GSNC

Article 1. General Provisions.

§ 108D-1. Definitions.

The following definitions apply in this Chapter:

Adverse benefit determination. — As defined in 42 C.F.R. § 438.400(b). In accordance with 42 C.F.R. § 457.1260, this definition applies to NC Health Choice beneficiaries in the same manner as it applies to Medicaid beneficiaries.
Adverse disenrollment determination. — A determination by the Department of Health and Human Services or the enrollment broker to (i) deny a request made by an enrollee, or the enrollee’s authorized representative, to disenroll from a prepaid health plan or (ii) approve a request made by a prepaid health plan to disenroll an enrollee from a prepaid health plan.
Applicant. — A provider who is seeking to participate in the network of one or more local management entity/managed care organizations or prepaid health plans.
Behavioral health and intellectual/developmental disabilities tailored plan or BH IDD tailored plan. — A capitated prepaid health plan contract under the Medicaid transformation demonstration waiver that meets all of the requirements of Article 4 of this Chapter, including the requirements pertaining to BH IDD tailored plans.
Beneficiary. — A person to whom or on whose behalf medical assistance or assistance through the North Carolina Health Choice for Children program is granted under Article 2 of Chapter 108A of the General Statutes.
Closed network. — The network of providers that have contracted with (i) a local management entity/managed care organization operating the combined 1915(b) and (c) waivers or (ii) an entity operating a BH IDD tailored plan to furnish mental health, intellectual or developmental disabilities, and substance abuse services to enrollees.
CMS. — The Centers for Medicare and Medicaid Services.
Contested case hearing. — The hearing or hearings conducted at the Office of Administrative Hearings under G.S. 108D-5.9 or G.S. 108D-15.
Department. — The North Carolina Department of Health and Human Services.
Emergency medical condition. — As defined in 42 C.F.R. § 438.114.

(12) Emergency services. — As defined in 42 C.F.R. § 438.114.

(13) Enrollee. — A Medicaid or NC Health Choice beneficiary who is currently enrolled with a local management entity/managed care organization or a prepaid health plan.

(14) Enrollment broker. — As defined in 42 C.F.R. § 438.810(a).

(16) Fee-for-service program. — 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 beneficiaries rather than contracting for the coverage of services through a capitated payment arrangement.

(21) Local Management Entity or LME. — As defined in G.S. 122C-3.

(22) Local Management Entity/Managed Care Organization or LME/MCO. — As defined in G.S. 122C-3.

(23) Mail. — United States mail or, if the enrollee or the enrollee’s authorized representative has given written consent to receive electronic communications, electronic mail.

(24) Managed care entity. — A local management entity/managed care organization or a prepaid health plan.

(25) Medicaid transformation demonstration waiver. — The waiver agreement entered into between the State and the Centers for Medicare and Medicaid Services under Section 1115 of the Social Security Act for the transition to prepaid health plans.

(26) Mental health, intellectual or developmental disabilities, and substance abuse services or MH/IDD/SA services. — Those mental health, intellectual or developmental disabilities, and substance abuse services covered by a local management entity/managed care organization under a contract with the Department of Health and Human Services to operate the combined Medicaid waiver program authorized under Section 1915(b) and Section 1915(c) of the Social Security Act.

(27) Network provider. — An appropriately credentialed provider that has entered into a contract for participation in the network of one or more local management entity/managed care organizations or prepaid health plans.

(28) Notice of adverse benefit determination. — The notice required by 42 C.F.R. § 438.404.

(29) OAH. — The North Carolina Office of Administrative Hearings.

(30) Prepaid health plan or PHP. — A prepaid health plan, as defined in G.S. 58-93-5, that is under a capitated contract with the Department for the delivery of Medicaid and NC Health Choice services, or a local management entity/managed care organization that is under a capitated contract with the Department to operate a BH IDD tailored plan.

(31) Provider. — As defined in G.S. 108C-2.

(32) Provider of emergency services. — A provider that is qualified to furnish emergency services to evaluate or stabilize an enrollee’s emergency medical condition.

(36) Standard benefit plan. — A capitated prepaid health plan contract under the Medicaid transformation demonstration waiver that meets all of the requirements of Article 4 of this Chapter except for the requirements pertaining to a BH IDD tailored plan.

History. 2013-397, s. 1; 2019-81, s. 1(a); 2021-62, ss. 4.6, 4.7(a).

Choice in Accreditation for LME/MCOS Operating BH IDD Tailored Plans.

