assistance Program.
2. Obtain, by means of false or fraudulent pretenses, representations, or promises of material fact, any of the money or property owned by, or under the custody or control of, the Medical Assistance Program.
It shall be unlawful for any provider, with the intent to obstruct, delay, or mislead an investigation of a violation of this section by the Attorney General's office, to knowingly and willfully make or cause to be made a false entry in, alter, destroy, or conceal, or make a false statement about a financial, medical, or other record related to the provision of a benefit, item, or service under this Part.
It shall be unlawful for any person to knowingly and willfully solicit or receive any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in-kind:
1. In return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under this Part.
2. In return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under this Part.
It shall be unlawful for any person to knowingly and willfully offer or pay any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in-kind to any person to induce such person:
1. To refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under this Part.
2. To purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under this Part.
Subsections (g) and (h) of this section shall not apply to:
1. Contracts between the State and a public or private agency where part of the agency's responsibility is referral of a person to a provider.
2. Any conduct or activity that is specified in 42 U.S.C. § 1320a-7b(b)(3), as amended, or any federal regulations adopted pursuant thereto.
Nothing in subsections (g) and (h) of this section shall be interpreted or construed to conflict with 42 U.S.C. § 1320a-7b(b), as amended, or with federal common law or federal agency interpretations of the statute.

A violation of this subsection is a Class H felony. A conspiracy to violate this subsection is a Class I felony.

History

(1979, c. 510, s. 1; 1981, c. 275, s. 1; 2009-554, s. 3; 2010-185, s. 1.)

Editor's Note. - For provisions relating to Medicaid Fraud Prevention Program, see Session Laws 2010-31, s. 10.26(a)-(e), noted in full under G.S. 108A-70.10.

§ 108A-63.1. Health care fraud subpoena to produce documents.

The Attorney General, acting through the Medicaid Investigations Unit of the Department of Justice, may, when engaged in an investigation of an alleged violation of G.S. 108A-63 and prior to the arrest of a suspect, issue in writing and cause to be served a subpoena to produce documents upon any corporation or governmental entity requiring the production of any records, books, papers, electronic media, objects, or other documents which may be relevant to a criminal investigation of a violation of G.S. 108A-63.
A subpoena under this section may require the custodian of records of the corporation or governmental entity to produce an affidavit certifying that the custodian made a thorough and diligent search for the documents requested and that the documents produced constitute all the records requested to the best of the custodian's knowledge, information, and belief.
A subpoena under this section shall describe the documents required to be produced and prescribe a return date within a reasonable period of time, of no less than 20 days from the date of service, within which the documents can be assembled and made available.
A corporation or governmental entity may comply with a subpoena issued under this section by delivering the documents to the Medicaid Investigations Unit by any of the following methods:
1. By hand delivery.
2. By mailing the documents by certified mail.
3. By making the documents reasonably available for transfer to an agent of the Medicaid Investigations Unit at a place of business of the corporation or governmental entity.
4. If agreed to by the Medicaid Investigations Unit and the corporation or governmental entity, by any other means.
A corporation or governmental entity may move to quash or modify a subpoena issued under this section if it is oppressive or unreasonable or does not comply with the requirements of this section. The motion must be made before the time specified in the subpoena for production and may be made before a judge of the superior court.
In the case of failure by any corporation or governmental entity without adequate excuse to obey a subpoena issued under this section, the Attorney General may invoke the aid of a judge of the superior court. The court may issue an order requiring the subpoenaed corporation or governmental entity to appear before the Attorney General to produce records. Failure to obey the order of the court may be punished as contempt of court.

History

(2009-554, s. 2.)

§ 108A-64. Medical assistance recipient fraud.

It shall be unlawful for any person to knowingly and willfully and with intent to defraud make or cause to be made a false statement or representation of a material fact in an application for assistance under this Part, or intended for use in determining entitlement to such assistance.
It shall be unlawful for any applicant, recipient or person acting on behalf of such applicant or recipient to knowingly and willfully and with intent to defraud, conceal or fail to disclose any condition, fact or event affecting such applicant's or recipient's initial or continued entitlement to receive assistance under this Part.
It is unlawful for any person knowingly, willingly, and with intent to defraud, to obtain or attempt to obtain, or to assist, aid, or abet another person, either directly or indirectly, to obtain money, services, or any other thing of value to which the person is not entitled as a recipient under this Part, or otherwise to deliberately misuse a Medicaid identification card. This misuse includes the sale, alteration, or lending of the Medicaid identification card to others for services and the use of the card by someone other than the recipient to receive or attempt to receive Medicaid program coverage for services rendered to that individual.
1. A person who violates a provision of this section shall be guilty of a Class I felony if the value of the assistance wrongfully obtained is more than four hundred dollars ($400.00). (c) (1) A person who violates a provision of this section shall be guilty of a Class I felony if the value of the assistance wrongfully obtained is more than four hundred dollars ($400.00).
2. A person who violates a provision of this section shall be guilty of a Class 1 misdemeanor if the value of the assistance wrongfully obtained is four hundred dollars ($400.00) or less.
For purposes of this section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization.

Proof of intent to defraud does not require proof of intent to defraud any particular person.

History

(1981, c. 275, s. 1; 1993, c. 539, s. 817; 1994, Ex. Sess., c. 24, s. 14(c); 1995, c. 317, s. 1.)

Editor's Note. - For provisions relating to Medicaid Fraud Prevention Program, see Session Laws 2010-31, s. 10.26(a)-(e), noted in full under G.S. 108A-70.10.

§ 108A-64.1. Incentives to counties to recover fraudulent Medicaid expenditures.

The Department of Health and Human Services, Division of Health Benefits, shall provide incentives to counties that successfully recover fraudulently spent Medicaid funds by sharing State savings with counties responsible for the recovery of the fraudulently spent funds.

History

(2013-360, s. 12H.5; 2019-81, s. 15(a).)

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance."

§ 108A-65. Conflict of interest.

It shall be unlawful for any person who is or has been an officer or employee of State or county government, and as such is or has been responsible for the expenditure of substantial amounts of federal, State or county money under the State medical assistance plan, or any person who is the partner of the present or former officer or employee, to engage in any of the following activities relating to the State medical assistance program:
1. Knowingly to act as agent or attorney for, or otherwise knowingly to represent, any person other than the United States, the State or a county, in any formal or informal appearance before, or with the intent to influence, make any oral or written communication on behalf of any other person other than the United States, the State or a county to:
  1. Any department, agency, court, board, commission, legislature or committee of the United States, the State or a county, or any officer or employee thereof,
  2. In connection with any of the following matters in which the United States, the State, or a county is a party or has a direct and substantial interest, such as any judicial or other proceeding, legislation, application, request for a ruling or other determination, contract, claim, controversy, investigation, charge, accusation, arrest, or other particular matter involving a specific party or parties,
  3. In which he participated personally and substantially as an officer or an employee through decision, approval, recommendation, the rendering of advice, investigation or otherwise.
2. Within two years after his employment has ceased, knowingly to act as agent or attorney for, or otherwise knowingly to represent, any other person other than the United States, the State or a county, in any formal or informal appearance before, or, with the intent to influence, make any oral or written communication on behalf of any other person other than the United States, the State or a county to:
  1. Any department, agency, court, board, commission, legislature or committee of the United States, the State, or a county, or any officer or employee thereof,
  2. In connection with any of the following matters in which the United States, the State, or a county is a party or has a direct and substantial interest, such as, any judicial or other proceeding, legislation, application, request for a ruling or other determination, contract, claim, controversy, investigation, charge, accusation, arrest, or other particular matter involving a specific party or parties,
  3. Which was actually pending under his official responsibility as an officer or employee within a period of one year prior to the termination of responsibility.
3. Within two years after his employment has ceased, knowingly to aid, counsel, advise, consult or by personal presence represent any other person other than the United States, the State or a county in any formal or informal appearance before:
  1. Any department, agency, court, board, commission, legislature or committee of the United States, the State, or the county, or any officer or employee thereof,
  2. In connection with any of the following matters in which the United States, the State, or a county is a party or has a direct and substantial interest, such as, any judicial or other proceeding, legislation, application, request for a ruling or other determination, contract, claim, controversy, investigation, charge, accusation, arrest, or other particular matter involving a specific party or parties,
  3. Which was actually pending under his official responsibility as an officer or employee within the period of one year prior to the termination of such responsibility.
4. To participate personally and substantially as an officer or employee, through decision, approval, disapproval, recommendation, rendering of advice, investigation or otherwise, in a judicial or other proceeding legislation, application, request for a ruling or other determination, contract, claim, controversy, charge, accusation, arrest or other particular matter in which, to his knowledge, he, his spouse, minor child, partner, organization in which he is serving as an officer, director, trustee, partner or employee, or any person or organization with whom he is negotiating or has any arrangement concerning prospective employment, has a financial interest.
Violation of this statute is a Class 1 misdemeanor.
The Department of Health and Human Services shall annually identify and designate by rule or regulation those positions which are filled by State or county officers or employees who are responsible for the expenditure of substantial amounts of moneys under the State medical assistance plan.

History

(1981, c. 679, s. 1; 1993, c. 539, s. 818; 1994, Ex. Sess., c. 24, s. 14(c); 1997-443, s. 11A.118(a).)

§ 108A-66: Repealed by Session Laws 1989, c. 702.

§ 108A-66.1. Medicaid buy-in for workers with disabilities.

Title. - This section may be cited as the Health Coverage for Workers With Disabilities Act. The Department shall implement a Medicaid buy-in eligibility category as permitted under P.L. 106-170, Ticket to Work and Work Incentives Improvement Act of 1999. The Department shall establish rules, policies, and procedures to implement this act in accordance with this section.
Definitions. - As used in this section, unless the context clearly requires otherwise:
1. "FPG" means the federal poverty guidelines.
2. "HCWD" means Health Coverage for Workers With Disabilities.
3. "SSI" means Supplemental Security Income.
4. "Ticket to Work" means the Ticket to Work and Work Incentives Improvement Act of 1999.
Eligibility. - An individual is eligible for HCWD if:
1. The individual is at least 16 years of age and is less than 65 years of age;
2. The individual meets Social Security Disability criteria, or the individual has been enrolled in HCWD and then becomes medically improved as defined in Ticket to Work and as further specified by the Department. An individual shall be determined to be eligible under this section without regard to the individual's ability to engage in, or actual engagement in, substantial gainful activity as defined in section 223 of the Social Security Act (42 U.S.C. § 423(d)(4)). In conducting annual redetermination of eligibility, the Department may not determine that an individual participating in HCWD is no longer disabled based solely on the individual's participation in employment or earned income;
3. The individual's unearned income does not exceed one hundred fifty percent (150%) of FPG, and countable resources for the individual do not exceed the resource limit for the minimum community spouse resource standard under 42 U.S.C. § 1396r, and as further determined by the Department. In determining an individual's countable income and resources, the Department may not consider income or resources that are disregarded under the State Medical Assistance Plan's financial methodology, including the sixty-five-dollar ($65.00) disregard, impairment-related work expenses, student earned-income exclusions, and other SSI program work incentive income disregards; and
4. The individual is engaged in a substantial and reasonable work effort (employed) as provided in this subdivision and as further defined by the Department and allowable under federal law. For purposes of this subsection, "engaged in substantial and reasonable work effort" means all of the following:
  1. Working in a competitive, inclusive work setting, or self-employed.
  2. Earning at least the applicable minimum wage.
  3. Having monthly earnings above the SSI basic sixty-five-dollar ($65.00) earned-income disregard.
  4. Being able to provide evidence of paying applicable Medicare, Social Security, and State and federal income taxes.
Fees, Premiums, and Co-Payments. - Individuals who participate in HCWD and have countable income greater than one hundred fifty percent (150%) of FPG shall pay an annual enrollment fee of fifty dollars ($50.00) to their county department of social services. Individuals who participate in HCWD and have countable income greater than or equal to two hundred percent (200%) of FPG shall pay a monthly premium in addition to the annual fee. The Department shall set a sliding scale for premiums, which is consistent with applicable federal law. An individual with countable income equal to or greater than four hundred fifty percent (450%) of FPG shall pay not less than one hundred percent (100%) of the cost of the premium, as determined by the Department. The premium shall be based on the experience of all individuals participating in the Medical Assistance Program. Individuals who participate in HCWD are subject to co-payments equal to those required under the Medical Assistance Program.

The Department may impose additional earnings requirements in defining "engaged in substantial and reasonable work effort" for individuals who are eligible for HCWD based on medical improvement.

Individuals who participate in HCWD but thereafter become unemployed for involuntary reasons, including health reasons, shall have continued eligibility in HCWD for up to 12 months from the time of involuntary unemployment, so long as the individual (i) maintains a connection with the workforce, as determined by the Department, (ii) meets all other eligibility criteria for HCWD during the period, and (iii) pays applicable fees, premiums, and co-payments.

History

(2005-276, s. 10.18(a); 2006-66, s. 10.9(a); 2007-144, s. 2; 2009-451, s. 10.69; 2013-360, s. 12H.10(f).)

Editor's Note. - Session Laws 2013-360, s. 38.6, recodified G.S. 108A-54.1 as G.S. 108A-66.1 by Session Laws 2013-360, s. 12H.10(f), effective July 1, 2013.

Session Laws 2013-360, s. 12H.10(a)-(e), provides: "(a) Families and children who are categorically and medically needy are eligible for Medicaid, subject to the following annual income levels:

Categorical ly Medically Family Needy Needy Size Income Level Income Level 1 $4,344 $2,900 2 5,664 3,800 3 6,528 4,400 4 7,128 4,800 5 7,776 5,200 6 8,376 5,600 7 8,952 6,000 8 9,256 6,300

"The Department of Health and Human Services shall provide Medicaid coverage to 19- and 20-year-olds under this subsection in accordance with federal rules and regulations. Medicaid enrollment of categorically needy families with children shall be continuous for one year without regard to changes in income or assets.

"(b) For the following Medicaid eligibility classifications for which the federal poverty guidelines are used as income limits for eligibility determinations, the income limits will be updated each April 1 immediately following publication of federal poverty guidelines. The Department of Health and Human Services, Division of Medical Assistance, shall provide Medicaid coverage to the following:

"(1) All elderly, blind, and disabled people who have incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines.

"(2) Pregnant women with incomes equal to or less than one hundred eighty-five percent (185%) of the federal poverty guidelines and without regard to resources. Services to pregnant women eligible under this subsection continue throughout the pregnancy but include only those related to pregnancy and to those other conditions determined by the Department as conditions that may complicate pregnancy.

"(3) Infants under the age of one with family incomes equal to or less than two hundred percent (200%) of the federal poverty guidelines and without regard to resources.

"(4) Children aged one through five with family incomes equal to or less than two hundred percent (200%) of the federal poverty guidelines and without regard to resources.

"(5) Effective until January 1, 2014, children aged six through 18 with family incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines and without regard to resources.

"(6) Effective January 1, 2014, children aged six through 18 with family incomes equal to or less than one hundred thirty-three percent (133%) of the federal poverty guidelines and without regard to resources.

"(7) Workers with disabilities described in G.S. 108A-66A with unearned income equal to or less than one hundred fifty percent (150%) of the federal poverty guidelines.

"The Department of Health and Human Services, Division of Medical Assistance, shall also provide family planning services to men and women of childbearing age with family incomes equal to or less than one hundred eighty-five percent (185%) of the federal poverty guidelines and without regard to resources.

"(c) The Department of Health and Human Services, Division of Medical Assistance, shall provide Medicaid coverage to adoptive children with special or rehabilitative needs, regardless of the adoptive family's income.

"(d) The Department of Health and Human Services, Division of Medical Assistance, shall provide Medicaid coverage to 'independent foster care adolescents,' ages 18, 19, and 20, as defined in section 1905(w)(1) of the Social Security Act (42 U.S.C. § 1396d(w)(1)), without regard to the adolescent's assets, resources, or income levels.

"(e) The Department of Health and Human Services, Division of Medical Assistance, shall provide Medicaid coverage to women who need treatment for breast or cervical cancer and who are defined in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XVIII)."

This section is former G.S. 108A-54.1, as recodified by Session Laws 2013-360, s. 12H.10(f), effective July 1, 2013. The historical citation from the former section has been retained in this section as recodified.

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Effect of Amendments. - Session Laws 2009-451, s. 10.69, effective July 1, 2009, substituted "Medical Assistance Program" for "North Carolina Health Choice Program" in the last sentence of subsection (d).

Session Laws 2013-360, s. 12H.10(f), effective July 1, 2013, substituted "section" for "act" in subsection (a).

§ 108A-67. Medicare/Qualified Disabled Working Individuals.

Qualified disabled working individuals are eligible for the payment of the Medicare Part A premium. An individual is qualified for this payment:

If the Social Security Administration determines the individual to be a "Disabled Working Individual";
If the individual's income is less than two hundred percent (200%) of the current federal poverty level, as revised annually; and
If the individual is less than 65 years of age.

History

(1991, c. 127, s. 1.)

§ 108A-68. Drug Use Review Program; rules.

Notwithstanding the provisions of Chapter 90 of the General Statutes or of any other provision of law, the Division of Health Benefits, Department of Health and Human Services, shall adopt rules implementing the drug use review provisions of the Omnibus Budget Reconciliation Act of 1990, as amended.

History

(1991 (Reg. Sess., 1992), c. 900, s. 128; 1997-443, s. 11A.118(a); 2019-81, s. 15(a).)

Editor's Note. - Session Laws 2010-31, s. 10.33(a)-(c), provides: "(a) The Secretary of the Department of Health and Human Services shall establish a Preferred Drug List (PDL) Policy Review Panel within 60 days after the effective date of this section. The purpose of the PDL Policy Review Panel is to review the Medicaid PDL recommendations from the Department of Health and Human Services, Division of Medical Assistance, and the Physician Advisory Group Pharmacy and Therapeutics (PAG P&T) Committee.

"(b) The Secretary shall appoint the following individuals to the review panel:

"(1) The Director of Pharmacy for the Division of Medical Assistance.

"(2) A representative from the PAG P&T Committee.

"(3) A representative from the Old North State Medical Society.

"(4) A representative from the North Carolina Association of Pharmacists.

"(5) A representative from Community Care of North Carolina.

"(6) A representative from the North Carolina Psychiatric Association.

"(7) A representative from the North Carolina Pediatric Society.

"(8) A representative from the North Carolina Academy of Family Physicians.

"(9) A representative from the North Carolina Chapter of the American College of Physicians.

"(10) A representative from a research-based pharmaceutical company.

"Individuals appointed to the Review Panel, except for the Division's Director of Pharmacy, shall only serve a two-year term.

"(c) Within 30 days after the Department, in consultation with the PAG P&T Committee, publishes a proposed policy or procedure related to the Medicaid PDL, the Review Panel shall hold an open meeting to review the recommended policy or procedure along with any written public comments received as a result of the posting. The Review Panel shall provide an opportunity for public comment at the meeting. After the conclusion of the meeting, the Review Panel shall submit policy recommendations about the proposed Medicaid PDL policy or procedure to the Secretary."

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance."

§ 108A-68.1. Certain prescription drugs exempt from prior authorization requirements.

Prior authorization shall not be required or utilized for any antihemophilic factor drugs prescribed for the treatment of hemophilia and blood disorders where there is no generically equivalent drug available. Nothing in this section shall prohibit the Secretary from implementing a disease management program.

History

(2003-179, s. 1; 2005-83, s. 1; 2009-210, s. 1.)

Editor's Note. - Session Laws 2003-179, s. 2, as amended by Session Laws 2005-83, s. 1, and by Session Laws 2009-210, s. 1, makes this section effective June 12, 2003. Session Laws 2009-210, s. 1, amended Session Laws 2003-179, s. 2, as amended, to delete a July 1, 2009, expiration date. Therefore, this section will not expire July 1, 2009.

§ 108A-68.2. Beneficiary lock-in program for certain controlled substances.

The following definitions apply in this section:
1. Covered substances. - Any controlled substance identified as an opioid or benzodiazepine, excluding benzodiazepine sedative-hypnotics, contained in Article 5 of Chapter 90 of the General Statutes, unless one of the following conditions are met:
  1. If the Department of Health and Human Services specifically identifies the opioid or benzodiazepine as a substance excluded from coverage by the Medicaid Beneficiary Management Lock-In Program described in its Outpatient Pharmacy Clinical Coverage Policy adopted in accordance with G.S. 108A-54.2, then the opioid or benzodiazepine is not a covered substance under this section.
  2. If the Department of Health and Human Services specifically identifies a controlled substance contained in Article 5 of Chapter 90 of the General Statutes other than an opioid or benzodiazepine as a controlled substance covered by the Medicaid Beneficiary Management Lock-In Program described in its Outpatient Pharmacy Clinical Coverage Policy adopted in accordance with G.S. 108A-54.2, then the controlled substance is a covered substance under this section.
2. Lock-in program. - A requirement that a Medicaid or NC Health Choice beneficiary select a single prescriber and a single pharmacy for obtaining covered substances.
3. Prepaid health plan or PHP. - As defined in G.S. 108D-1.
Repealed by Session Laws 2021-62, s. 4.4, effective June 29, 2021.
Repealed by Session Laws 2021-62, s. 4.4, effective June 29, 2021.
This section does not apply to any lock-in program for Medicaid or NC Health Choice beneficiaries who are not enrolled in a Prepaid Health Plan.
A Prepaid Health Plan may develop a lock-in program for Medicaid or NC Health Choice beneficiaries who meet any of the following criteria:
1. Have filled six or more prescriptions for covered substances in a period of two consecutive months.
2. Have received prescriptions for covered substances from three or more providers in a period of two consecutive months.
3. Are recommended as a candidate for the lock-in program by a provider.
A lock-in program developed pursuant to subsection (e) of this section shall comply with all of the following:
1. A beneficiary shall not be subject to the lock-in program until the Prepaid Health Plan has notified the beneficiary in writing that the beneficiary will be subject to the lock-in program.
2. A beneficiary subject to the lock-in program shall be given the opportunity to select a single prescriber and a single pharmacy from a list of prescribers and pharmacies in the Prepaid Health Plan's provider network. For any beneficiary who fails to select a single prescriber, the Prepaid Health Plan shall use algorithmic guidelines to assign the beneficiary a single prescriber from a list of prescribers in the Prepaid Health Plan's network. For any beneficiary who fails to select a single pharmacy, the Prepaid Health Plan shall use algorithmic guidelines to assign the beneficiary a single pharmacy from a list of pharmacies in the Prepaid Health Plan's network.
3. A beneficiary shall not be required to use the single prescriber or single pharmacy selected for the lock-in program to obtain prescriptions drugs covered by the Medicaid program or the Prepaid Health Plan that are not covered substances.
A Prepaid Health Plan's use of a lock-in program developed pursuant to subsection (e) of this section shall not constitute a violation of the terms of a contract between the Prepaid Health Plan and the Department that relate to a beneficiary's ability to utilize a pharmacy of choice.

History

(2018-49, s. 3(a); 2021-62, s. 4.4.)

Editor's Note. - Session Laws 2018-49, s. 3(d), made this section effective June 22, 2018.

Effect of Amendments. - Session Laws 2021-62, s. 4.4, effective June 29, 2021, rewrote the section.

§ 108A-69. Employer obligations.

As used in this section and in G.S. 108A-70:
1. "Health benefit plan" means an accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscriber contract; a plan provided by a multiple employer welfare arrangement; the State Health Plan for Teachers and State Employees under Chapter 135 of the General Statutes; or a plan provided by another benefit arrangement. "Health benefit plan" does not mean a Medicare supplement policy as defined in G.S. 58-54-1(5).
2. "Health insurer" means any health insurance company subject to Articles 1 through 63 of Chapter 58 of the General Statutes, including a multiple employee welfare arrangement, and any corporation subject to Articles 65 and 67 of Chapter 58 of the General Statutes; a group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974; and the State Health Plan for Teachers and State Employees under Chapter 135 of the General Statutes.
If a parent is required by a court or administrative order to provide health benefit plan coverage for a child, and the parent is eligible for family health benefit plan coverage through an employer, the employer:
1. Must allow the parent to enroll, under family coverage, the child if the child would be otherwise eligible for coverage without regard to any enrollment season restrictions.
2. Must enroll the child under family coverage upon application of the child's other parent or upon receipt of notice from the Department of Health and Human Services in connection with its administration of the Medical Assistance or Child Support Enforcement Program if the parent is enrolled but fails to make application to obtain coverage for the child.
3. May not disenroll or eliminate coverage of the child unless:
  1. The employer is provided satisfactory written evidence that:
    1. The court or administrative order is no longer in effect; or
    2. The child is or will be enrolled in comparable health benefit plan coverage that will take effect not later than the effective date of disenrollment; or
  2. The employer has eliminated family health benefit plan coverage for all of its employees.
4. Must withhold from the employee's compensation the employee's share, if any, of premiums for health benefit plan coverage, not to exceed the maximum amount permitted to be withheld under section 303(b) of the federal Consumer Credit Protection Act, as amended; and must pay this amount to the health insurer; subject to regulations, if any, adopted by the Secretary of the U.S. Department of Health and Human Services.

History

(1993 (Reg. Sess., 1994), c. 644, s. 3; 1995, c. 193, s. 44; 1997-433, s. 3.2; 1997-443, s. 11A.118(a); 1998-17, s. 1; 1999-293, s. 8; 2007-323, s. 28.22A(o); 2007-345, s. 12.)

Effect of Amendments. - Session Laws 2007-323, s. 28.22A(o), as amended by Session Laws 2007-345, s. 12, effective July 1, 2008, substituted "State Health Plan for Teachers and State Employees" for "Teachers' and State Employees' Comprehensive Major Medical Plan" in subdivisions (a)(1) and (a)(2).

Opinions of Attorney General

Medical Child Support Enforcement Provisions. - The medical child support enforcement provisions of House Bill 1563, 1993 (Reg. Sess., 1994) N.C. Session Laws c. 644, are inapplicable to the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan (now State Health Plan for Teachers and State Employees) and the governmental entities whose employees and retirees, along with their dependents, are eligible for coverage under the Plan or its HMO option. Medical child support orders nonetheless may be enforced directly against State employees and retirees who fail to enroll, or maintain coverage for, their eligible dependent children under the State Health Plan in accordance with the provisions of G.S. 50-13.4(f), 50-13.9 and 50-13.11. See opinion of Attorney General to Patricia Crawford, Associate General Counsel, University of North Carolina at Chapel Hill, 1995 N.C. AG LEXIS 6 (August 10, 1995).

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

To the extent necessary to reimburse the Department or a PHP for expenditures for costs under this Part, and provided that claims for current and past due child support shall take priority over claims for those expenditures, the Department may garnish the wages, salary, or other employment income of, and the Secretary of Revenue shall withhold amounts from State tax refunds to, any person who meets all of the following criteria:
1. Is required by court or administrative order to provide health benefit plan coverage for the cost of health care services to a child eligible for medical assistance under Medicaid.
2. Has received payment from a third party for the costs of such services.
3. Has not used such payments to reimburse, as appropriate, either the other parent or guardian of the child or the provider of the services.
To the extent that payment for covered services has been made under G.S. 108A-55 for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the Department of Health and Human Services is considered to have acquired the rights of the individual to payment by any other party for those health care items or services.

History

(1993 (Reg. Sess., 1994), c. 644, s. 3; 1997-443, s. 11A.118(a); 2019-81, s. 5.)

Effect of Amendments. - Session Laws 2019-81, s. 5, effective October 1, 2019, rewrote subsection (a).

Legal Periodicals. - For 1997 legislative survey, see 20 Campbell L. Rev. 399.

Opinions of Attorney General

§§ 108A-70.1 through 108A-70.3: Reserved for future codification purposes.

§ 108A-70.4. Long-Term Care Partnership Program.

The following definitions apply in this section:
1. Asset. - Resources and income.
2. Department. - The Department of Health and Human Services.
3. Division. - The Division of Health Benefits.
4. Estate recovery. - The placing of a statutory claim on the estate of a deceased Medicaid recipient, as provided by G.S. 108A-70.5.
5. Medicaid. - The federal medical assistance program established under Title XIX of the Social Security Act.
6. Qualified long-term care partnership policy or qualified policy. - A long-term care insurance policy approved for use in North Carolina and that meets all the requirements of the federal Deficit Reduction Act of 2005, P.L. 109-171.
7. Resource. - Cash or its equivalent and real or personal property that is available to an applicant or recipient.
8. Resource disregard. - The amount of resources of an applicant for long-term care Medicaid that is equal to the amount of benefits paid to the applicant under a qualified long-term care partnership policy.
9. Resource protection. - An amount equal to the resource disregard given to a Medicaid recipient during the long-term care Medicaid eligibility determination process.
There is established the North Carolina Long-Term Care Partnership Program (Partnership Program) to be administered by the Division with assistance from the Department of Insurance. The Partnership Program shall:
1. Provide a mechanism for individuals to qualify for coverage of the cost of their long-term care needs under Medicaid without first being required to substantially exhaust their resources.
2. Provide counseling services to individuals planning for their long-term care needs.
3. Reduce the financial burden on the State medical assistance program by encouraging individuals to obtain private long-term care insurance.
Under the Partnership Program, the Department shall:
1. Provide resource disregard to an applicant for long-term care Medicaid who has received benefits under a qualified long-term care partnership policy. The amount of the resource disregard shall be equal to the total insurance benefits paid to the individual under a qualified policy after the implementation of the Partnership Program and prior to the individual's first application for long-term care Medicaid.
2. Provide resource protection by reducing any subsequent recovery by the State under G.S. 108A-70.5 from a deceased recipient's estate for payment of Medicaid paid services by the amount of resource disregard given under subdivision (1) of this subsection.
The Department shall adopt rules and amendments to the State Plan to allow for resource disregard at long-term care Medicaid eligibility determination and resource protection at estate recovery. The Department and the Department of Insurance shall adopt rules to implement the provisions of the Partnership Program and to provide for its administration.
Effective January 1, 2011, or 60 days after approval of the Medicaid State Plan amendment, whichever is later, a qualified long-term care partnership policy shall be accompanied by a Partnership Disclosure Notice detailing in plain language the current law pertaining to the Partnership Program, resource disregard, and resource protection.
The Department may enter into a reciprocal agreement with other states that enter into a national reciprocity agreement to extend the resource disregard and resource protection to residents of the State who purchased, or purchased and used, a qualified long-term care policy in another state.
G.S. 108A-70.5 applies to the estate of an individual who received benefits under a qualified long-term care partnership policy.

History

(2010-68, s. 1; 2019-81, s. 15(a).)

Contingent effective date. - Session Laws 2010-68, s. 5, made this section effective January 1, 2011, or 60 days after approval of the Medicaid State Plan amendment, whichever is later. The plan was approved January 6, 2011.

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" in subdivision (a)(3).

§ 108A-70.5. Medicaid Estate Recovery Plan.

There is established in the Department of Health and Human Services, the Medicaid Estate Recovery Plan, as required by the Omnibus Budget Reconciliation Act of 1993, to recover from the estates of recipients of medical assistance an equitable amount of the State and federal shares of the cost paid for the recipient. The Department shall administer the program in accordance with applicable federal law and regulations, including those under Title XIX of the Social Security Act, 42 U.S.C. § 1396(p).
The following definitions apply in this section:
1. Recodified as subdivision (b)(4) of this section by Session Laws 2021-88, s. 9(d).
2. Estate. - All the real and personal property considered assets of the estate available for the discharge of debt pursuant to G.S. 28A-15-1. The Department has all rights available to estate creditors, including the right to qualify as personal representative or collector of an estate. For individuals who have received benefits under a qualified long-term care partnership policy as described in G.S. 108A-70.4, this term also includes any other real and personal property and other assets in which the individual had any legal title or interest at the time of death (to the extent of the interest), including assets conveyed to a survivor, heir, or assign of the deceased individual through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement.
3. Repealed by Session Laws 2007-442, s. 1, effective August 23, 2007.
4. Medical assistance. - Medical care services paid for by the North Carolina Medicaid Program on behalf of the recipient as follows:
  1. If the recipient of any age is receiving medical care services as an inpatient in a nursing facility, intermediate care facility for individuals with intellectual disabilities, or other medical institution, and cannot reasonably be expected to be discharged to return home.
  2. If the recipient is 55 years of age or older and is receiving one or more of the following medical care services:
    1. Nursing facility services.
    2. Home and community-based services.
    3. Hospital care.
    4. Prescription drugs.
    5. Personal care services.
The amount the Department recovers from the estate of any recipient shall not exceed the amount of medical assistance made on behalf of the recipient and is recoverable only for medical care services prescribed in subsection (b) of this section. The Department is a sixth-class creditor, as prescribed in G.S. 28A-19-6, for purposes of determining the order of claims against an estate; however, judgments in favor of other sixth-class creditors docketed and in force before the Department seeks recovery for medical assistance shall be paid prior to recovery by the Department.
The Department of Health and Human Services shall adopt rules pursuant to Chapter 150B of the General Statutes to implement the Plan, including rules to waive whole or partial recovery when this recovery would be inequitable because it would work an undue hardship or because it would not be administratively cost-effective and rules to ensure that all recipients are notified that their estates are subject to recovery at the time they become eligible to receive medical assistance.
Repealed by Session Laws 2007-442, s. 1, effective August 23, 2007.
With regard to any recipient who has received compensation pursuant to Part 30 of Article 9 of Chapter 143B of the General Statutes, the Department shall reduce the amount of any recovery it seeks from the deceased recipient's estate under this section by the amount of the resource disregard provided for in G.S. 143B-426.56(b)(1).

History

(1993 (Reg. Sess., 1994), c. 769, s. 25.47(a); 1997-443, s. 11A.118(a); 2002-126, s. 10.11(b); 2005-276, s. 10.21C(a); 2005-345, s. 16; 2006-66, s. 10.9B; 2007-145, s. 10; 2007-323, ss. 10.42(a), (b); 2007-442, s. 1(a); 2010-68, s. 2; 2012-18, s. 3.6; 2013-378, s. 2; 2014-100, s. 6.13(f); 2021-62, s. 4.1; 2021-88, ss. 9(d), (e).)

Contingent Effective Date. - Session Laws 2010-68, which amended this section, in s. 5 provides: "This act becomes effective January 1, 2011, or 60 days after approval of the Medicaid State Plan amendment, whichever is later." The plan was approved January 6, 2011.

Editor's Note. - Session Laws 2005-276, s. 10.21C(c), as amended by Session Laws 2005-345, s. 16, as amended by Session Laws 2006-66, s. 10.9B, as amended by Session Laws 2007-145, s. 10, as amended by Session Laws 2007-323, s. 10.42(a), made the amendments to this section by Session Laws 2005-276, s. 10.21C(a), effective July 1, 2008, and applicable to recipients of medical assistance on and after that date.

However, Session Laws 2007-323, s. 10.42(b) provides: "In the event the effective date of Section 10.21C(c) of S.L. 2005-276 made applicable under subsection (a) of this section conflicts with the effective date of a provision in House Bill 1537, enacted by the 2007 General Assembly, pertaining to Medicaid Estate Recovery, the effective date contained in House Bill 1537 shall apply." House Bill 1537 was enacted as Session Laws 2007-442, effective August 23, 2007. As a result, the amendments by Session Laws 2007-442, which reversed many of the 2005 amendments and made additional changes, took effect August 23, 2007.

Session Laws 2005-276, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2005'."

Session Laws 2005-276, s. 46.5 is a severability clause.

Session Laws 2006-66, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2006'."

Session Laws 2006-66, s. 28.6 is a severability clause.

Session Laws 2007-323, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2007'."

Session Laws 2007-323, s. 32.5 is a severability clause.

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Effect of Amendments. - Session Laws 2005-276, s. 10.21C(a), as amended by Session Laws 2005-345, s. 16, as amended by Session Laws 2006-66, s. 10.9B, as amended by Session Laws 2007-145, s. 10, and as amended by Session Laws 2007-323, s. 10.42, effective August 23, 2007, and applicable to recipients of medical assistance on and after that date, in subsection (a), in the first sentence, deleted "to recover from the estates of recipients of medical assistance an equitable amount of the State and federal shares of the cost paid the recipient" preceding "1993" and added the last two sentences; substituted "of any age is receiving" for "is receiving these" in sub-subdivision (b)(1)a.; rewrote sub-subdivision (b)(1)b.; added subdivision (b)(3); in subsection (c), at the beginning of the second sentence, added "To the extent that allowable Medicaid claims are not satisfied as a result of the execution of any liens held by the Department"; and in subsection (d), deleted "including rules to waive whole or partial recovery when this recovery would be inequitable because it would work an undue hardship or because it would not be administratively cost-effective and rules" following "Plan."