Session Laws 2021-180, s. 9D.17(a)-(c), provides: “(a) During the initial four-year contract term for Medicaid BH IDD tailored plans, as defined under G.S. 108D-1, the Department of Health and Human Services, Division of Health Benefits (DHB), shall not require, by contract or otherwise, any local management entity/managed care organization (LME/MCO) to be accredited by any one specific accreditation organization. DHB shall require each LME/MCO awarded a BH IDD tailored plan contract to be accredited by a nationally recognized accreditation organization that has been selected by the LME/MCO and approved by DHB. DHB shall create a process by which DHB approves the accreditation organization selected by the LME/MCO.

“(b) No accreditation organization shall be approved by DHB for use by an LME/MCO under this section unless the accreditation organization meets, at a minimum, all of the following criteria:

“(1) Prior experience conducting accreditation reviews for managed care organizations in at least five other states within the United States or in at least two regions that correspond to the areas covered by the regional office locations of the United States Department of Health and Human Services.

“(2) A review program that includes, at a minimum, standards for the following aspects of operation of the LME/MCO:

“a. Quality assurance.

“b. Provider credentialing.

“c. Utilization review.

“d. Enrollee rights and responsibilities.

“e. Medical records.

“f. Governance of the LME/MCO.

“g. Preventative health services.

“(3) Development of accreditation standards that include input from the medical, managed care organization, and health care consumer communities.

“(4) Reviews of, and updates to, the standards listed under subdivision (3) of this subsection at regular intervals not exceeding two years.

“(5) An internal quality assurance program that ensures the quality and continuity of its review program.

“(6) No current involvement in the operation of the LME/MCO or the delivery of health services to any of its enrollees.

“(7) No contract or consultations with the LME/MCO within the prior two years for any services other than accreditation.

“(c) All accreditation organizations approved for use by an LME/MCO under this section shall be required to submit their standards for accreditation to DHB every three years to maintain approval for use by the LME/MCO.”

Evaluate DHB Needs in Managed Care Environment.

Session Laws 180, s. 9D.18(a)-(c), provides: “(a) Evaluations. — The Department of Health and Human Services, Division of Health Benefits (DHB), shall conduct a two part evaluation of the current staffing and administrative functions for the Medicaid and NC Health Choice programs and how those staffing needs and administrative functions will change as the Medicaid and NC Health Choice programs move further into a managed care service delivery environment. In conducting this evaluation, DHB shall do all of the following:

“(1) Identify the changing administrative needs and required staff based upon the introduction of capitated contracts for standard benefit plans and BH IDD tailored benefit plans.

“(2) Determine whether any administrative or staffing functions are duplicative of any functions carried out through vendor contracts, by local management entities/managed care organizations (LME/MCOs), or prepaid health plans (PHPs).

“(b) Initial Report. — No later than March 1, 2022, DHB shall report to the Joint Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on the evaluation required by subsection (a) of this section as it pertains to the implementation of capitated contracts for standard benefit plans for PHPs. The report shall include planned staffing and administrative changes, including any changes to contractual agreements with vendors, to align more appropriately with a managed care delivery environment for the Medicaid and NC Health Choice programs. The report shall also include a detailed time line for making changes within DHB as managed care continues.

“(c) Final Report. — No later than March 1, 2024, DHB shall report to the Joint Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on the evaluation required by subsection (a) of this section as it pertains to the implementation of capitated contracts for standard benefit plans operated by PHPs and the implementation of BH IDD tailored plans. The report shall include the staffing and administrative changes that have been made since the initial report required under subsection (b) of this section. The report shall also include any additional planned staffing and administrative changes and any planned changes to contractual agreements with vendors to continue to align DHB's functions more appropriately with a managed care delivery environment for the Medicaid and NC Health Choice programs. The report shall also include an updated detailed time line for making these changes within DHB, as well as an assessment of whether the goals of the time line submitted in the initial report were met.”

Require LME/MCOS to Pay for Behavioral Health Services Provided to Beneficiaries Awaiting Hospital Discharge.

Session Laws 2018-180, s. 9D.22(a)-(h), provides: “(a) Intent. — It is the intent of the General Assembly to provide funding to hospitals for behavioral health services provided to Medicaid beneficiaries while those beneficiaries await discharge to a more appropriate setting.

“(b) Criteria for Coverage. — The Department of Health and Human Services, Division of Health Benefits (DHB), is directed to develop a clinical coverage policy, or amend an existing clinical coverage policy as applicable, assign a CPT code, and develop billing instructions for Medicaid coverage of the services described in subsection (c) of this section provided to a beneficiary who meets all of the following criteria:

“(1) The beneficiary no longer meets criteria for observation under Section 3.2.1(b) of Medicaid Clinical Coverage Policy 2A 1: Acute Inpatient Hospital Services.

“(2) The beneficiary is not currently receiving inpatient behavioral health services covered under Medicaid Clinical Coverage Policy 8B: Inpatient Behavioral Health Services.

“(3) A physician, physician assistant, or nurse practitioner has determined that one of the following actions is appropriate for the beneficiary:

“a. Admission to an inpatient psychiatric or behavioral health facility.

“b. Admission to a facility, other than an inpatient facility, for care for psychiatric or behavioral health needs, such as a group home.

“c. Arrangement for community based services or supports without which the beneficiary cannot be safely discharged to the beneficiary's home due to the beneficiary's psychiatric or behavioral health needs.

“(4) The beneficiary has been in the care of the hospital for a minimum of 30 continuous hours.

“(c) Services Covered. — The clinical coverage policy developed in accordance with this section shall provide Medicaid coverage of the following services in an acute care hospital setting when medically necessary and ordered by a physician or other appropriate provider:

“(1) Treatment, including assessment and medication management, of both psychiatric and behavioral health conditions and physical health conditions.

“(2) Crisis stabilization and support.

“(3) Ongoing monitoring of a beneficiary's medical status and medical clearance.

“(4) Nursing services and support.

“(5) Reasonable and appropriate efforts to maintain patient safety.

“(6) Provision of community resource information and psychoeducation, including connections to the relevant local management entity/managed care organization (LME/MCO).

“(7) Development of a safety plan, including any revisions to that plan.

“(8) Coordination with the beneficiary or the beneficiary's legal representative and the LME/MCO to establish a safe discharge plan or transfer plan.

“Services developed in accordance with this subsection shall be considered outpatient services. Other ancillary services, such as laboratory services, imaging, and prescription drugs, shall continue to be billed as separate and additional services not included as part of this new Medicaid coverage. Notwithstanding G.S. 108D 35, any new services developed in accordance with this subsection shall be limited to beneficiaries enrolled in NC Medicaid Direct or in a BH IDD tailored plan, as defined in G.S. 108D 1.

“(d) Reimbursement for Beneficiaries Enrolled in NC Medicaid Direct. – Services covered under the Medicaid clinical coverage policy developed in accordance with subsection (b) of this section and provided to beneficiaries enrolled in NC Medicaid Direct who are not also enrolled with an LME/MCO shall be reimbursed at a fee for service rate determined by DHB.

“(e) Reimbursement for Beneficiaries Enrolled in an LME/MCO or a BH IDD Tailored Plan. — Services covered under the Medicaid clinical coverage policy developed in accordance with subsection (b) of this section shall be covered by LME/MCOs, including LME/MCOs operating BH IDD tailored plans. If a beneficiary who is an enrollee of an LME/MCO or a BH IDD tailored plan receives these services, then the applicable LME/MCO shall be responsible for making the reimbursement payment to the hospital billing for the services. The reimbursement amount shall be determined through negotiations between each hospital and LME/MCO. If an LME/MCO and any hospital are unable to negotiate a reimbursement amount for these services, then the reimbursement rate shall be the most prevalent semiprivate room rate at the applicable hospital.

“(f) CMS Approval. — The Department of Health and Human Services, Division of Health Benefits, shall submit to the Centers for Medicare and Medicaid Services (CMS) any State Plan amendments necessary to establish the new Medicaid coverage required by this section. The new Medicaid covered services and rates shall be implemented July 1, 2022. If approval from CMS is not granted by July 1, 2022, DHB shall retroactively implement services and rates upon approval from CMS to July 1, 2022. The new Medicaid covered services and rates shall only be implemented to the extent allowable by CMS.

“(g) Capitation Rates. — It is the intent of the General Assembly that there will be no increase in the capitation rates paid to LME/MCOs for any services developed under this section. If an increase in capitation rates paid to LME/MCOs is necessary to maintain the actuarial soundness of those paid capitation rates, then DHB shall increase the capitation rates by the minimum amount necessary for federal approval of the rates.

“(h) Effective Date. — This section is effective when it becomes law.” This section became effective November 18, 2021.

Editor’s Note.

Session Laws 2013-397, s. 11, made this Chapter effective August 23, 2013, and applicable to grievances and managed care actions filed on or after that date.