Session Laws 2007-442, s. 1(a), effective August 23, 2007, rewrote subsection (a); in subdivision (b)(1), deleted "and prescription drugs related to nursing facility services or home and community based services" from the end of subdivision (b)(1)b.3., added (b)(1)b.3a., deleted (b)(1)b.5. through (b)(1)b.9; substituted "The" for "To the extent that allowable Medicaid claims are not satisfied as a result of the execution of any liens held by the Department, the" at the beginning of the second sentence of subsection (c); inserted "including rules to waive whole or partial recovery when this recovery would be inequitable because it would work an undue hardship or because it would not be administratively cost-effective and rules" in subsection (d); and deleted former subsection (e) concerning trust assets of disabled individuals.

Session Laws 2010-68, s. 2, effective January 1, 2011, or 60 days after the approval of the Medicaid State Plan amendment, whichever is later, rewrote the introductory language in subsection (b), which formerly read: "As used in this section"; in the introductory paragraph in subdivision (b)(1), substituted "Medical assistance. - Medical care" for "'Medical assistance' means medical care"; and in subdivision (b)(2), substituted "Estate. - All" for "'Estate' means all" and added the last sentence.

Session Laws 2012-18, s. 3.6, effective June 11, 2012, substituted "sixth-class" for "fifth-class" in two places in subsection (c).

Session Laws 2013-378, s. 2, effective October 1, 2013, added the second sentence in subdivision (b)(2).

Session Laws 2014-100, s. 6.13(f), effective July 1, 2014, added subsection (f).

Session Laws 2021-88, ss. 9(d), (e), effective July 22, 2021, recodified subdivision (b)(1) as subdivision (b)(4), and sub-sub-subdivisions (b)(4)b.3a. and (b)(4)b.4 as sub-sub-subdivisions (b)(4)b.4. and (b)(4)b.5.; substituted "this term” for "‘estate'” and "extent of the interest” for "extent of such interest” in subdivision (b)(2); inserted "as follows” in subdivision (b)(4); in sub-subdivision (b)(4)a., substituted "individuals with intellectual disabilities” for "the mentally retarded”, and made a stylistic change; and substituted "is recoverable” for "shall be recoverable,” and "however, judgments” for "provided, however, that judgments” in subsection (c).

CASE NOTES

Cited in State HHS v. Thompkins, 205 N.C. App. 285, 695 S.E.2d 133 (2010).

§§ 108A-70.6 through 108A-70.9: Repealed by Session Laws 2007-442, s. 1(b), effective August 23, 2007.

Editor's Note. - Session Laws 2005-276, s. 10.21C(c), as amended by Session Laws 2005-345, s. 16, as amended by Session Laws 2006-66, s. 10.9B, as amended by Session Laws 2007-145, s. 10, as amended by Session Laws 2007-323, s. 10.42(a), made the enactment of G.S. 108A-70.6 through 108A-70.9 by Session Laws 2005-276, s. 10.21C(b), effective July 1, 2008, and applicable to recipients of medical assistance on and after that date.

PART 6A. APPEALS PROCESS FOR CERTAIN MEDICAID AND NC HEALTH CHOICE DETERMINATIONS.

§ 108A-70.9A. Definitions; Medicaid recipient appeals.

Definitions. - The following definitions apply in this Part:
1. Adverse determination. - A determination by the Department to deny, terminate, suspend, or reduce a Medicaid service or an authorization for a Medicaid service through the fee-for-service program. An adverse benefit determination as defined in G.S. 108D-1 is not an adverse determination for purposes of this Part.
2. Adverse disenrollment decision. - As defined in G.S. 108D-1.
3. Contested Medicaid case. - A case commenced by (i) a Medicaid recipient appealing an adverse determination under this Part or (ii) a Medicaid or a NC Health Choice recipient appealing an adverse disenrollment determination under G.S. 108D-5.9.
4. OAH. - The Office of Administrative Hearings.
5. Recipient. - A recipient and the recipient's parent, guardian, or legal representative, unless otherwise specified.
Medicaid Recipient Appeals. - Notwithstanding any provision of State law or rules to the contrary, this section shall govern the process used by a Medicaid recipient to appeal an adverse determination made by the Department and the process used by a Medicaid or NC Health Choice recipient to appeal an adverse disenrollment determination by the Department.
Notice. - Except as otherwise provided by federal law or regulation, at least 10 days before the effective date of an adverse determination, the Department shall notify the recipient, and the provider, if applicable, in writing of the adverse determination and of the recipient's right to appeal the adverse determination. The Department shall not be required to notify a recipient's parent, guardian, or legal representative unless the recipient's parent, guardian, or legal representative has requested in writing to receive the notice. The notice shall be mailed on the date indicated on the notice as the date of the determination. The notice shall include:
1. An identification of the recipient whose services are being affected by the adverse determination, including the recipient's full name and Medicaid identification number.
2. An explanation of what service is being denied, terminated, suspended, or reduced and the reason for the determination.
3. The specific regulation, statute, or medical policy that supports or requires the adverse determination.
4. The effective date of the adverse determination.
5. An explanation of the recipient's right to appeal the Department's adverse determination in an evidentiary hearing before an administrative law judge.
6. An explanation of how the recipient can request a hearing and a statement that the recipient may represent himself or herself or use legal counsel, a relative, or other spokesperson.
7. A statement that the recipient will continue to receive Medicaid services at the level provided on the day immediately preceding the Department's adverse determination or the amount requested by the recipient, whichever is less, if the recipient requests a hearing before the effective date of the adverse determination. The services shall continue until the hearing is completed and a final decision is rendered.
8. The name and telephone number of a contact person at the Department to respond in a timely fashion to the recipient's questions.
9. The telephone number by which the recipient may contact a Legal Aid/Legal Services office.
10. The appeal request form described in subsection (e) of this section that the recipient may use to request a hearing.
Notice Availability. - The Department shall make available to OAH a copy of the notice of adverse determination required under subsection (c) of this section. The information contained in the notice is confidential unless the recipient appeals the adverse determination under subsection (d) of this section. OAH may dispose of these records after one year.
Appeals. - Except as provided by this section and G.S. 108A-70.9B, a request for a hearing to appeal an adverse determination of the Department under this section is a contested case subject to the provisions of Article 3 of Chapter 150B of the General Statutes. The recipient shall request a hearing within 30 days of the mailing of the notice required by subsection (c) of this section by filing an appeal request with OAH. Where a request for hearing concerns the reduction, modification, or termination of Medicaid services, including the failure to act upon a timely request for reauthorization with reasonable promptness, upon the receipt of a timely appeal, the Department shall reinstate the services to the level or manner prior to action by the Department as permitted by federal law or regulation. The Department may not influence, limit, or interfere with the recipient's decision to request a hearing.
Appeal Request Form. - Along with the notice required by subsection (c) of this section, the Department shall also provide the recipient with an appeal request form which shall be no more than one side of one page. The form shall include the following:
1. A statement that, in order to request an appeal, the recipient must file the form with OAH within 30 days of mailing of the notice, and the form may be filed by either (i) sending the form by mail or fax to the address or fax number listed on the form or (ii) calling the telephone number on the form and providing the information requested on the form.
2. The recipient's name, address, telephone number, and Medicaid identification number.
3. A preprinted statement that indicates that the recipient would like to appeal the specific adverse determination of which the recipient was notified in the notice.
4. The option for the recipient to request an expedited appeal.
5. A statement informing the recipient that he or she may choose to be represented by a lawyer, a relative, a friend, or other spokesperson.
6. A space for the recipient's signature and date.
Expedited Appeal Request. - In accordance with 42 C.F.R. § 431.224, a recipient may request that an appeal under subsection (d) of this section be expedited if the time otherwise permitted for a hearing could jeopardize the recipient's life, health, or ability to attain, maintain, or regain maximum function. With regard to a request for an expedited appeal, all of the following apply:
1. The recipient shall submit any additional documentation from a licensed health care professional with relevant excerpts from the recipient's medical record that was not already provided with regard to the adverse determination to demonstrate the need for an expedited appeal.
2. The Department shall determine if the recipient's request meets the criteria for an expedited appeal.
3. If the Department determines that the recipient's request does not meet the criteria for an expedited appeal, then (i) the Department shall make reasonable efforts to give the recipient, or the recipient's parent, guardian, or legal representative, oral notice of the denial as expeditiously as possible and shall follow up with a written notice of denial and (ii) the recipient's appeal shall not be subject to the expedited time frame in subdivision (4) of this subsection. The denial is not appealable.
4. If the Department determines that the recipient's request meets the criteria for an expedited appeal, then (i) the mediation procedure under G.S. 108A-70.9B(c) shall not apply to the appeal request and (ii) the decision required under G.S. 108A-70.9B(g) shall be made as expeditiously as possible.
Final Decision. - After a hearing before an administrative law judge, the judge shall return the decision to the Department in accordance with G.S. 150B-37. The Department shall notify the recipient of the final decision and of the right to judicial review of the decision pursuant to Article 4 of Chapter 150B of the General Statutes.

History

(2010-31, s. 10.30(a); 2011-398, s. 32; 2019-81, s. 6; 2021-62, ss. 2.1(a)-(c), 2.2(a), (b).)

Medicaid Appeals 2008-10. - Medicaid appeals from July 1, 2008, to July 1, 2010, which was the effective date of this section, were governed by Session Laws 2008-107, ss. 10.15A(h1), as amended by Session Laws 2008-118, s. 3.13(a), Session Laws 2009-526, s. 2(a), and Session Laws 2009-550, s. 1.1(a), and (h2), as added by Session Laws 2008-118, s. 3.13(b), and amended by Session Laws 2009-526, s. 2(b), and Session Laws 2009-550, s. 1.1(b), and that these provisions expired pursuant to (h6), as added by, Session Laws 2010-31, s. 10.30(b).

Session Laws 2019-81, s. 6, effective October 1, 2019, rewrote the Part 6A heading, which formerly read "Medicaid Reipient Appeals Process."

Editor's Note. - The definitions in subdivisions (a)(2) and (a)(3) were redesignated as subdivisions (a)(3) and (a)(2), respectively, at the direction of the Revisor of Statutes to preserve alphabetical order.

Session Laws 2010-31, s. 10.30(c), provides: "Not later than October 1, 2011, the Department of Health and Human Services and the Office of Administrative Hearings (OAH) shall submit a report to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Subcommittee on Health and Human Services, the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services, and the Fiscal Research Division on the number, status, and outcome of contested Medicaid cases handled by OAH pursuant to the appeals process established in Part 6A of Article 2 of Chapter 108A of the General Statutes. The report shall include information on the number of contested Medicaid cases resolved through mediations and through formal hearings, the outcome of settled and withdrawn cases, and the number of incidences in which the Division of Medical Assistance (DMA) reverses the decision of an administrative law judge along with DMA's rationale for the reversal."

Session Laws 2010-31, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2010'."

Session Laws 2010-31, s. 32.6 is a severability clause.

Session Laws 2021-62, s. 2.1(i), made the amendments to this section by Session Laws 2021-62, s. 2.1(a), (b), (c), effective June 29, 2021, and applicable to (i) appeal request forms under G.S. 108A-70.9A(e), 108D-5.7(a), and 108D-15(f) issued on or after that date and (ii) appeals requested on or after that date.

Session Laws 2021-62, s. 2.2(j), made subdivision (e)(3a) and subsection (e1) of this section, as added by Session Laws 2021-62, s. 2.2(a), (b), effective June 29, 2021, and applicable to (i) notices of action under G.S. 108A-79(c) and appeal request forms under G.S. 108A-70.9A(e) and G.S. 108D-15(f) issued on or after that date and (ii) requests to expedite an appeal made on or after that date.

Effect of Amendments. - Session Laws 2011-398, s. 32, effective January 1, 2012, and applicable to contested cases commenced on or after that date, in subsection (f), in the first sentence, deleted "and record" following "decision" and updated the section reference, and in the last sentence, deleted "make a final decision in the case within 20 days of receipt of the decision and record from the administrative law judge and promptly" following "The Department shall."

Session Laws 2019-81, s. 6, effective October 1, 2019, rewrote subsections (a) and (b).

Session Laws 2021-62, ss. 2.1(a)-(c), added subsection (c1); in subsection (d), substituted "section by filing” for "section by sending”, and "request with OAH” for "request form to OAH and the Department” in the second sentence, deleted the fourth and fifth sentences which read: "The Department shall immediately forward a copy of the notice to OAH electronically. The information contained in the notice is confidential unless the recipient appeals. OAH may dispose of the records after one year”; and rewrote subsection (e)(1). For effective date and applicability, see editor's note.

Session Laws 2021-62, ss. 2.2(a), (b), added subdivision (e)(3a) and subsection (e1). For effective date and applicability, see editor's note.

§ 108A-70.9B. Contested Medicaid cases.

Application. - This section applies only to contested Medicaid cases as defined in this Part. Except as otherwise provided by Article 1A of Chapter 108D of the General Statutes, G.S. 108A-70.9A, and this section governing time lines and procedural steps, a contested Medicaid case commenced by a Medicaid or NC Health Choice recipient is subject to the provisions of Article 3 of Chapter 150B of the General Statutes. To the extent any provision in this section, Article 1A of Chapter 108D of the General Statutes, or G.S. 108A-70.9A conflicts with another provision in Article 3 of Chapter 150B of the General Statutes, this section, Article 1A of Chapter 108D of the General Statutes, and G.S. 108A-70.9A control.
Simple Procedures. - Notwithstanding any other provision of Article 3 of Chapter 150B of the General Statutes, the chief administrative law judge may limit and simplify the procedures that apply to a contested Medicaid case involving a Medicaid or NC Health Choice recipient in order to complete the case as quickly as possible.
1. To the extent possible, OAH shall schedule and hear contested Medicaid cases within 55 days of submission of a request for appeal.
2. Hearings shall be conducted telephonically or by video technology with all parties, however the recipient may request that the hearing be conducted in person before the administrative law judge. An in-person hearing shall be conducted in Wake County, however, for good cause shown, the in-person hearing may be conducted in the county of residence of the recipient or a nearby county. Good cause shall include, but is not limited to, the recipient's impairments limiting travel or the unavailability of the recipient's treating professional witnesses. The Department shall provide written notice to the recipient of the use of telephonic hearings, hearings by video conference, and in-person hearings before the administrative law judge, and how to request a hearing in the recipient's county of residence.
3. 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. An administrative law judge assigned to a contested Medicaid case shall make reasonable efforts in a case involving a Medicaid or NC Health Choice recipient who is not represented by an attorney to assure a fair hearing and to maintain a complete record of the hearing.
4. The administrative law judge may allow brief extensions of the time limits contained in this section for good cause and to ensure that the record is complete. Good cause includes delays resulting from untimely receipt of documentation needed to render a decision and other unavoidable and unforeseen circumstances. Continuances shall only be granted in accordance with rules adopted by OAH and shall not be granted on the day of the hearing, except for good cause shown. If a petitioner fails to make an appearance at a hearing that has been properly noticed via certified mail by OAH, OAH shall immediately dismiss the contested case, unless the recipient moves to show good cause within three business days of the date of dismissal.
5. The notice of hearing provided by OAH to the recipient shall include the following information:
  1. The recipient's right to examine at a reasonable time before the hearing and during the hearing the contents of the recipient's case file and documents to be used by the Department in the hearing before the administrative law judge.
  2. The recipient's right to an interpreter during the appeals process.
  3. Circumstances in which a medical assessment may be obtained at agency expense and be made part of the record. Qualifying circumstances include those in which (i) a hearing involves medical issues, such as a diagnosis, an examining physician's report, or a medical review team's decision; and (ii) the administrative law judge considers it necessary to have a medical assessment other than that performed by the individual involved in making the original decision.
Mediation. - Upon receipt of an appeal request form as provided by G.S. 108A-70.9A(e) or other clear request for a hearing by a Medicaid or NC Health Choice recipient, OAH shall immediately notify the Mediation Network of North Carolina, which shall contact the recipient within five days to offer mediation in an attempt to resolve the dispute. If mediation is accepted, the mediation must be completed within 25 days of submission of the request for appeal. Upon completion of the mediation, the mediator shall inform OAH and the Department within 24 hours of the resolution by facsimile or electronic messaging. If the parties have resolved matters in the mediation, OAH shall dismiss the case. OAH shall not conduct a hearing of any contested Medicaid case until it has received notice from the mediator assigned that either: (i) the mediation was unsuccessful, or (ii) the petitioner has rejected the offer of mediation, or (iii) the petitioner has failed to appear at a scheduled mediation.
Burden of Proof. - The recipient has the burden of proof on all issues submitted in a contested Medicaid case to OAH and has the burden of going forward. The administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence.
New Evidence. - The recipient shall be permitted to submit evidence regardless of whether obtained prior to or subsequent to the Department's actions and regardless of whether the Department had an opportunity to consider the evidence in making its adverse determination. When the evidence is received, at the request of the Department, the administrative law judge shall continue the hearing for a minimum of 15 days and a maximum of 30 days to allow for the Department's review of the evidence. Subsequent to review of the evidence, if the Department reverses its original decision, it shall immediately inform the administrative law judge.
Issue for Hearing. - For each adverse determination and each adverse disenrollment determination, the hearing shall determine whether the Department substantially prejudiced the rights of the recipient and if the Department, based upon evidence at the hearing, did any of the following:
1. Exceeded its authority or jurisdiction.
2. Acted erroneously.
3. Failed to use proper procedure.
4. Acted arbitrarily or capriciously.
5. Failed to act as required by law or rule.
Decision. - The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision and send it to the parties in accordance with G.S. 150B-37.

History

(2010-31, s. 10.30(a); 2011-398, s. 33; 2014-100, s. 12H.27(b); 2019-81, s. 6.)

Editor's Note. - Session Laws 2014-100, s. 12H.27(d), made the amendments to subsections (c) and (d) by Session Laws 2014-100, s. 12H.27(b), applicable to appeals of notices of adverse determination mailed on or after October 1, 2014, and appeals of notices of resolution mailed on or after October 1, 2014.

Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'"

Session Laws 2014-100, s. 38.7, is a severability clause.