Session Laws 2013-397, s. 5, provides: “By September 30, 2013, the Department of Health and Human Services shall take any action necessary to implement this act, including submitting to the Centers for Medicare and Medicaid Services a Medicaid State Plan Amendment with a retroactive effective date of July 1, 2013. On or before September 30, 2013, the Department of Health and Human Services shall report to the Joint Legislative Oversight Committee on Health and Human Services on the status of the implementation of this act.”

Session Laws 2019-81, s. 1(a), effective October 1, 2019, rewrote the Chapter 108D heading, which formerly read: “Medicaid Managed Care for Behavioral Health Services.”

Session Laws 2019-81, s. 1(b), provides: “This section is effective October 1, 2019, and applies to (i) appeals arising from local management entity/managed care organization (LME/MCO) notices of adverse benefit determination mailed on or after that date and (ii) grievances received by an LME/MCO on or after that date.”

Session Laws 2021-3, s. 2.20, provides: “Notwithstanding any provision of Chapter 130A of the General Statutes or any other provision of law to the contrary, the Department of Health and Human Services shall, by July 1, 2021, grant each prepaid health plan, as defined in G.S. 108D-1, access to client-specific immunization information contained within the secure, web-based North Carolina Immunization Registry.”

Session Laws 2021-180, s. 1.1, provides: “This act shall be known as the ‘Current Operations Appropriations Act of 2021.”

Session Laws 2021-180, s. 43.5, provides: “Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2021-2023 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2021-2023 fiscal biennium.”

Session Laws 2021-180, s. 43.7, is a severability clause.

Editor’s Note.

Session Laws 2013-397, s. 11, made this Chapter effective August 23, 2013, and applicable to grievances and managed care actions filed on or after that date.

Session Laws 2019-81, s. 1(a), effective October 1, 2019, rewrote the Chapter 108D heading, which formerly read: “Medicaid Managed Care for Behavioral Health Services.”

Session Laws 2021-180, s. 1.1, provides: “This act shall be known as the ‘Current Operations Appropriations Act of 2021.”

Session Laws 2021-180, s. 43.7, is a severability clause.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), effective October 1, 2019, rewrote the section. For effective date and applicability, see Editor’s note.

Session Laws 2021-62, ss. 4.6, 4.7(a), effective June 29, 2021, added subdivision (6a), and in subdivision (6), inserted “operating the combined 1915(b) and (c) waivers or (ii) an entity operating a BH IDD tailored plan” and made a minor stylistic change.

§ 108D-2. Scope; applicability of this Chapter.

This Chapter applies to every managed care entity, applicant, enrollee, provider of emergency services, and network provider of a managed care entity. This Chapter does not apply to Medicaid or NC Health Choice services delivered through the fee-for-service program. Nothing in this Chapter shall be construed to grant a NC Health Choice beneficiary benefits in excess of what is required by G.S. 108A-70.21.

History. 2013-397, s. 1; 2019-81, s. 1(a).

Editor’s Note.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), rewrote the section, which formerly read: “This Chapter applies to every LME/MCO and to every applicant, enrollee, provider of emergency services, and network provider of an LME/MCO.” For effective date and applicability, see Editor’s note.

§ 108D-3. Conflicts; severability.

To the extent that this Chapter conflicts with the Social Security Act or 42 C.F.R. Parts 438 and 457, federal law prevails, except when 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.
To the extent that this Chapter conflicts with any other provision of State law that is contrary to the principles of managed care that will ensure successful containment of costs for health care services, this Chapter prevails and applies.
If any section, term, or provision of this Chapter is adjudged invalid for any reason, these judgments shall not affect, impair, or invalidate any other section, term, or provision of this Chapter, but the remaining sections, terms, and provisions shall be and remain in full force and effect.

History. 2013-397, s. 1; 2019-81, s. 1(a).

Editor’s Note.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), rewrote subsection (a), which formerly read: “To the extent that this Chapter conflicts with the Social Security Act or 42 C.F.R. Part 438, federal law prevails”; and in subsection (b), deleted “behavioral” preceding “health care services.” For effective date and applicability, see Editor’s note.

§§ 108D-4, 108D-5.

Reserved for future codification purposes.

Article 1A. Disenrollment from Prepaid Health Plans.

§ 108D-5.1. General provisions.