Effect of Amendments. - Session Laws 2011-398, s. 33, effective January 1, 2012, and applicable to contested cases commenced on or after that date, rewrote subsection (g).

Session Laws 2014-100, s. 12H.27(b), effective October 1, 2014, substituted the present last sentence of subsection (c) for the former last sentence, which read: "Nothing in this subsection shall restrict the right to a contested case hearing."; and rewrote subsection (d). See Editor's note for applicability.

Session Laws 2019-81, s. 6, effective October 1, 2019, rewrote subsection (a); substituted "Medicaid or NC Health Choice recipient" for "Medicaid recipient" in subsections (b) and (c) and subdivision (b)(3); in subsection (c), deleted the last sentence, which read "If the recipient accepts an offer of mediation and then fails to attend mediation without good cause, OAH shall dismiss the contested case"; in subsection (d), substituted "in a contested Medicaid case to OAH" for "to OAH for a Medicaid contested case hearing"; in subsection (f), inserted "and each adverse disenrollment determination" and "did any of the following."

CASE NOTES

Cited in Robinson v. N.C. HHS, 215 N.C. App. 372, 715 S.E.2d 569 (2011).

§ 108A-70.9C. Informal review permitted.

Nothing in this Part shall prevent the Department from engaging in an informal review of a contested Medicaid case with a recipient prior to issuing a notice of adverse determination under G.S. 108A-70.9A(c) or a notice of resolution under G.S. 108D-5.7.

History

(2010-31, s. 10.30(a); 2019-81, s. 6.)

Effect of Amendments. - Session Laws 2019-81, s. 6, effective October 1, 2019, substituted "under G.S. 108A-70.9A(c) or a notice of resolution under G.S. 108D-5.7" for "as provided by G.S. 108A-70.9A(c)."

PART 7. MEDICAL ASSISTANCE PROVIDER FALSE CLAIMS ACT.

§ 108A-70.10. Short title.

This Part may be cited as the Medical Assistance Provider False Claims Act.

History

(1997-338, s. 1.)

Editor's Note. - Session Laws 2010-31, s. 10.26(a)-(e), provides: "(a) The Department of Health and Human Services (Department) is authorized to create a fraud prevention program that uses information, lawfully obtained, from State and private databases to develop a fraud risk analysis of Medicaid providers and recipients. This analysis would be used to prevent fraud before it takes place and to achieve cost avoidance savings. For the purposes of the fraud prevention program created pursuant to this subsection, State agencies shall provide the Department with access to their databases, and the Department shall comply with all necessary security measures and restrictions to ensure that access to any specific information held confidential under federal and State law is limited to authorized persons.

"(b) The information obtained by the Department pursuant to subsection (a) of this section shall be privileged and confidential, is not a public record pursuant to G.S. 132-1, and may only be used for investigative or evidentiary purposes related to violations of State or federal law and regulatory activities. The Department shall release data collected pursuant to this section to the following persons only:

"(1) An individual who requests the individual's own Medicaid recipient information.

"(2) A provider who requests the provider's Medicaid provider information.

"(3) The Office of the Attorney General, a county department of social services for investigative or evidentiary purposes related to violations of State or federal law by Medicaid recipients, and the Medicaid Fraud Investigations Unit of the Office of the Attorney General of North Carolina for investigative or evidentiary purposes related to violations of State or federal law by Medicaid providers.

"(4) To a court pursuant to a lawful court order in a criminal action.

"The Department may provide data to public or private entities for statistical, research, or educational purposes only after removing information that could be used to identify individual recipients or providers of Medicaid services.

"(c) Notwithstanding any other provision of law to the contrary, the Department may modify or extend existing contracts to achieve Medicaid fraud prevention savings in a timely manner, subject to review and approval by the Secretary of the Department of Administration. The requirements of G.S. 143-59 apply to contracts entered into, modified, or extended pursuant to this section.

"(d) The Department shall report on the activities conducted under this section, including actions taken relating to compliance with G.S. 143-59 and any contract modifications or extensions that are approved pursuant to this section to the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, the Office of State Budget and Management, and the Fiscal Research Division on or before April 1, 2011.

"(e) The authority granted to the Department to modify or extend existing contracts in subsection (c) of this section expires one year following the effective date of this section. The Department shall destroy all records and information obtained pursuant to this section after five years unless there has been criminal, civil, or administrative action involving the records and information obtained. Any records or information turned over to the Office of the Attorney General, a county department of social services, the Medicaid Fraud Investigation Unit of the Office of the Attorney General, or a court of competent jurisdiction shall not be subject to the destruction requirements of this subsection."

§ 108A-70.11. Definitions.

Definitions. - As used in this Part:

"Attorney General" means the Attorney General or any Deputy, Assistant, or Associate Attorney General.
"Claim" means an application for payment or approval or for use in determining entitlement to payment presented to the Medical Assistance Program in any form, including written, electronic, or magnetic, which identifies a service, good, or accommodation as reimbursable under the Medical Assistance Program.
"Damages" means the difference between what the Medical Assistance Program paid a provider and the amount it would have paid the provider in the absence of a violation of this section and may be established by statistical sampling methods.
"Knowingly" means that a provider, with respect to the information:
1. Has actual knowledge of the information;
2. Acts in deliberate ignorance of the truth or falsity of the information; or
3. Acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
"Medical Assistance Program" means the Division of Health Benefits and its fiscal agent.

History

(1997-338, s. 1; 2019-81, s. 15(a).)

Effect of Amendments. - Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "North Carolina Division of Medical Assistance" in subdivision (5).

§ 108A-70.12. Liability for certain acts; damages; effect of repayment.

Liability for Certain Acts. - It shall be unlawful for any provider of medical assistance under the Medical Assistance Program to:
1. Knowingly present, or cause to be presented to the Medical Assistance Program a false or fraudulent claim for payment or approval; or
2. Knowingly make, use, or cause to be made or used a false record or statement to get a false or fraudulent claim paid or approved by the Medical Assistance Program.
Damages. -
1. Except as provided in subdivision (2) of this subsection, a court shall assess against any provider of medical assistance under the Medical Assistance Program who violates this section a civil penalty of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000) plus three times the amount of damages which the Medicaid Assistance Program sustained because of the act of the provider.
2. A court may assess a penalty of not less than two times the amount of damages which the Medical Assistance Program sustains because of the act of the provider if a court finds that:
  1. The provider committing a violation of this section furnished officials of the State responsible for investigating false claims violations with all information known to the provider about the violation within 30 days after the date the provider first obtained the information;
  2. The provider fully cooperated with any State investigation of the violation; and
  3. At the time the provider furnished the State with the information about the violation, no criminal prosecution, civil action, or administrative action had commenced with respect to the violation, and the provider did not have actual knowledge of the existence of an investigation into the violation.
3. In addition to the damages and penalty assessed by the court pursuant to subdivision (1) or (2) of this subsection, a provider violating this section shall also be liable for the costs of a civil action brought to recover any penalty or damages, interest on the damages at the maximum legal rate in effect on the date the payment was made to the provider for the period from the date upon which payment was made to the provider to the date upon which repayment is made by the provider to the Medical Assistance Program, and the costs of the investigation.
4. As applied to providers that are subject to certification review by the Division of Health Service Regulation, a violation of Medicaid provider certification standards in providing a service, good, or accommodation shall not be considered an independent basis for liability under this Act. However, liability may be imposed if a false or fraudulent claim is presented as set forth in subsection (a) of this section in connection with that service, good, or accommodation.
Effect of Repayment. - Intent to repay or repayment of any amounts obtained by a provider as a result of any acts described in subsection (a) of this section shall not be a defense to or grounds for dismissal of an action brought pursuant to this section. However, a court may consider any repayment in mitigation of the amount of any penalties assessed.

Each claim presented or caused to be presented in violation of this section is a separate violation.

History

(1997-338, s. 1; 2007-182, s. 1.)

Effect of Amendments. - Session Laws 2007-182, s. 1, effective July 5, 2007, substituted "Division of Health Service Regulation" for "Division of Facility Services" in subdivision (b)(4).

§ 108A-70.13. False claims procedure.

The Attorney General shall have the authority to investigate, institute proceedings, compromise and settle any investigation or action, and perform all duties in connection with any civil action to enforce G.S. 108A-70.12.
A civil action under G.S. 108A-70.12 may not be brought more than six years after the date the violation of G.S. 108A-70.12 is committed, or more than three years after the date when facts material to the right of action are known or reasonably should have been known by the official of the State of North Carolina charged with responsibility to act in the circumstances, but in no event more than 10 years after the date on which the violation is committed, whichever occurs last.
In any action brought under G.S. 108A-70.12, the State shall be required to prove all essential elements of the cause of action, including damages, by the greater weight of the evidence.
Notwithstanding any other provision of law or rule, a final judgment rendered in favor of the State in any criminal proceeding charging fraud or false statements, whether upon a verdict after trial or upon a plea of guilty or nolo contendere, shall estop the defendant from denying the essential elements of the offense in any action which involves the same transaction as in the criminal proceeding and which is brought under G.S. 108A-70.12.
No criminal or administrative action need be brought against any provider as a condition for establishing civil liability under G.S. 108A-70.12. The civil liability under G.S. 108A-70.12 is in addition to any other criminal, civil, and administrative liabilities or penalties that may be prescribed by law. However, treble and double damages and civil penalties provided by G.S. 108A-70.12 shall not be assessed against a provider if treble or double damages or civil penalties have been previously assessed against the provider for the same claims under the federal False Claims Act, 31 U.S.C. § 3729, et seq., or the federal Civil Monetary Penalty Law, 42 U.S.C. § 1320a-7a. In the event that any provider is found liable under the provisions of this Act and is subsequently found liable for the same claim under the federal False Claims Act, or the appropriate sections of the federal Civil Monetary Penalty Law, the State and the Medical Assistance Program shall pay to the federal government on behalf of the provider any amounts, other than restitution, recovered or otherwise obtained by the State under this Act, not to exceed the amount of the federal damages and penalties.
The amount of damages and number of violations of G.S. 108A-70.12 shall be established by the trial judge or, in the event of a jury trial, by jury verdict. The amount of penalties, treble or double damages, interest, cost of the investigation, and cost of the civil action shall be determined by the trial judge as prescribed in G.S. 108A-70.12(b).
Venue for any action brought pursuant to G.S. 108A-70.12 shall be in either Wake County or in any county in which claim originated, or in which any statement or record was made, or acts done, or services, goods, or accommodations rendered in connection with any act constituting part of the violation of G.S. 108A-70.12.

History

(1997-338, s. 1.)

Editor's Note. - Session Laws 2009-554, s. 4, provides, in part, that: "A civil action may be filed after January 1, 2010, under Section 1 of this act based on acts committed prior to that date if the activity would also be covered under Part 7 of Article 2 of Chapter 108A of the General Statutes and if the limitation period set forth in G.S. 1-615(a) and G.S. 108A-70.14 has not lapsed."

§ 108A-70.14. Civil investigative demand.

If the Attorney General has reasonable cause to believe that a person has information or is in possession, custody, or control of any document or other tangible object relevant to an investigation or that would lead to the discovery of relevant information in an investigation of a violation of G.S. 108A-70.12, the Attorney General may serve upon the person, before bringing an action under G.S. 108A-70.12 or other false claims law, a civil investigative demand to appear and be examined under oath, to answer written interrogatories under oath, and to produce any documents or objects for their inspection and copying.
The civil investigative demand shall:
1. Be served upon the person in the manner required for service of process in civil actions and may be served by the Attorney General or investigator assigned to the North Carolina Department of Justice;
2. Describe the nature of the conduct constituting the violation under investigation;
3. Describe the class or classes of any documents or objects to be produced with sufficient definiteness to permit them to be fairly identified;
4. Contain a copy of any written interrogatories to be answered;
5. Prescribe a reasonable date and time at which the person shall appear to testify, answer any written interrogatories, or produce any document or object;
6. Advise the person that objections to or reasons for not complying with the demand may be filed with the Attorney General on or before that date and time;
7. Specify a place for the taking of testimony;
8. Designate a person to whom answers to written interrogatories shall be submitted and to whom any document or object shall be produced; and
9. Contain a copy of subsections (b) and (c) of this section.
The date within which to answer any written interrogatories and within which any document or object must be produced shall be more than 30 days after the civil investigative demand has been served upon the person. The date within which a person must appear to testify shall be more than 15 days after the demand has been served upon a person who resides out-of-state or more than 10 days after the demand has been served upon a person who resides in-state.
The person before whom the oral examination is to be taken shall put the person to be examined on oath and shall personally, or by someone acting under the person's direction and in the person's presence, record the testimony of the person to be examined. The Attorney General may exclude from the place where the examination is held all persons except the person giving the testimony, the attorney or other representative of the person giving the testimony, the Attorney General conducting the examination, the investigator assisting the Attorney General, the stenographer, and any other person agreed upon by the Attorney General and the person giving the testimony. When the testimony is transcribed, the person shall have a reasonable opportunity to examine and read the transcript, unless an examination and reading are waived by the person. Any changes in form or substance which the person desires to make shall be entered and identified upon the transcript by the person. The transcript shall then be signed by the person, unless the person in writing waives the signing, is ill, cannot be found, or refuses to sign.
Each interrogatory in a civil investigative demand served under this section shall be answered separately and fully in writing under oath and shall be submitted under sworn certificate by the person to whom the demand is directed, or in the case of a person other than a natural person, a person having knowledge of the facts and circumstances relating to the production and authorized to act on behalf of the person. If a person objects to any interrogatory, the reasons for the objection shall be stated in the certificate instead of an answer. The certificate shall state that all information required by the demand and in the possession, custody, control, or knowledge of the person to whom the demand is directed has been submitted. To the extent that any information is not furnished, the information shall be identified and reasons set forth with particularity regarding the reasons why the information was not furnished.
The production of documents and objects in response to a civil investigative demand served under this section shall be made under a sworn certificate by the person to whom the demand is directed, or in the case of a person other than a natural person, a person having knowledge of the facts and circumstances relating to the production and authorized to act on behalf of the person. The certificate shall state that all of the documentary material required by the demand and in the possession, custody, or control of the person to whom the demand is directed has been produced and made available. Upon written agreement between the person served with the civil investigative demand and the Attorney General, the person may substitute copies for originals of all or any part of the documents requested.
No person shall be excused from testifying, answering interrogatories, or producing documents or objects in response to a civil investigative demand on the ground that the testimony, answers, documents, or objects required of the person may tend to incriminate the person. However, no testimony, answers, documents, or objects compelled pursuant to G.S. 108A-70.14 may be used against the person in a criminal action, except a prosecution for perjury or for contempt arising from a failure to comply with an order of the court.
Any person appearing for oral testimony under a civil investigative demand issued pursuant to this section shall be entitled to the same fees and allowances paid to witnesses in the General Court of Justice of the State of North Carolina.
If a person objects to or otherwise fails to comply with a civil investigative demand served upon the person under subsection (a) of this section, the Attorney General may file an action in superior court for an order to enforce the demand. Venue for the action to enforce the demand shall be in either Wake County or the county in which the person resides. Notice of a hearing on the action to enforce the demand and a copy of the action shall be served upon the person in the same manner as prescribed in the Rules for Civil Procedure. If the court finds that the demand is proper, that there is reasonable cause to believe that there may have been a violation of G.S. 108A-70.12, and that the information sought or document or object demanded is relevant to the violation, the court shall order the person to comply with the demand, subject to modifications the court may prescribe.
If the person fails to comply with an order entered pursuant to subsection (i) of this section, the court may:
1. Adjudge the person to be in contempt of court;
2. Grant injunctive relief against the person to whom the demand is issued to restrain the conduct which is the subject of the investigation; or
3. Grant any other relief as the court may deem proper.
Any transcript of oral testimony, answers to written interrogatories, and documents and objects produced pursuant to this section may be used in connection with any civil action brought under G.S. 108A-70.12.
The North Carolina Rules of Civil Procedure shall apply to this section to the extent that the rules are not inconsistent with the provisions of this section.

History

(1997-338, s. 1.)

§ 108A-70.15. Employee remedies.

In the absence of fraud or malice, no person who furnishes information to officials of the State responsible for investigating false claims violations shall be liable for damages in a civil action for any oral or written statement made or any other action that is necessary to supply information required pursuant to this Part.
Any employee of a provider who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by the employee's employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under G.S. 108A-70.12, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under G.S. 108A-70.12, shall be entitled to all relief necessary to make the employee whole. Relief shall include reinstatement with the same seniority status as the employee would have had but for the discrimination, two times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorney's fees. An employee may bring an action in the appropriate court for the relief provided in this section.

History

(1997-338, s. 1.)

§ 108A-70.16. Uniformity of interpretation.

This Part shall be so interpreted and construed as to be consistent with the federal False Claims Act, 31 U.S.C. § 3729, et seq., and any subsequent amendments to that act.

History

(1997-338, s. 1.)

§ 108A-70.17: Reserved for future codification purposes.

PART 8. HEALTH INSURANCE PROGRAM FOR CHILDREN.

§ 108A-70.18. Definitions.

As used in this Part, unless the context clearly requires otherwise, the term:

"Comprehensive health coverage" means creditable health coverage as defined under Title XXI.
"Family income" has the same meaning as used in determining eligibility for the Medical Assistance Program.
"FPL" or "federal poverty level" means the federal poverty guidelines established by the United States Department of Health and Human Services, as revised each April 1.
"Medical Assistance Program" means the State Medical Assistance Program established under Part 6 of Article 2 of Chapter 108A of the General Statutes.
Repealed by Session Laws 2015-96, s. 1, effective June 19, 2015.
"Program" means The Health Insurance Program for Children established in this Part.
"State Plan" means the State Child Health Plan for the State Children's Health Insurance Program established under Title XXI.
"Title XXI" means Title XXI of the Social Security Act, as added by Pub. L. 105-33, 111 Stat. 552, codified in scattered sections of 42 U.S.C.
"Uninsured" means the applicant for Program benefits is not covered under any private or employer-sponsored comprehensive health insurance plan on the date of enrollment.

History

(1998-1, s. 1; 1998-166, s. 6; 2000-67, s. 11.8(a); 2000-140, s. 90(d); 2001-424, s. 21.22(b); 2008-107, s. 10.13(d); 2015-96, s. 1.)

Editor's Note. - Session Laws 1998-1, s. 11 provides in part that health insurance coverage provided to children under the Health Insurance Program for Children established under this act shall become effective no earlier than October 1, 1998. Since the Health Insurance Program for Children established in this act is dependent upon federal funds, it is the intent of the General Assembly that the Health Insurance Program for Children will continue and benefits will be paid for so long as federal funds are available and State funds are specifically appropriated for this purpose.

Session Laws 2007-323, s. 28.22(j), provides: "To ensure a smooth and effective transition of the administration of the NC Health Choice Program, enacted under Part 8 of Article 2 of Chapter 108A of the General Statutes, and administered under Part 5 of Article 3 of Chapter 135 of the General Statutes, the Executive Administrator of the Teachers' and State Employees' Comprehensive Major Medical Plan and the Department of Health and Human Services, Division of Medical Assistance, shall meet to discuss the administration of NC Health Choice in view of the implementation of the State Health Plan for Teachers and State Employees effective July 1, 2008. These meetings shall address all issues that may arise regarding the administration of NC Health Choice under the State Health Plan, including provider payment rates and collection of applicable premiums and co-payments. The Executive Administrator and the Department shall report to the Committee on Employee Hospital and Medical Benefits not later than February 1, 2008, with recommendations on statutory or other changes necessary to ensure effective administration of NC Health Choice."

Session Laws 2007-323, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2007'."

Session Laws 2007-323, s. 32.5 is a severability clause.

Session Laws 2007-323, 10.48(d)-(n), as added by Session Laws 2008-107, s. 10.12(a), provides:

"(d) The Department of Health and Human Services, Division of Medical Assistance, shall implement a health care assistance program, NC Kids' Care, to provide health insurance coverage to children in families with incomes above two hundred percent (200%) and not more than two hundred fifty percent (250%) of the federal poverty level, by expanding the Health Insurance Program for Children established under Part 8 of Article 2 of Chapter 108A of the General Statutes. Except as otherwise provided, all the requirements of Part 8 of Article 2 of Chapter 108A of the General Statutes shall apply to the NC Kids' Care program. The Department shall submit any State Child Health Plan amendments required to implement this section. Eligibility for and benefits under this program are not an entitlement and are subject to availability of funds and other changes to State and federal law.

"(e) Eligibility. - The Department may enroll eligible children based on the availability of funds. Following are the eligibility and other requirements for participation in NC Kids' Care. Children must:

"(1) Be between the ages of birth through 18 years of age;

"(2) Be ineligible for Medicaid, Medicare, or other government sponsored health insurance, except that any child covered under G.S. 108A-70.21(g) [now repealed] as of the effective date of this section shall be eligible for participation in NC Kids' Care as provided in subsection (o) of this section;

"(3) If permitted by federal law, have been uninsured for a period of time established by the Department in accordance with federal law. A child enrolled in NC Health Choice pursuant to Part 8 of Article 1 of Chapter 108A of the General statutes immediately prior to enrollment under NC Kids' Care shall not be required to satisfy a waiting period in order to receive coverage under NC Kids' Care.

"(4) Be in a family whose family income is above two hundred percent (200%) through two hundred fifty percent (250%) of the federal poverty level;

"(5) Be a resident of this State, meet applicable federal citizenship and immigration requirements, and be eligible under federal law; and

"(6) Have paid the monthly premiums required under this section.

"(f) Benefits and Limitations. - Except as otherwise provided in this section for eligibility and cost-sharing requirements, health benefits coverage provided to children eligible for NC Kids' Care shall be the same as coverage provided under Part 8 of Article 2 of Chapter 108A of the General Statutes.

"(g) Community Care of North Carolina. - The Department of Health and Human Services shall provide services to children enrolled in the NC Kids' Care program through Community Care of North Carolina and shall pay Community Care of North Carolina providers a care management fee for these services as allowed under Medicaid.

"(h) Cost-Sharing. - The Department shall require NC Kids' Care enrollees to contribute to the cost of their care through the use of deductibles, co-payments, and premiums as follows:

"(1) No annual enrollment fee. - In lieu of an annual enrollment fee, a monthly premium shall be charged for each child or family enrolled in NC Kids' Care. The Department shall establish a procedure for sharing a portion of premium receipts with each county department of social services to cover the cost of determining eligibility for services under NC Kids' Care.

"(2) Premiums. - The premium amount charged for each child or family shall vary depending on family income. Enrollees shall pay monthly premiums as follows:

"a. Enrollees whose family income is above two hundred percent (200%) through two hundred twenty-five percent (225%) of the federal poverty level shall pay a monthly premium not to exceed thirty dollars ($30.00) per child.

"b. Enrollees whose family income is above two hundred twenty-five percent (225%) through two hundred fifty percent (250%) of the federal poverty level shall pay a monthly premium not to exceed sixty dollars ($60.00) per child.

"(3) Co-payments. - NC Kids' Care enrollees shall be responsible for co-payments to providers as follows:

"a. Ten dollars ($10.00) per child for each primary care physician visit;

"b. Twenty-five dollars ($25.00) per child for each specialty care physician visit;

"c. Twenty-five dollars ($25.00) per child for each physical therapy, occupational therapy, or speech therapy visit;

"d. Thirty dollars ($30.00) per child for each outpatient hospital visit;

"e. Fifty dollars ($50.00) per child for each inpatient hospital visit;

"f. Twenty dollars ($20.00) per child for durable medical equipment, except there shall be no co-payment required for diabetic supplies;

"g. One hundred dollars ($100.00) for each emergency room visit, except the co-payment is waived if the enrollee is admitted to the hospital;

"h. One hundred fifty dollars ($150.00) for each ambulance service, except the co-payment is waived if the enrollee is admitted to the hospital;

"i. Outpatient prescription drugs, as follows:

"1. Five dollars ($5.00) for each generic prescription drug, for each brand-name prescription drug for which there is no generic substitution available, and for each covered over-the-counter medication; and

"2. Twenty dollars ($20.00) for each brand-name prescription drug for which there is a generic substitution available.

"(4) Deductible. - The Department may establish an annual deductible not to exceed two hundred fifty dollars ($250.00) per child.

"(5) The Department shall establish maximum annual cost-sharing limits per individual or family, provided that the total annual aggregate cost-sharing, including premiums, with respect to all children in a family receiving benefits under this section shall not exceed five percent (5%) of the family's income for the year involved.

"(i) Enrollment in NC Kids' Care shall not exceed 15,000 children for the 2008-2009 fiscal year. This enrollment cap shall not be exceeded even if State and federal funds are available to enroll additional children for the current fiscal year.

"(j) The nonfederal costs of NC Kids' Care shall be paid with State funds and enrollee premiums. Counties shall not be required to share in the nonfederal costs of NC Kids' Care.

"(k) To the extent allowed by federal law, providers of services under NC Kids' Care shall be paid at rates equivalent to Medicaid rates, less any applicable co-payments or deductibles.

"( l ) Administration of NC Kids' Care shall be in accordance with Part 8 of Article 2 of Chapter 108A of the General Statutes.

"(m) Enrollees covered under G.S. 108A-70.21(g) [now repealed] prior to the effective date of subsection (n) of this section may choose to continue coverage under that section through the end of their buy-in coverage period or enroll in NC Kids' Care provided they meet the eligibility requirements, pay the applicable premium, and notify their county department of social services within 60 days of receiving notice of their potential eligibility under NC Kids' Care. For any enrollee electing to transfer coverage from the buy-in program to NC Kids' Care, coverage under NC Kids' Care shall become effective the first day of the next month immediately following the month in which they notified their county department of social services of their intent to enroll in NC Kids' Care.

"(n) This section becomes effective July 1, 2009, or upon the reauthorization of SCHIP. The Department shall not apply for a State Child Health Plan amendment to implement NC Kids' Care until the US Congress acts to reauthorize the State Children's Health Insurance Program with sufficient funding to support the current NC Health Choice program and the provisions of this section. At the time the Department has determined that SCHIP has been reauthorized with sufficient funds, the Department will move forward as quickly as possible to implement NC Kids' Care."

Session Laws 2008-107, s. 10.13( l ), provides: "The Secretary of the Department of Health and Human Services shall develop and implement a plan for assuming administrative responsibility for the North Carolina Health Choice for Children program by transitioning all administrative oversight and claims processing activities from the Executive Administrator and Board of Trustees of the State Health Plan for Teachers and State Employees to the Division of Medical Assistance. The transition of all administrative oversight and claims processing from the State Health Plan to the Division of Medical Assistance shall be completed not later than July 1, 2010. The Secretary shall report to the Joint Legislative Health Care Oversight Committee and the Committee on Employee Hospital and Medical Benefits at least 30 days prior to effecting the transition of the responsibilities for the administration and processing of claims for benefits provided under the North Carolina Health Choice for Children program from the Executive Administrator and Board of Trustees of the State Health Plan for Teachers and State Employees to the Department."

Session Laws 2008-107, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2008'."

Session Laws 2008-107, s. 30.5 is a severability clause.

Effect of Amendments. - Session Laws 2008-107, s. 10.13(d), effective July 16, 2008, added subdivision (4a).

Session Laws 2015-96, s. 1, effective June 19, 2015, repealed former subdivision (4a), which read: "'Predecessor Plan' means the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan in effect prior to July 1, 2008."

§ 108A-70.19. Short title; purpose; no entitlement.

This Part may be cited as "The Health Insurance Program for Children Act of 1998." The purpose of this Part is to provide comprehensive health insurance coverage to uninsured low-income children who are residents of this State. Coverage shall be provided from federal funds received, State funds appropriated, and other nonappropriated funds made available for this purpose. Nothing in this Part shall be construed as obligating the General Assembly to appropriate funds for the Program or as entitling any person to coverage under the Program.

History

(1998-1, s. 1.)

§ 108A-70.20. Program established.

The Health Insurance Program for Children is established. The Program shall be known as North Carolina Health Choice for Children, and it shall be administered by the Department of Health and Human Services in accordance with this Part and as required under Title XXI and related federal rules and regulations. Administration of claims processing shall be as described in 42 C.F.R. 447.45(d)(1).

History

(1998-1, s. 1; 2008-107, s. 10.13(e); 2015-96, s. 2.)

Editor's Note. - Session Laws 2009-451, s. 10.31(a), provides: "The Secretary of the Department of Health and Human Services shall develop and implement a plan for assuming administrative responsibility for the North Carolina Health Choice for Children program by transitioning all administrative oversight activities from the Executive Administrator and Board of Trustees of the State Health Plan for Teachers and State Employees to the Division of Medical Assistance. The transition of all administrative oversight from the State Health Plan to the Division of Medical Assistance shall be completed not later than July 1, 2010. The Secretary shall report to the Joint Legislative Health Care Oversight Committee and the Committee on Employee Hospital and Medical Benefits at least 30 days prior to effecting the transition of the responsibilities for the administration from the Executive Administrator and Board of Trustees of the State Health Plan for Teachers and State Employees to the Department."

Session Laws 2009-451, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2009'."

Session Laws 2009-451, s. 28.3, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2009 2011 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2009 2011 fiscal biennium."

Session Laws 2009-451, s. 28.5 is a severability clause.

Effect of Amendments. - Session Laws 2008-107, s. 10.13(e), effective July 1, 2008, inserted "known as North Carolina Health Choice for Children, and it shall be" near the middle of the paragraph.

Session Laws 2015-96, s. 2, effective June 19, 2015, rewrote the last sentence in the section, which formerly read: "Administration of Program benefits and claims processing shall be as provided under Part 5 of Article 3 of Chapter 135 of the General Statutes."

§ 108A-70.20A: Repealed by Session Laws 2015-96, s. 3, effective June 19, 2015.

History

(2008-107, s. 10.13(c); 2011-85, s. 2.8; repealed by 2015-96, s. 3, effective June 19, 2015.)

Editor's Note. - This section was codified as G.S. 135-43, by Session Laws 2008-107, s. 10.13(c). It was renumbered as G.S. 135-47.2 at the direction of the Revisor of Statutes.

Session Laws 2011-85, s. 2.8, effective January 1, 2012, recodified former G.S. 135-47.2 as G.S. 108A-70.20A.

Former G.S. 108A-70.20A pertained to a child health insurance fund.

§ 108A-70.21. Program eligibility; benefits; enrollment fee and other cost-sharing; coverage from private plans.

Eligibility. - The Department may enroll eligible children based on availability of funds. Following are eligibility and other requirements for participation in the Program:
1. Children must:
  1. Be between the ages of 6 through 18;
  2. Be ineligible for Medicaid, Medicare, or other federal government-sponsored health insurance;
  3. Be uninsured;
  4. Be in a family whose family income is above one hundred thirty-three percent (133%) and less than or equal to two hundred eleven percent (211%) of the federal poverty level;
  5. Be a resident of this State and eligible under federal law; and
  6. Have paid the Program enrollment fee required under this Part.
2. Proof of family income and residency and declaration of uninsured status shall be provided by the applicant at the time of application for Program coverage. The family member who is legally responsible for the children enrolled in the Program has a duty to report any change in the enrollee's status within 60 days of the change of status.
3. If a responsible parent is under a court order to provide or maintain health insurance for a child and has failed to comply with the court order, then the child is deemed uninsured for purposes of determining eligibility for Program benefits if at the time of application the custodial parent shows proof of agreement to notify and cooperate with the child support enforcement agency in enforcing the order.
4. Except as otherwise provided in this section, enrollment shall be continuous for one year. At the end of each year, applicants may reapply for Program benefits.
Benefits. - All health benefits changes of the Program shall meet the coverage requirements set forth in this subsection. Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under [the] North Carolina Medicaid Program except for the following:
1. No services for long-term care.
2. No nonemergency medical transportation.
3. No EPSDT.
4. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.
5. Routine diagnostic examinations and tests: annual routine diagnostic examinations and tests, including x-rays, blood and blood pressure checks, urine tests, tuberculosis tests, and general health check-ups that are medically necessary for the maintenance and improvement of individual health are covered.
Payments. - Prescription drug providers shall accept as payment in full, for outpatient prescriptions filled, amounts allowable for prescription drugs under Medicaid. For all other providers, services provided to children enrolled in the Program shall be provided at rates equivalent to one hundred percent (100%) of Medicaid rates, less any co-payments assessed to enrollees under this Part.
Annual Enrollment Fee. - There shall be no enrollment fee for Program coverage for enrollees whose family income is less than or equal to one hundred fifty-nine percent (159%) of the federal poverty level. The enrollment fee for Program coverage for enrollees whose family income is above one hundred fifty-nine percent (159%) and less than or equal to two hundred eleven percent (211%) of the federal poverty level shall be fifty dollars ($50.00) per year per child with a maximum annual enrollment fee of one hundred dollars ($100.00) for two or more children. The enrollment fee shall be collected by the county department of social services and retained to cover the cost of determining eligibility for services under the Program. County departments of social services shall establish procedures for the collection of enrollment fees.
Cost-Sharing. - There shall be no deductibles, copayments, or other cost-sharing charges for families covered under the Program whose family income is less than or equal to one hundred fifty-nine percent (159%) of the federal poverty level, except that fees for outpatient prescription drugs are applicable and shall be one dollar ($1.00) for each outpatient generic prescription drug, for each outpatient brand-name prescription drug for which there is no generic substitution available, and for each covered over-the-counter medication. The fee for each outpatient brand-name prescription drug for which there is a generic substitution available is three dollars ($3.00). Families covered under the Program whose family income is above one hundred fifty-nine percent (159%) of the federal poverty level shall be responsible for copayments to providers as follows:
1. Five dollars ($5.00) per child for each visit to a provider, except that there shall be no copayment required for well-baby, well-child, or age-appropriate immunization services;
2. Five dollars ($5.00) per child for each outpatient hospital visit;
3. A one dollar ($1.00) fee for each outpatient generic prescription drug, for each outpatient brand-name prescription drug for which there is no generic substitution available, and for each covered over-the-counter medication. The fee for each outpatient brand-name prescription drug for which there is a generic substitution available is ten dollars ($10.00).
4. Twenty dollars ($20.00) for each emergency room visit unless:
  1. The child is admitted to the hospital, or
  2. No other reasonable care was available as determined by the Department.
    1. Benefits provided to an enrollee in the Program may be subject to lifetime maximum limits set forth in Medicaid and NC Health Choice medical coverage policies adopted pursuant to G.S. 108A-54.2.
Cost-Sharing Limitations. - The Department shall establish maximum annual cost-sharing limits per individual or family, provided that the total annual aggregate cost-sharing, including enrollment fees, with respect to all children in a family receiving benefits under this section shall not exceed five percent (5%) of the family's income for the year involved.
Coverage From Private Plans. - The Department shall, from funds available for the Program, pay the cost for dependent coverage provided under a private insurance plan for persons eligible for coverage under the Program if all of the following conditions are met:
1. The person eligible for Program coverage requests to obtain dependent coverage from a private insurer in lieu of coverage under the Program and shows proof that coverage under the private plan selected meets the requirements of this subsection;
2. The dependent coverage under the private plan is actuarially equivalent to the coverage provided under the Program and the private plan does not engage in the exclusive enrollment of children with favorable health care risks;
3. The cost of dependent coverage under the private plan is the same as or less than the cost of coverage under the Program; and
4. The total annual aggregate cost-sharing, including fees, paid by the enrollee under the private plan for all dependents covered by the plan, do not exceed five percent (5%) of the enrollee's family income for the year involved.
, (h) Repealed by Session Laws 2015-241, s. 12H.14(a), effective September 18, 2015.

If health insurance other than under the Program is provided to the child after enrollment and prior to the expiration of the eligibility period for which the child is enrolled in the Program, then the child is deemed to be insured and ineligible for continued coverage under the Program. The custodial parent has a duty to notify the Department within 10 days of receipt of the other health insurance, and the Department, upon receipt of notice, shall disenroll the child from the Program. As used in this paragraph, the term "responsible parent" means a person who is under a court order to pay child support.

In addition to the benefits provided under the North Carolina Medicaid Program, the following services and supplies are covered under the Health Insurance Program for Children established under this Part:

(1), (1a) Repealed by Session Laws 2011-145, s. 10.41(b), effective July 1, 2011.