Nothing in this Article shall be construed to limit or prevent the Department from disenrolling, from a PHP, an enrollee who (i) is no longer eligible to receive services through the Medicaid or NC Health Choice programs or (ii) becomes a member of a population of beneficiaries that is not required to enroll in a PHP under State law.
Nothing in this Article shall be construed to exclude a Medicaid or NC Health Choice beneficiary who is otherwise required by State law to enroll in a PHP from enrolling in a PHP, or to prevent a beneficiary who is otherwise exempted from enrollment in a PHP from disenrolling from a PHP and receiving services through the fee-for-service program.

History. 2019-81, s. 1(a).

Editor’s Note.

§ 108D-5.3. Enrollee requests for disenrollment.

In General. — An enrollee, or the enrollee’s authorized representative, who is requesting disenrollment from a PHP, shall submit an oral or written request for disenrollment to the enrollment broker.
Without Cause Enrollee Requests for Disenrollment. — An enrollee shall be allowed to disenroll from the PHP without cause only during the times specified in 42 C.F.R. § 438.56(c)(2), except that enrollees who are in any of the following groups may disenroll at any time:
1. Beneficiaries who meet the definition of Indian under 42 C.F.R. § 438.14(a).
2. Beneficiaries who are enrolled in the foster care system.
3. Beneficiaries who are in the former foster care Medicaid eligibility category.
4. Beneficiaries who receive Title IV-E adoption assistance.
5. Beneficiaries who are receiving long-term services and supports in institutional or community-based settings.
6. Any other beneficiaries who are not required to enroll in a PHP under G.S. 108D-40.
With Cause Enrollee Requests for Disenrollment. — An enrollee, or the enrollee’s authorized representative, may submit a request to disenroll from a PHP for cause at any time. For cause reasons for disenrollment from a PHP include the following:
1. The enrollee moves out of the PHP’s service area.
2. The PHP, because of the PHP’s moral or religious objections, does not cover a service the enrollee seeks.
3. The enrollee needs concurrent, related services that are not all available within the PHP’s network and the enrollee’s provider determines that receiving services separately would subject the enrollee to unnecessary risk.
4. An enrollee who receives long-term services and supports will be required to change residential, institutional, or employment supports providers due to the enrollee’s provider’s change from in-network to out-of-network status with the PHP and, as a result, the enrollee would experience a disruption in residence or employment.
5. The enrollee’s complex medical conditions could be better served under a different PHP. For purposes of this subsection, an enrollee is considered to have a complex medical condition if the enrollee has a condition that could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function.
6. A family member of the enrollee becomes, or is determined, eligible for Medicaid or NC Health Choice and the family member is, or becomes, enrolled in a different PHP.
7. Poor performance by the PHP, as determined by the Department. The Department shall not make a determination of poor performance by any PHP until the Department has completed an annual PHP performance evaluation following the first year of that PHP’s contract.
8. Poor quality of care, lack of access to services covered under the PHP’s contract, lack of access to providers experienced in addressing the enrollee’s health care needs, or any other reasons established by the Department in the PHP’s contract or in rule.
Expedited Enrollee Requests for Disenrollment. — An enrollee, or the enrollee’s authorized representative, may submit an expedited request for disenrollment to the enrollment broker when the enrollee has an urgent medical need that requires disenrollment from the PHP. For purposes of this subsection, an urgent medical need means that continued enrollment in the PHP could jeopardize the enrollee’s life, health, or ability to attain, maintain, or regain maximum function.

History. 2019-81, s. 1(a); 2021-62, s. 4.8(a).

Editor’s Note.

Effect of Amendments.

Session Laws 2021-62, s. 4.8(a), effective July 1, 2021, rewrote subdivision (b)(1).

§ 108D-5.5. PHP requests for disenrollment.

In General. — A PHP requesting disenrollment of an enrollee from the PHP shall submit a written request for disenrollment to the enrollment broker.
Limitations on PHP Requests for Disenrollment. — A PHP shall not request disenrollment of an enrollee from the PHP for any reason prohibited by 42 C.F.R. § 438.56(b)(2). A PHP may request disenrollment of an enrollee only when both of the following criteria are met:
1. The enrollee’s behavior seriously hinders the PHP’s ability to care for the enrollee or other enrollees of the PHP.
2. The PHP has documented efforts to resolve the issues that form the basis of the request for disenrollment of the enrollee.

History. 2019-81, s. 1(a).

Editor’s Note.

§ 108D-5.7. Notices.