(2) Vision: Scheduled routine eye examinations once every 12 months, eyeglass lenses or contact lenses once every 12 months, routine replacement of eyeglass frames once every 24 months, and optical supplies and solutions when needed. NCHC recipients must obtain optical services, supplies, and solutions from NCHC enrolled, licensed or certified ophthalmologists, optometrists, or opticians. In accordance with G.S. 148-134, NCHC providers must order complete eyeglasses, eyeglass lenses, and ophthalmic frames through Nash Optical Plant. Eyeglass lenses are limited to NCHC-approved single vision, bifocal, trifocal, or other complex lenses necessary for a Plan enrollee's visual welfare. Coverage for oversized lenses and frames, designer frames, photosensitive lenses, tinted contact lenses, blended lenses, progressive multifocal lenses, coated lenses, and laminated lenses is limited to the coverage for single vision, bifocal, trifocal, or other complex lenses provided by this subsection. Eyeglass frames are limited to NCHC-approved frames made of zylonite, metal, or a combination of zylonite and metal. All visual aids covered by this subsection require prior approval. Requests for medically necessary complete eyeglasses, eyeglass lenses, and ophthalmic frames outside of the NCHC-approved selection require prior approval. Requests for medically necessary fabrication of complete eyeglasses or eyeglass lenses outside of Nash Optical Plant require prior approval. Upon prior approval refractions may be covered more often than once every 12 months.

(3) Under the North Carolina Health Choice Program for Children, the co-payment for nonemergency visits to the emergency room for children whose family income is less than or equal to one hundred fifty-nine percent (159%) of the federal poverty level is ten dollars ($10.00). The co-payment for children whose family income is above one hundred fifty-nine percent (159%) and less than or equal to two hundred eleven percent (211%) of the federal poverty level is twenty-five dollars ($25.00).

(4) Over the counter medications: Selected over the counter medications provided the medication is covered under the State Medical Assistance Plan. Coverage shall be subject to the same policies and approvals as required under the Medicaid program.

No benefits are to be provided for services and materials under this subsection that do not meet the standards accepted by the American Dental Association.

The Department shall provide services to children enrolled in the NC Health Choice Program through Community Care of North Carolina (CCNC) and shall pay Community Care of North Carolina providers the per member, per month fees as allowed under Medicaid.

Copayments required under this subsection for prescription drugs apply only to prescription drugs prescribed on an outpatient basis.

The Department may reimburse an enrollee for private coverage under this subsection upon a showing of proof that the dependent coverage is in effect for the period for which the enrollee is eligible for the Program.

History

(1998-1, s. 1; 1999-237, s. 11.9; 2002-126, s. 10.20(a); 2003-284, s. 10.29(a); 2005-276, ss. 10.22(b), 10.22(c), 10.22(d); 2007-323, s. 28.22A(o); 2007-345, s. 12; 2008-107, ss. 10.12(b), (c), 10.13(f), (k); 2008-118, s. 1.6(b), (c); 2009-16, s. 4(d); 2009-451, s. 10.35(a); 2011-145, s. 10.41(b); 2013-360, s. 12H.10(g); 2015-96, s. 4; 2015-241, ss. 12H.2(f), 12H.14(a), (b), 12H.25(b), 12H.26(b); 2015-245, s. 22; 2017-102, s. 16.)

Health Choice Enrollment Growth Cap. - Session Laws 2008-107, s. 10.14(b)-(e), as amended by Session Laws 2008-118, s. 1.6(d), provides: "(b) The Department of Health and Human Services may, in the NC Health Choice Program for the 2008-2009 fiscal year, allow up to six percent (6.0%) enrollment growth over the number of children enrolled in the NC Health Choice Program on June 30, 2008.

"(c) On January 15, 2009, or upon the convening of the 2009 General Assembly, whichever occurs later, the Department of Health and Human Services shall report to the 2009 General Assembly. The report shall provide the following information:

"(1) The number of children enrolled in NC Health Choice for the month of January 2009, as determined by using December 2008 Pull-Night data.

"(2) Projected enrollment and program costs for each of the remaining six months of the 2008-2009 fiscal year. The projected enrollment shall be based on NC Health Choice enrollment data and program costs from the immediately preceding five fiscal years.

"(3) The status of current expenditures and availability of State and federal funds for the 2008-2009 fiscal year.

"The Department shall submit the report to the Chairs of the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division.

"(d) If the report submitted pursuant to subsection (c) of this section indicates, or if the Department becomes later aware that growth in NC Health Choice enrollment for the 2008-2009 fiscal year will exceed the maximum six percent (6%) growth allowed under subsection (a) of this section, or if there will be a shortfall of federal funds, then the Department shall notify the Centers for Medicare and Medicaid Services (CMS) that it anticipates a freeze on enrolling new enrollees. The Department will continue to provide monthly reports to the chairs of the House of Representatives Committee on Appropriations, the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, the Office of State Budget and Management, and the Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services, and the Fiscal Research Division. If enrollment in NC Health Choice continues to follow the Department's projections that the six percent (6%) cap will be exceeded, or there will be a shortfall of federal funds, then the Department shall formally notify CMS, the Chairs of the House of Representatives Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division of a freeze on new enrollees.

"(e) The limitation on enrollment growth under this section may not be exceeded unless Congress has reauthorized SCHIP so as to provide sufficient federal funds or has appropriated additional federal funds for the 2008-2009 fiscal year. If Congress has reauthorized SCHIP to provide sufficient federal funds, then the Department may continue to enroll new enrollees up to an increase of eight and seventy-three one hundredths percent (8.73%) from such funds as are available to the Department."

Session Laws 2009-451, s. 10.34, provides: "The Department of Health and Human Services may, in the NC Health Choice Program for the 2009-2010 fiscal year, allow enrollment to grow by not more than 9,098 children."

Editor's Note. - Session Laws 2002-126, s. 10.20(c), provides: "It is the intent of the General Assembly to consider the recommendations of the Institute of Medicine study in determining whether Medicaid rates or some other rates should apply to Program services."

Session Laws 2005-276, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2005'."

Session Laws 2005-276, s. 10.22(a), provides: "Effective January 1, 2006, the Department of Health and Human Services may allow up to three percent (3%) enrollment growth in the NC Health Choice Program every six months."

Session Laws 2005-276, s. 46.5 is a severability clause.

G.S. 108A-70.21(b) was amended by Session Laws 2008-107, s. 10.13(f), effective July 1, 2008. Session Laws 2008-107, s. 10.13(k), as amended by Session Laws 2008-118, s. 1.6(b), states in the introductory language "Effective July 1, 2009, G.S. 108A-70.21(b)(1), as amended by subsection (f) of this section [S.L. 2008-107, s. 10.13], reads as rewritten."

Session Laws 2008-107, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2008'."

Session Laws 2008-107, s. 10.13(n), as amended by Session Laws 2008-118, s. 1.6(c), provides: "Subsections (a) through (c) and subsections (e) through (j) of this section become effective July 1, 2008. Effective July 1, 2010, G.S. 135-42 [renumbered as G.S. 135-47, now repealed], as amended by subsection (b) of this section, is repealed. The remainder of this section is effective when this act becomes law [July 16, 2008]."

Session Laws 2008-107, s. 30.5 is a severability clause.

Session Laws 2009-16, s. 4(a), provides: "Over-the-Counter Medications. - Coverage of over-the-counter medication authorized under G.S. 108A-70.21(d) for the NC Health Choice Program shall become effective on the later of July 1, 2010, or the date upon which the Department of Health and Human Services assumes full responsibility for administration and processing of claims under the NC Health Choice Program."

Session Laws 2009-16, s. 4(b), provides: "Subrogation. - For the period authorized under subsection (a) of this section, the right of subrogation under G.S. 108A-57 applies to the State Health Plan for payments made by the Plan under the NC Health Choice Program. This subsection expires on the later of July 1, 2010, or the date upon which the Department of Health and Human Services assumes full responsibility for administration, processing, and payment of claims under the NC Health Choice Program."

Session Laws 2010-31, s. 10.14, provides: "Under the North Carolina Health Choice Program for Children, the co-payment for nonemergency visits to the emergency room for children whose family income is at or below one hundred fifty percent (150%) of the federal poverty level is ten dollars ($10.00). The co-payment for children whose family income is between one hundred fifty-one percent (151%) and two hundred percent (200%) of the federal poverty level is twenty-five dollars ($25.00)."

Session Laws 2010-31, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2010'."

Session Laws 2010-31, s. 32.6 is a severability clause.

Session Laws 2011-145, s. 10.41(f), provides: "Effective July 1, 2011, the Department shall begin planning to transition all health benefit changes of the Program to meet the coverage requirements set forth in subsection (b) of this section with implementation to begin no later than October 1, 2011, and completed no later than March 12, 2012."

Session Laws 2011-145, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2011.'"

Session Laws 2011-145, s. 32.5 is a severability clause.

Session Laws 2013-360, s. 12H.10(a)-(e), provides: "(a) Families and children who are categorically and medically needy are eligible for Medicaid, subject to the following annual income levels:

Categorical ly Medically Family Needy Needy Size Income Level Income Level 1 $4,344 $2,900 2 5,664 3,800 3 6,528 4,400 4 7,128 4,800 5 7,776 5,200 6 8,376 5,600 7 8,952 6,000 8 9,256 6,300

"(1) All elderly, blind, and disabled people who have incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines.

"(3) Infants under the age of one with family incomes equal to or less than two hundred percent (200%) of the federal poverty guidelines and without regard to resources.

"(4) Children aged one through five with family incomes equal to or less than two hundred percent (200%) of the federal poverty guidelines and without regard to resources.

"(7) Workers with disabilities described in G.S. 108A-66A with unearned income equal to or less than one hundred fifty percent (150%) of the federal poverty guidelines.

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Session Laws 2015-241, s. 12H.14(c), provides: "Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirements of G.S. 108A-54.1A(e) [repealed] and G.S. 108A-70.25(b)."

Session Laws 2015-241, s. 12H.14(d), made the amendments to this section by Session Laws 2015-241, s. 12H.14(a), (b), effective September 18, 2015.

Session Laws 2015-245, s. 22, effective September 23, 2015, repealed Session Laws 2015-241, s. 12H.25. Session Laws 2015-241, s. 12H.25(b) had amended this section contingent on House Bill 372 of the 2015 Regular Session [Session Laws 2015-245] not being ratified prior to March 1, 2016, which contingency failed. The amendment did not take effect.

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Effect of Amendments. - Session Laws 2005-276, ss. 10.22(c) and (d), effective July 1, 2005, in subsection (b), deleted the last two sentences in the first paragraph, deleted the second and fourth paragraphs, and added the last paragraph; and added subsection (b1).

Session Laws 2005-276, s. 10.22(b), effective January 1, 2006, in sub-subdivision (a)(1)a., substituted "between the ages of 6 through 18" for "under the age of 19"; and rewrote sub-subdivision (a)(1)d.

Session Laws 2007-323, s. 28.22A(o), as amended by Session Laws 2007-345, s. 12, effective July 1, 2008, substituted "State Health Plan for Teachers and State Employees" for "North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan" throughout the section.

Session Laws 2008-107, ss. 10.12(b), 10.12(c), and 10.13(f), effective July 1, 2008, in subsection (b), substituted "Predecessor Plan" for "State Health Plan for Teachers and State Employees, including optional prepaid plans" in the first paragraph and inserted "Predecessor" preceding "Plan" in the second paragraph; rewrote subdivision (b)(1); substituted "prior approval. Upon prior approval" for "prior approval of the Plan. Upon prior approval by the Plan" in subdivision (b)(2); in subdivision (b)(3), inserted "approved" preceding "hearing aid" and substituted "specialist. Prior approval" for "specialist approved by the Plan. Prior approval of the Plan"; added subdivisions (b)(4) and (b)(5); deleted "Effective January 1, 2006" at the beginning of the last paragraph in subsection (b); in subsection (b1), deleted "effective no later than January 1, 2006", substituted "percent (100%)" for "fifteen percent (115%)", and deleted the last two sentences; inserted "through two hundred percent (200%)" in subsection (c); in subsection (d) and subdivision (d)(3), made minor grammatical changes and inserted "and for each covered over-the-counter medication"; substituted "Department" for "Claims Processing Contractor of the State Health Plan for Teachers and State Employees" in subdivision (d)(4)b; rewrote subsections (e) and (g); added subsection (i).

Session Laws 2008-107, s. 10.13(k), as amended by Session Laws 2008-118, s. 1.6(b), effective July 1, 2009, in subdivision (b)(1), deleted "Dental:" at the beginning, substituted "topical fluoride treatments" for "scaling" and "sealants, extractions, other than impacted teeth or wisdom teeth" for "fluoride applications twice during a twelve-month period, fluoride varnish, sealants, simple extractions" and added "space maintainers, root canal therapy for permanent anterior teeth and permanent first molars", added subdivision (b)(1a); and transferred the last sentence of former subdivision (b)(1) to follow subdivision (b)(1a) as an undesignated paragraph.

Session Laws 2009-16, s. 4(d), effective April 23, 2009, in subsection (g) substituted "two hundred percent (200%)" for "two hundred fifty percent (250%)" twice and substituted "two hundred twenty-five percent (225%)" for "two hundred seventy-five percent (275%)".

Session Laws 2009-451, s. 10.35(a), effective July 1, 2009, in the last paragraph of subsection (b), inserted "(CCNC)" in the first sentence, and added the last sentence.

Session Laws 2011-145, s. 10.41(b), effective July 1, 2011, rewrote subsection (b).

Session Laws 2013-360, s. 12H.10(g), effective January 1, 2014, substituted "one hundred thirty-three percent (133%)" for "one hundred percent (100%)" in sub-subdivision (a)(1)d.

Session Laws 2015-96, s. 4, effective June 19, 2015, added a third sentence to subsection (b1), which read: "Payments to NC Health Choice Program providers under this Part shall be paid in full and shall not be subject to cost settlement"; and made a capitalization change in subsection (e).

Session Laws 2015-241, s. 12H.26(b), effective July 1, 2015, deleted the third sentence in subsection (b1), which was added by Session Laws 2015-96, s. 4.

Session Laws 2015-241, s. 12H.2(f), effective July 1, 2015, substituted "and less than or equal to two hundred eleven percent (211%)" for "through two hundred percent (200%)" in sub-subdivision (a)(1)d; in subdivision (3) of the second paragraph of subsection (b), substituted "less than or equal to one hundred fifty-nine percent (159%)" for "at or below one hundred fifty percent (150%)" near the end of the first sentence, and rewrote the last sentence; in subsection (c), substituted "less than or equal to one hundred fifty-nine percent (159%)" for "at or below one hundred fifty percent (150%)" in the first sentence and substituted "one hundred fifty-nine percent (159%) and less than or equal to two hundred eleven percent (211%)" for "one hundred fifty percent (150%) through two hundred percent (200%)" in the second sentence; and, in the introductory paragraph of subsection (d), substituted "less than or equal to one hundred fifty-nine percent (159%)" for "at or below one hundred fifty percent (150%)" in the first sentence, and substituted "one hundred fifty-nine percent (159%)" for "one hundred fifty percent (150%)" in the last sentence.

Session Laws 2015-241, s. 12H.14(a), (b), effective September 18, 2015, repealed subsections (g) and (h), concerning extended coverage; and rewrote subsection (i), which formerly read: "No Lifetime Maximum Benefit Limit. - Benefits provided to an enrollee in the Program shall not be subject to a maximum lifetime limit."

Session Laws 2017-102, s. 16, effective July 12, 2017, substituted "private plans" for "private plans; purchase of extended coverage" in the section heading.

§ 108A-70.22: Repealed by Session Laws 2008-107, s. 10.13(g), effective July 1, 2008.

Editor's Note. - Session Laws 2008-107, s. 1.2, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2008'."

Session Laws 2008-107, s. 30.5 is a severability clause.

§ 108A-70.23: Repealed by Session Laws 2011-145, s. 10.41(c), effective July 1, 2011.

History

(1998-1, s. 1; 2003-284, s. 10.29(b); 2008-107, s. 10.13(h); repealed by 2011-145, s. 10.41(c).)

Editor's Note. - Former G.S. 108A-70.23 pertained to services for children with special needs.

Session Laws 2011-145, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2011.'"

Session Laws 2011-145, s. 32.5 is a severability clause.

§ 108A-70.24: Repealed by Session Laws 2008-107, s. 10.13(i), effective July 1, 2008.

§ 108A-70.25. State Plan for Health Insurance Program for Children.

The NC Health Choice program shall be administered and operated in accordance with this Part and the NC Health Choice State Plan, as periodically amended by the Department of Health and Human Services and approved by the federal government.
The requirements in G.S. 108A-54.1A shall apply to NC Health Choice State Plan amendments in the same manner in which they apply to Medicaid State Plan amendments.

History

(1998-1, s. 1; 2011-291, s. 2.23; 2013-360, s. 12H.2(b).)

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'"

Session Laws 2015-241, s. 33.6, is a severability clause.

Effect of Amendments. - Session Laws 2011-291, s. 2.23, effective June 24, 2011, substituted "Joint Legislative Oversight Committee on Health and Human Services" for "Joint Legislative Health Care Oversight Committee" in the next-to-last sentence.

Session Laws 2013-360, s. 12H.2(b), effective July 1, 2013, rewrote the section.

§ 108A-70.26. Application process; outreach efforts; appeals.

Application. - The Department shall use an application form for the Program that is concise, relatively easy for the applicant to comprehend and complete, and only as lengthy as necessary for identifying applicants, determining eligibility for the Program or Medicaid, and providing information to applicants on requirements for application submission and proof of eligibility. Application forms shall be obtainable from public health departments and county departments of social services. Applications shall be processed by the county department of social services and may be submitted by mail. The Department may adopt rules for the submission and processing of applications and for securing the proof of eligibility for benefits under this Part.
Outreach Efforts. - The Department shall adopt procedures to ensure that the Program is adequately publicized statewide and to comply with federal outreach requirements. The Department shall make information about the Program available through the Internet and shall explore the feasibility of securing a 24-hour toll-free telephone number to facilitate access to Program information. In order to avoid duplication of efforts, in developing outreach procedures the Department shall establish system linkages to ensure the collaboration and coordination of information between and among the Program and such ongoing programs and efforts as:
Appeals. - A person who is dissatisfied with the action of a county department of social services with respect to the determination of eligibility for benefits under the Program may appeal the action in accordance with G.S. 108A-79.

The application form for the Program shall have printed on it or attached to it a notice stating substantially: "The Health Insurance Program for Children is a federally and State funded program that may be discontinued if federal funds are not provided for its continuation."

WIC Program.

Maternal and Child Health Block Grant.

Children's Special Health Services.

Smart Start.

Head Start.

The Department shall seek private and federal grant funds for outreach activities. The Department shall also seek the participation of the private sector in providing no-cost or low-cost avenues for publicizing the Program in local communities and statewide. The Department may work with the State Health Plan Purchasing Alliance Board to develop programs that utilize the expertise and resources of the Alliances in outreach activities to employees of small businesses.

History

(1998-1, s. 1.)

§ 108A-70.27. (See editor's note) Data collection; reporting.

The Department shall ensure that the following data are collected, analyzed, and reported in a manner that will most effectively and expeditiously enable the State to evaluate Program goals, objectives, operations, and health outcomes for children:
1. Number of applicants for coverage under the Program;
2. Number of Program applicants deemed eligible for Medicaid;
3. Number of applicants deemed eligible for the Program, by income level, age, and family size;
4. Number of applicants deemed ineligible for the Program and the basis for ineligibility;
5. Number of applications made at county departments of social services, public health departments, and by mail;
6. Total number of children enrolled in the Program to date and for the immediately preceding fiscal year;
7. Total number of children enrolled in Medicaid through the Program application process;
8. Trends showing the Program's impact on hospital utilization, immunization rates, and other indicators of quality of care, and cost-effectiveness and efficiency;
9. Trends relating to the health status of children;
10. Other data that would be useful in carrying out the purposes of this Part.
Repealed by Session Laws 2013-360, s. 12A.8(e), effective July 1, 2013.
The Division of Health Benefits shall provide to the Department data required under this section that are collected by this Division. Data shall be reported by the Division of Health Benefits in sufficient detail to meet federal reporting requirements under Title XXI.

History

(1998-1, s. 1; 2011-145, s. 10.41(d); 2011-291, ss. 2.24, 2.25; 2013-360, s. 12A.8(e); 2015-96, s. 5; 2019-81, s. 15(a).)

Editor's Note. - Session Laws 2008-107, s. 10.13(j), provides that "G.S. 108A-27 reads as rewritten" when in fact it is G.S. 108A-70.27(c) that is set out. At the direction of the Revisor of Statutes, the amendment has not been given effect. If the amendment had taken effect, subsection (c) would read: "(c) The Department shall report periodically to the Joint Legislative Health Care Oversight Committee claims processing data for the Program and any other information the Department or the Committee deems appropriate and relevant to assist the Committee in its review of the Program."

Session Laws 2008-107, s. 1.2 provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2008'."

Session Laws 2008-107, s. 30.3 provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2008-2009 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2008-2009 fiscal year."

Session Laws 2008-107, s. 30.5 is a severability clause.

Effect of Amendments. - Session Laws 2011-145, s. 10.41(d), effective July 1, 2011, substituted "The Division of Medical Assistance" for "The Executive Administrator and Board of Trustees of the North Carolina Teachers' and State Employees' Major Medical Plan ('Plan')" in the first sentence of subsection (c).

Session Laws 2011-291, ss. 2.24 and 2.25, effective June 24, 2011, in the introductory paragraph of subsection (b) and in subsection (c), substituted "Joint Legislative Oversight Committee on Health and Human Services" for "Joint Legislative Health Care Oversight Committee."

Session Laws 2013-360, s. 12A.8(e), effective July 1, 2013, repealed subsection (b).

Session Laws 2015-96, s. 5, effective June 19, 2015, in subsection (c), substituted "this Division" for "the Plan" at the end of the first sentence, substituted "the Division of Medical Assistance" for "the Plan" in the second sentence, and deleted the former third sentence, which read: "The Plan shall report periodically to the Joint Legislative Oversight Committee on Health and Human Services claims processing data for the Program and any other information the Plan or the Committee deems appropriate and relevant to assist the Committee in its review of the Program."

Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" twice in subsection (c).

§ 108A-70.28. Fraudulent misrepresentation.

It shall be unlawful for any person to knowingly and willfully, and with intent to defraud, make or cause to be made a false statement or representation of a material fact in an application for coverage under this Part or intended for use in determining eligibility for coverage.
It shall be unlawful for any applicant, recipient, or person acting on behalf of the applicant or recipient to knowingly and willfully, and with intent to defraud, conceal, or fail to disclose any condition, fact, or event affecting the applicant's or recipient's initial or continued eligibility to receive coverage or benefits under this Part.
It is unlawful for any person knowingly, willingly, and with intent to defraud, to obtain or attempt to obtain, or to assist, aid, or abet another person, either directly or indirectly, to obtain money, services, or any other thing of value to which the person is not entitled as a recipient under this Part, or otherwise to deliberately misuse a Program identification card. This misuse includes the sale, alteration, or lending of the Program identification card to others for services and the use of the card by someone other than the recipient to receive or attempt to receive Program coverage for services rendered to that individual.
A person who violates a provision of this section shall be guilty of a Class I felony.
For purposes of this section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity, or organization.

Proof of intent to defraud does not require proof of intent to defraud any particular person.

History

(1998-1, s. 1.)

§ 108A-70.29. Program review process.

Review of Eligibility and Program Enrollment Decisions. - Eligibility and Program enrollment decisions for Program applicants or recipients shall be reviewable pursuant to G.S. 108A-79. Program recipients shall remain enrolled in the NC Health Choice Program during the review of a decision to terminate or suspend enrollment. This subsection does not apply to requests for disenrollment from a PHP under Article 1A of Chapter 108D of the General Statutes.
Review of Fee-for-Service Program Health Services Decisions. - This subsection applies only to health services decisions for services being provided to NC Health Choice recipients through the fee-for-service program as defined in G.S. 108A-24. This subsection does not apply to adverse benefit determinations as defined in G.S. 108D-1. In accordance with 42 C.F.R. § 457.1130 and 42 C.F.R. § 457.1150, a Program recipient may seek review of any delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services, through a two-level review process.
1. Internal review. - Within 30 days from the date of the decision subject to review under this subsection, a recipient may request a first-level internal review, which shall be conducted by the Clinical Medical Director of the Division of Health Benefits or the Director's clinical designee.
2. External review. - If the recipient is dissatisfied with the first-level review decision, then within 15 days after the internal review decision is rendered the recipient may request a second-level independent external review by the Department of Health and Human Services Hearing Office. The external review process shall comply with the provisions of 42 C.F.R. § 457.1140. The Department's Hearing Office shall assign the matter to a hearing officer who will preside over the review. The hearing may be in person at the Hearing Office in Raleigh or by telephone. Recipients may:
  1. Represent themselves or have representatives of their choosing in the review process.
  2. Review, in a timely manner, their files and other applicable information relevant to the review of the decision.
  3. Fully participate in the review process, including the opportunity to present supplemental information during the review process.
3. Time frames. - The hearing officer shall render a written decision within 90 calendar days of the date the recipient requested first-level review, as specified at 42 C.F.R. § 457.1160. If the recipient's physician or health plan determines that operating under the standard 90-day time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, then each level of review must be completed within 72 hours, except that this expedited time frame may be extended by up to 14 calendar days if the recipient requests an extension.
4. Coverage of services during review. - When the decision is a reduction, suspension, termination, or denied request for increase of existing services, notwithstanding the request for review, the services shall be covered in accordance with the decision under review, and services which are terminated or suspended services shall not be covered, unless and until the decision is overturned on review.
Review of decisions pursuant to Programmatic changes. - The Program review process set forth in this section shall not apply to instances in which the sole basis for the decision is a provision in the State plan or in Federal or State law requiring an automatic change in eligibility, enrollment, or a change in coverage under the health benefits package that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.
Notice. - A recipient shall receive timely written notice of any decision subject to review under this section in accordance with the requirements of 42 C.F.R. § 457.1180. The notice shall include the reasons for the decision, an explanation of applicable rights to review of that decision, the standard and expedited time frames for review, the manner in which a review can be requested, and the circumstances under which enrollment may continue pending review.
Rule-Making authority. - The Department shall have the authority to adopt rules for the implementation and operation of the Program review process.
Additional Rule-Making Authority. - The Department of Health and Human Services shall have the authority to adopt rules for the transition and operation of the North Carolina Health Choice Program. Notwithstanding G.S. 150B-21.1(a), the Department of Health and Human Services may adopt temporary rules in accordance with Chapter 150B of the General Statutes for enrolling providers to participate in the NC Health Choice Program, for regulating provider participation in the NC Health Choice Program, and for other operational issues regarding the NC Health Choice Program.

History

(2010-70, s. 1; 2010-96, s. 39(a); 2011-145, s. 10.41(e); 2019-81, ss. 7, 15(a).)

Editor's Note. - Session Laws 2010-70, s. 3, made this section effective July 1, 2010, and applicable to reviews of Health Choice Program enrollment, eligibility, or health services decisions requested by Health Choice Program applicants or recipients on or after that date.

Session Laws 2010-96, s. 39(a) was contingent upon House Bill 382, 2009 Regular Session, becoming law. House Bill 382 was enacted as Session Laws 2010-70.

Effect of Amendments. - Session Laws 2010-96, s. 39(a), effective July 1, 2010, and applicable to reviews of Health Choice Program enrollment, eligibility, or health services decisions requested by Health Choice Program applicants or recipients on or after that date, substituted "Review, in a timely manner" for "Timely review" in subdivision (b)(2)b.

Session Laws 2011-145, s. 10.41(e), effective July 1, 2011, added subsection (f).

Session Laws 2019-81, s. 7, effective October 1, 2019, in subsection (a), twice inserted "Program," inserted "in the NC Health Choice Program" and added the last sentence, in subsection (b), inserted "Fee-for-Service Program" in the catchline and added the first two sentences.

Session Laws 2019-81, s. 15(a), effective July 1, 2019, substituted "Division of Health Benefits" for "Division of Medical Assistance" in subdivision (b)(1).

PART 9. WEATHERIZATION ASSISTANCE PROGRAM AND HEATING/AIR REPAIR AND REPLACEMENT PROGRAM.

§ 108A-70.30: Recodified as Part 33 of Article 7 of Chapter 143B, G.S. 143B-344.46, by Session Laws 2013-360, s. 15.22(h), effective July 1, 2013.

Editor's Note. - Session Laws 2013-360, s. 15.22(h), effective July 1, 2013, provides: "Part 9 of Article 2 of Chapter 108A of the General Statutes, G.S. 108A-70.30, is recodified as Part 33 of Article 7 of Chapter 143B of the General Statutes, G.S. 143B-344.46."

Session Laws 2013-360, s. 15.22(a), provides: "The State Energy Office is hereby transferred from the Department of Commerce to the Department of Environment and Natural Resources. This transfer shall have all of the elements of a Type I transfer, as defined in G.S. 143A-6."

Session Laws 2013-360, s. 15.22(g), provides: "The programs administered under the North Carolina Energy Assistance Act for Low-Income Persons, being the Weatherization Assistance Program for Low-Income Families and the Heating/Air Repair and Replacement Program, and any other energy-related assistance program for the benefit of low-income persons in existing housing, are transferred from the Department of Commerce to the State Energy Office in the Department of Environment and Natural Resources. The transfer under this subsection shall have all of the elements of a Type I transfer, as defined in G.S. 143A-6."

Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'"

Session Laws 2013-360, s. 38.5 is a severability clause.

§§ 108A-70.31 through 108A-70.35: Reserved for future codification purposes.

PART 10. MEDICAID ELIGIBILITY DECISION PROCESSING TIMELINESS.

§ 108A-70.36. Applicability.

If a federally recognized Native American tribe within the State has assumed responsibility for the Medicaid program pursuant to G.S. 108A-25(e), then this Part applies to the tribe in the same manner as it applies to county departments of social services.

History

(2016-94, s. 12H.17(b).)

Medical Eligibility Determination Timeliness. - Session Laws 2016-94, s. 12H.17(a), provides: "The Department of Health and Human Services, Division of Medical Assistance (DHHS), shall submit a report annually for the 2015-2016 and 2016-2017 fiscal year to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, the Joint Legislative Oversight Committee on Health and Human Services, and the Fiscal Research Division containing the following information:

"(1) The annual statewide percentage of Medicaid applications processed in a timely manner for the fiscal year.

"(2) The statewide average number of days to process Medicaid applications for each month in the fiscal year.

"(3) The annual percentage of Medicaid applications processed in a timely manner by each county department of social services for the fiscal year.

"(4) The average number of days to process Medicaid applications for each month for each county department of social services.

"(5) The number of months during the fiscal year that each county department of social services met the timely processing standards in Part 10 of Article 2 of Chapter 108A of the General Statutes.

"(6) The number of months during the fiscal year that each county department of social services failed to meet the timely processing standards in Part 10 of Article 2 of Chapter 108A of the General Statutes.

"(7) A description of all corrective action activities conducted by DHHS and county departments of social services in accordance with G.S. 108A-70.36.

"(8) A description of how DHHS plans to assist county departments of social services in meeting timely processing standards for Medicaid applications, for every county in which the performance metrics for processing Medicaid applications in a timely manner do not show significant improvement compared to the previous fiscal year.

"The report for the 2015-2016 fiscal year shall be submitted by November 1, 2016, and the report for the 2016-2017 fiscal year shall be submitted by November 1, 2017."

Editor's Notes. - Session Laws 2016-94, s. 12H.17(d), effective January 1, 2017, provides: "The corrective action procedures described in this section supersede the corrective action procedures in 10A NCAC 23C.0204 and 10A NCAC 23C.0205 related to timeliness processing of Medicaid applications by county departments of social services."

Session Laws 2016-94, s. 12H.17(e), effective July 1, 2016, provides: "The Department of Health and Human Services may adopt and amend rules to implement subsections (b) through (d) of this section."

Session Laws 2016-94, s. 12H.17(f), made this Part effective January 1, 2017, and applicable to monthly timely processing standards beginning on that date.

Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'"

Session Laws 2016-94, s. 39.7, is a severability clause.

§ 108A-70.37. Timely decision standards.

The county department of social services shall render a decision on an individual's application for Medicaid within 45 calendar days from the date of application, except for applications in which a disability determination has already been made or is needed. For those applications, the county department of social services shall render a decision on an individual's eligibility within 90 calendar days from the date of application.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.38. Timely processing standards.

The Department shall require counties to comply with timely processing standards. The timely processing standards are the average processing time standards and the percentage processed timely standards set forth in G.S. 108A-70.39 and G.S. 108A-70.40. The Department shall monitor county department of social services' compliance with these standards in accordance with this Part.
For purposes of this Part, processing time is the number of days between the date of application and the date of disposition of the application, except in cases where an eligibility determination is dependent upon receipt of information related to one or more of the following:
1. Medical expenses sufficient to meet a deductible.
2. The applicant's need for institutionalization.
3. The applicant's plan of care for the home- and community-based waivers.
4. The disability decision made by the Disability Determination Services Section of the Division of Vocational Rehabilitation of the Department.
5. Medical records needed to determine emergency dates for nonqualified aliens.
6. The applicant's application or other information from the federally facilitated marketplace.
7. The applicant's application or other information in connection with an application for a Low Income Subsidy for Medicare prescription drug coverage.
Processing times for the following types of cases shall be excluded from the calculation of the average processing time and percent processed timely:
1. Newborns who are automatically enrolled based on their mother's eligibility.
2. Applications for individuals who are presumptively eligible for Medicaid.
3. Active cases in which an individual who is eligible for one program is transferred to another program, regardless of whether the transfer occurs between allowable or nonallowable program categories.
4. Cases in which an individual transfers from an open case to another case, including establishing a new administrative case for the individual.
5. Actions to post eligibility to a terminated or denied case within one year of the termination or denial.
6. Cases that are reopened because they were terminated in error or because reopening of the terminated case is allowed by policy.
7. Cases in which the eligibility decision was appealed and the decision was reversed or remanded.
The Department may, in its discretion, exclude days, other than those required by subsection (b) of this section, from the calculation of processing time under this section if the Department determines that the delay was caused by circumstances outside the control of county departments of social services. The Department also may, in its discretion, exclude types of cases, other than those described in subsection (c) of this section, from the calculation of processing time. When the Department exercises its discretion pursuant to this subsection, the Department's determination regarding circumstances outside the control of county departments of social services and the Department's decision to exclude types of cases shall be applied uniformly to all county departments of social services.

In these cases, processing time shall exclude the number of days between the date when the county determines all eligibility criteria other than the criteria in subdivisions (1) through (7) of this subsection and the date when the county receives the information related to the criteria in subdivisions (1) through (7) of this subsection.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.39. Average processing time standards.

Average processing time is calculated by finding the processing time for each case that received a disposition during a given month and finding the average of those processing times.
The standard for average processing time is 90 days for cases in which the individual has applied for the Medicaid Aid to the Disabled category (M-AD) and 45 days for all other cases.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.40. Percentage processed timely standards.

Percentage processed timely is the percentage of cases that received a timely disposition in a given month. The percentage processed timely is calculated by expressing the number of cases during a given month with a processing time equal to or less than the standard set in G.S. 108A-70.37 as a percentage of the total cases receiving a disposition during that month. When the deadline for meeting the timely decision standard in G.S. 108A-70.37 falls on a weekend or holiday, an application that receives a disposition on the first workday following the deadline shall be considered timely for purposes of calculating the percentage processed timely.
The Department is authorized to adopt rules to establish a percentage standard for each county department of social services that will be the percentage processed timely standard for that county department of social services. Until the Department adopts rules establishing percentage standards for each county, the percentage processed timely standards are those established in 10A NCAC 23C.0203 as of April 2016.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.41. Corrective action.

If for any three consecutive months or for any five months out of a period of 12 consecutive months a county department of social services fails to meet either the average processing time standard or the percentage processed timely standard or both standards, the Department and the county department of social services shall enter into a joint corrective action plan to improve the timely processing of applications.
A joint corrective action plan entered into pursuant to this section shall specifically identify the following components:
1. The duration of the joint corrective action plan, not to exceed 12 months. If a county department of social services shows measurable progress in meeting the performance requirements in the joint corrective action plan, then the duration of the joint corrective action plan may be extended by six months, but in no case shall a joint corrective action plan exceed 18 months.
2. A plan for improving timely processing of applications that specifically describes the actions to be taken by the county department of social services and the Department.
3. The performance requirements for the county department of social services that constitute successful completion of the joint corrective action plan.
4. Acknowledgement that failure to successfully complete the joint corrective action plan will result in temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.42.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.42. Temporary assumption of Medicaid eligibility administration.

If a county department of social services fails to successfully complete its joint corrective action plan, the Department shall give the county department of social services, the county manager, and the board of social services or the consolidated human services board created pursuant to G.S. 153A-77(b) at least 90 days' notice that the Department intends to temporarily assume Medicaid eligibility administration, in accordance with subsection (b) of this section. The notice shall include the following information:
1. The date on which the Department intends to temporarily assume administration of Medicaid eligibility decisions.
2. The performance requirements in the joint corrective action plan that the county department of social services failed to meet.
3. Notice of the county department of social services' right to appeal the decision to the Office of Administrative Hearings, pursuant to Article 3 of Chapter 150B of the General Statutes.
Notwithstanding any provision of law to the contrary, if a county department of social services fails to successfully complete its joint corrective action plan, the Department shall temporarily assume Medicaid eligibility administration for the county upon giving notice as required by subsection (a) of this section. During a period of temporary assumption of Medicaid eligibility administration, the following shall occur:
1. The Department shall administer the Medicaid eligibility function in the county. Administration by the Department may include direct operation by the Department, including supervision of county Medicaid eligibility workers, or contracts for operation to the extent permitted by federal law and regulations.
2. The county department of social services is divested of Medicaid administration authority.
3. The Department shall direct and oversee the expenditure of all funding for the administration of Medicaid eligibility in the county.
4. The county shall continue to pay the nonfederal share of the cost of Medicaid eligibility administration and shall not withdraw funds previously obligated or appropriated for Medicaid eligibility administration.
5. The county shall pay the nonfederal share of additional costs incurred to ensure compliance with the timely processing standards required by this Part.
6. The Department shall work with the county department of social services to develop a plan for the county department of social services to resume Medicaid eligibility administration and perform Medicaid eligibility determinations in a timely manner.
7. The Department shall inform the county board of commissioners, the county manager, the county director of social services, and the board of social services or the consolidated human services board created pursuant to G.S. 153A-77(b) of key activities and any ongoing concerns during the temporary assumption of Medicaid eligibility administration.
Upon the Department's determination that Medicaid eligibility determinations can be performed in a timely manner based on the standards set forth in G.S. 108A-70.39 and G.S. 108A-70.40 by the county department of social services, the Department shall notify the county department of social services, the county manager, and the board of social services or the consolidated human services board created pursuant to G.S. 153A-77(b) that temporary assumption of Medicaid eligibility administration will be terminated and the effective date of termination. Upon termination, the county department of social services resumes its full authority to administer Medicaid eligibility determinations.

History

(2016-94, s. 12H.17(b).)

§ 108A-70.43. Reporting.

No later than November 1 of each year, the Department shall submit a report for the prior fiscal year to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, the Joint Legislative Oversight Committee on Health and Human Services, and the Fiscal Research Division containing the following information:

The annual statewide percentage of Medicaid applications processed in a timely manner for the fiscal year.
The statewide average number of days to process Medicaid applications for each month in the fiscal year.
The annual percentage of Medicaid applications processed in a timely manner by each county department of social services for the fiscal year.
The average number of days to process Medicaid applications for each month for each county department of social services.
The number of months during the fiscal year that each county department of social services met the timely processing standards under G.S. 108A-70.38.
The number of months during the fiscal year that each county department of social services failed to meet the timely processing standards under G.S. 108A-70.38.
A description of all corrective action activities conducted by the Department and county departments of social services in accordance with G.S. 108A-70.36.
A description of how the Department plans to assist county departments of social services in meeting timely processing standards for Medicaid applications, for every county in which the performance metrics for processing Medicaid applications in a timely manner do not show significant improvement compared to the previous fiscal year.

History

(2017-57, s. 11H.21.)

Editor's Note. - Session Laws 2017-57, s. 39.7, made this section effective July 1, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-70.44: Reserved for future codification purposes.

PART 11. MEDICAID ELIGIBILITY DETERMINATIONS ACCURACY AND QUALITY ASSURANCE.

§ 108A-70.45. Applicability.

History

(2017-57, s. 11H.22(c).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(b), provides: "(b) No later than November 1, 2017, the Department of Health and Human Services (Department) shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice on progress made regarding the accuracy of county Medicaid eligibility determinations in response to the State Auditor's January 2017 Performance Audit entitled 'North Carolina Medicaid Program Recipient Eligibility Determination.' The Department's report shall include the following information:

"(1) An identification of stakeholders, including the county departments of social services, the Department has engaged to address issues surrounding the accuracy of Medicaid eligibility determinations by county departments of social services.

"(2) Opportunities identified by the Department and stakeholders to address accuracy in Medicaid determinations.

"(3) Any steps the Department has taken, or plans to take, to assist county departments of social services with improving accuracy in Medicaid eligibility determinations, including a time line for implementation of each planned action.

"(4) Any changes to legislation or needs for funding identified by the Department to assist with improving accuracy in Medicaid determinations."

Session Laws 2017-57, s. 11H.22(e), provides: "(e) The Department of Health and Human Services, Division of Central Management and Support (Department), shall collaborate with the State Auditor to develop a plan of implementation of the annual audits under this section. The plan must include the following information:

"(1) Accuracy standards and quality assurance standards to be implemented.

"(2) The audit schedule that includes all counties.

"(3) The audit methodology to be utilized, including any information that may vary based upon county size or other factors.

"(4) Details illustrating that the audit methodology is statistically sound, including the statistically significant number of cases to be reviewed in each county.

"(5) Anticipated costs of implementing the plan.

"(6) A certification from the State Auditor that the Department's plan for the annual audits has the approval of the State Auditor.

"No later than March 1, 2018, the Department shall submit a copy of the plan to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice with any proposed recommendations, suggested legislation, or funding requests."

"(2) A plan of implementation of the training and certification program, including a specific time line of implementation.

"(4) Any other information the Department is able to provide regarding the training and certification program development.

"(j) The Department of Health and Human Services may adopt and amend rules to implement this section."

Session Laws 2017-57, s. 11H.22(k), made this Part effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-70.46. Audit of county Medicaid determinations.

Beginning January 1, 2019, the Department of Health and Human Services, Division of Central Management and Support, shall audit county departments of social services for compliance with the accuracy standards adopted under G.S. 108A-70.47 for Medicaid eligibility determinations made within a 12-month period. This audit shall also include an evaluation of compliance with the quality assurance standards under G.S. 108A-70.48 by the county department of social services. Audits shall be conducted for initial Medicaid eligibility determination applications as well as Medicaid reenrollment determinations. The Department shall ensure that every county is audited no less than once every three years.
Beginning 18 months after the Department has implemented the training and certification program under G.S. 108A-26.5, the Department shall include in its audits required under this section a verification that all county departments of social services are in compliance with the certification program requirements for individuals involved in the Medicaid eligibility determination process.

History

(2017-57, s. 11H.22(c), (h); 2018-5, s. 11H.5(a), (d).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(h)-(j), provides: "(h) No later than 18 months after the Department has implemented the training and certification program under subsection (g) of this section [G.S. 108A-26.5], the Department shall include in its audits required under G.S. 108A-70.46 a verification that all county departments of social services are in compliance with the certification program requirements for individuals involved in the Medicaid eligibility determination process.

"(2) A plan of implementation of the training and certification program, including a specific time line of implementation.

"(4) Any other information the Department is able to provide regarding the training and certification program development.

"(j) The Department of Health and Human Services may adopt and amend rules to implement this section."

Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2017-57, s. 11H.22(h), as amended by Session Laws 2018-5, s. 11H.5(d), was codified as subsection (b) of this section at the direction of the Revisor of Statutes. The existing provisions of the section were designated as subsection (a).

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Effect of Amendments. - Session Laws 2018-5, s. 11H.5(a), effective July 1, 2018, in subsection (a), substituted "shall audit" for "shall, on an annual basis, audit all" in the first sentence, deleted "annual" preceding "audit shall" near the beginning of the second sentence, and added the last sentence.

§ 108A-70.47. Medicaid eligibility determination processing accuracy standards.

The Department shall require county departments of social services to comply with accuracy standards set forth in rule for the processing of Medicaid eligibility determinations. The Department shall set the following standards:
1. Accuracy standards with regards to errors that caused an ineligible Medicaid recipient to be approved for Medicaid benefits.
2. Accuracy standards with regards to errors that caused the denial of benefits to an applicant that should have been approved for Medicaid benefits.
3. Accuracy standards with regards to errors made during the eligibility determination process that did not change the outcome of the eligibility determination.
Standards under this section shall be developed by the Department in consultation with the State Auditor.

History

(2017-57, s. 11H.22(c).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-70.48. Quality assurance.

The Department shall require county departments of social services to comply with quality assurance minimum standards set forth in rule. The quality assurance standards shall be based upon best practices and shall be developed by the Department in consultation with the State Auditor.

History

(2017-57, s. 11H.22(c).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-70.49. Corrective action.

If the Department's audit under G.S. 108A-70.46 results in a determination that a county department of social services fails to meet any of the standards adopted under G.S. 108A-70.47 or G.S. 108A-70.48, the Department and the county department of social services shall enter into a joint corrective action plan to improve the accurate processing of applications.
A joint corrective action plan entered into pursuant to this section shall specifically identify the following components:
1. The duration of the joint corrective action plan, not to exceed 24 months. If a county department of social services shows measurable progress in meeting the performance requirements in the joint corrective action plan, then the duration of the joint corrective action plan may be extended by six months, but in no case shall a joint corrective action plan exceed 36 months.
2. A plan for improving the accurate processing of applications that specifically describes the actions to be taken by the county department of social services and the Department.
3. The performance requirements for the county department of social services that constitute successful completion of the joint corrective action plan.
4. Acknowledgment that failure to successfully complete the joint corrective action plan will result in temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.50.
Any county department of social services under a joint corrective action plan shall be audited under G.S. 108A-70.46 on an annual basis until the joint corrective action plan is successfully completed or until the failure to successfully complete the joint corrective action plan results in the temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.50.

History

(2017-57, s. 11H.22(c); 2018-5, s. 11H.5(b).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Effect of Amendments. - Session Laws 2018-5, s. 11H.5(b), effective July 1, 2018, deleted "annual" preceding "audit" near the beginning of subsection (a) and added subsection (c).

§ 108A-70.50. Temporary assumption of Medicaid eligibility administration.

If a county department of social services fails to successfully complete its joint corrective action plan, the Department shall give the county department of social services, the county manager, and the board of social services or the consolidated human services board, created pursuant to G.S. 153A-77(b), at least 90 days' notice that the Department intends to temporarily assume Medicaid eligibility administration, in accordance with subsection (b) of this section. The notice shall include the following information:
1. The date on which the Department intends to temporarily assume administration of Medicaid eligibility determinations.
2. The performance requirements in the joint corrective action plan that the county department of social services failed to meet.
3. Notice of the county department of social services' right to appeal the decision to the Office of Administrative Hearings, pursuant to Article 3 of Chapter 150B of the General Statutes.
Notwithstanding any provision of law to the contrary, if a county department of social services fails to successfully complete its joint corrective action plan, the Department shall temporarily assume Medicaid eligibility administration for the county upon giving notice as required by subsection (a) of this section. During a period of temporary assumption of Medicaid eligibility administration, the following shall occur:
1. The Department shall administer the Medicaid eligibility function in the county. Administration by the Department may include direct operation by the Department, including supervision of county Medicaid eligibility workers or contracts for operation to the extent permitted by federal law and regulations.
2. The county department of social services is divested of the authority to administer Medicaid eligibility determinations.
3. The Department shall direct and oversee the expenditure of all funding for the administration of Medicaid eligibility in the county.
4. The county shall continue to pay the nonfederal share of the cost of Medicaid eligibility administration and shall not withdraw funds previously obligated or appropriated for Medicaid eligibility administration.
5. The county shall pay the nonfederal share of additional costs incurred to ensure compliance with the accuracy and quality assurance standards required by this Part.
6. The Department shall work with the county department of social services to develop a plan for the county department of social services to resume Medicaid eligibility administration and perform Medicaid eligibility determinations more accurately.
7. The Department shall inform the county board of commissioners, the county manager, the county director of social services, and the board of social services or the consolidated human services board, created pursuant to G.S. 153A-77(b), of key activities and any ongoing concerns during the temporary assumption of Medicaid eligibility administration.
Upon the Department's determination that Medicaid eligibility determinations can be performed accurately and with proper quality assurance by the county department of social services based on the standards adopted under G.S. 108A-70.47 and G.S. 108A-70.48, the Department shall notify the county department of social services, the county manager, and the board of social services or the consolidated human services board, created pursuant to G.S. 153A-77(b), that temporary assumption of Medicaid eligibility administration will be terminated and the effective date of termination. Upon termination, the county department of social services resumes its full authority to administer Medicaid eligibility determinations.

History

(2017-57, s. 11H.22(c).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

§ 108A-70.51. Reporting.

Beginning with the calendar year 2020, no later than March 1 of each year, the Department shall submit a report to the Joint Legislative Committee on Medicaid and NC Health Choice, the Fiscal Research Division, and the State Auditor that contains the following information about the prior calendar year:

The percentage of audited county departments of social services that met the accuracy standards adopted under G.S. 108A-70.47 in the prior fiscal year.
The percentage of audited county departments of social services that met the quality assurance standards adopted under G.S. 108A-70.48 in the prior fiscal year.
The audit result for each standard adopted under G.S. 108A-70.47 for each county of department services in the prior fiscal year.
The number of years in the preceding 10-year period that any county department of social services failed to meet the standards in G.S. 108A-70.47 or G.S. 108A-70.48.
A description of all corrective action activities conducted by the Department and county departments of social services in accordance with G.S. 108A-70.49.
For every county in which the performance metrics for processing Medicaid applications in an accurate manner do not show significant improvement compared to the previous audit of that county, a description of how the Department plans to assist county departments of social services in accuracy and quality assurance standards for Medicaid applications.

History

(2017-57, s. 11H.22(c); 2018-5, s. 11H.5(c).)

Editor's Note. - Session Laws 2017-57, s. 11H.22(k), made this section effective June 28, 2017.

Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'"

Session Laws 2017-57, s. 39.6, is a severability clause.

Session Laws 2018-5, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2018.'"

Session Laws 2018-5, s. 39.7, is a severability clause.

Effect of Amendments. - Session Laws 2018-5, s. 11H.5(c), effective July 1, 2018, in subdivisions (1) and (2), substituted "percentage of audited county" for "annual statewide percentage of county"; in subdivision (3), deleted "annual" preceding "audit", and added "in the prior fiscal year"; in subdivision (4), substituted "10-year period that any county" for "five-year period that each"; and, in subdivision (6), substituted "audit of that county" for "fiscal year".

ARTICLE 3. Social Services Programs.

Sec.

§ 108A-71. Authorization of social services programs.

The Department is hereby authorized to accept all grants-in-aid available for programs of social services under the Social Security Act, other federal laws or regulations, State appropriations and other non-federal sources. The Department is designated as the single State agency responsible for administering or supervising the administration of such programs. It is the intent of this Article that programs of social services be administered so that the State and its citizens may benefit fully from any grants-in-aid.

History

(1981, c. 275, s. 1.)

Editor's Note. - Session Laws 2016-94, s. 12B.5(a)-(f) provides: "(a) The Department of Health and Human Services, in consultation with the Department of Public Instruction and any other agencies or organizations that administer, support, or study early education in this State, and within resources currently available, shall collaborate on an ongoing basis to develop and implement a statewide vision for early childhood education. In collaborating in this effort, the agencies shall develop a comprehensive approach to early childhood education, birth through third grade, including creating cross agency accountability with a comprehensive set of data indicators, including consideration of the NC Pathways to Grade-Level Reading, to monitor and measure success of the early childhood education systems.

"(1) Methods to standardize student transition information such that it is quantifiable.

"(3) Recommendations for sharing data contained in a student's transition plan between preschool teachers and the parents or guardians of the child who is transitioning to kindergarten.

"(4) Recommendations for preschool teacher training and continuing education to support their role in completing transition plans for preschool children.

"(5) Recommendations for baseline information that should be compiled in transition plans for students transitioning to kindergarten.

"(6) Procedures for the management of transition plan documents, including recommendations for the length of records retention, provisions for confidentiality, and proper disposal.

"(7) Any other components the Department deems appropriate in the provision of information between preschools, students' families, and kindergartens."

Session Laws 2016-94, s. 12C.1(a), (b) provides: "(a) Federal Improvement Plan Implementation. - The Department of Health and Human Services, Division of Social Services, shall implement the requirements of the federal Program Improvement Plan to bring our State into compliance with national standards for child welfare policy and practices. The Division shall collaborate with county departments of social services to develop a model of oversight that supports program outcomes and a county's ability to meet performance standards as outlined in the Program Improvement Plan. Oversight may include support for continuous quality improvement, staff training, and data analysis. During the first two years of implementing the Program Improvement Plan, the Division shall ensure the three new Human Services/Planner Evaluator positions funded by this act are used to carry out the activities detailed in the Plan. Upon complete implementation of the Plan, these positions shall be used in child welfare services to continually improve outcomes for children and families.

Session Laws 2017-41 provides in its preamble: "Whereas, the children and families involved in North Carolina's child welfare system are among our most vulnerable children and most fragile families; and

"Whereas, transforming the child welfare system to better ensure the safety, permanency, and well-being of children and families is the right thing to do; and

"Whereas, county social services agencies are facing significant resource and administration challenges in areas other than child welfare, such as public assistance and adult services; and

"Whereas, a recent report by the Program Evaluation Division reached similar conclusions regarding county administration of Medicaid eligibility determinations; and

"Whereas, it is our charge to spend public dollars wisely and effectively on administration of public assistance; and

Session Laws 2017-41, s. 1.1, provides: "Regional Supervision of and Collaboration by Local Social Services Programs. -

"(1) The Department of Health and Human Services (Department) is responsible for supervision of the local administration of social services programs, including child welfare, adult protective services and guardianship, public assistance, child support enforcement, and other programs. In order to enhance State supervision and oversight for these programs, the Department shall develop a plan for establishing regional offices charged with supervision of administration of social services at the local level. The plan shall also identify any necessary legislative and regulatory changes necessary to improve regional collaboration among county or regional social services agencies or programs.