Notices of Resolution. — For each disenrollment request by an enrollee or a PHP, the Department shall issue a written notice of resolution approving or denying the request by mail to the enrollee before the first day of the second month following the month in which the enrollee or PHP requested disenrollment. For expedited enrollee requests for disenrollment made under G.S. 108D-5.3(d), the Department shall issue the written notice of resolution approving or denying the expedited request within three calendar days of receipt of the request. In the same mailing as the notice, the Department shall also provide the enrollee with an appeal request form that includes all of the following:
1. A statement that, in order to request an appeal, the enrollee must file the form with OAH no later than 30 days after the mailing date of the notice of resolution, 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 enrollee’s name, address, telephone number, and Medicaid or NC Health Choice identification number.
3. A preprinted statement that indicates that the enrollee would like to appeal the specific adverse disenrollment determination identified in the notice of resolution.
4. A statement informing the enrollee of the right to be represented at the contested case hearing by a lawyer, a relative, a friend, or other spokesperson.
5. A space for the enrollee’s signature and date.
Notices Pertaining to Expedited Enrollee Requests for Disenrollment. — If the Department determines that an enrollee’s request for disenrollment does not meet the criteria for an expedited request, the Department shall do the following:
1. No later than three calendar days after receiving the enrollee’s request for disenrollment, make reasonable efforts to give the enrollee and all other affected parties oral notice of the denial and follow up with a written notice of the denial. The denial is not appealable.
2. Issue the notice of resolution within the time limits established for standard disenrollment requests under subsection (a) of this section.

History. 2019-81, s. 1(a); 2021-62, ss. 2.1(d), 2.2(e).

Editor’s Note.

Session Laws 2021-62, s. 2.1(i), made the rewriting of subdivision (a)(1) of this section by Session Laws 2021-62, s. 2.1(d), 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 the substitution of “denial” for “determination by mail” at the end of the first sentence, and the addition of the second sentence in subdivision (b)(1) by Session Laws 2021-62, s. 2.2(e), 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 2021-62, s. 2.1(d), rewrote subdivision (a)(1). For effective date and applicability, see editor’s note.

Session Laws 2021-62, s. 2.2(e), in subdivision (b)(1), substituted “denial” for “determination by mail” at the end of the first sentence, and added the second sentence. For effective date and applicability, see editor’s note.

§ 108D-5.9. Appeals of adverse disenrollment determinations.

Appeals. — An enrollee, or the enrollee’s authorized representative, who is dissatisfied with an adverse disenrollment determination may request a hearing to appeal the determination by filing the appeal request form provided under G.S. 108D-5.7(a) with the Office of Administrative Hearings within 30 calendar days of the date on the notice of resolution. 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. A request for a hearing to appeal an adverse disenrollment 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 appeal shall be conducted in accordance with the procedures in Part 6A of Article 2 of Chapter 108A of the General Statutes.
Parties. — The Department shall be the respondent for purposes of appeals under this section.

History. 2019-81, s. 1(a); 2021-62, s. 2.1(e).

Editor’s Note.

Session Laws 2021-62, s. 2.1(i), made the rewriting of subsection (a) of this section by Session Laws 2021-62, s. 2.1(e), 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.

Effect of Amendments.

Session Laws 2021-62, s. 2.1(e), rewrote subsection (a). For effective date and applicability, see editor’s note.

§§ 108D-6 through 108D-10.

Reserved for future codification purposes.

Article 2. Enrollee Grievances and Appeals.

§ 108D-11. Managed care entity grievance and appeal procedures, generally.

Each managed care entity shall establish and maintain internal grievance and appeal procedures that (i) comply with the Social Security Act and 42 C.F.R. Part 438, Subpart F, and (ii) afford enrollees and their authorized representatives constitutional rights to due process and a fair hearing.
An enrollee, or the enrollee’s authorized representative, may file grievances and managed care entity level appeals orally or in writing.
A managed care entity shall not attempt to influence, limit, or interfere with an enrollee’s right or decision to file a grievance, request for a managed care entity level appeal, or a contested case hearing. However, nothing in this Chapter shall be construed to prevent a managed care entity from doing any of the following:
1. Offering an enrollee alternative services.
2. Engaging in clinical or educational discussions with enrollees or providers.
3. Engaging in informal attempts to resolve enrollee concerns prior to the issuance of a notice of grievance disposition or notice of resolution.
A managed care entity shall not take punitive action against a provider for any of the following:
1. Filing a grievance on behalf of an enrollee or supporting an enrollee’s grievance.
2. Requesting a managed care entity level appeal on behalf of an enrollee or supporting an enrollee’s request for a managed care entity level appeal.
3. Requesting an expedited managed care entity level appeal on behalf of an enrollee or supporting an enrollee’s request for a managed care entity level expedited appeal.
4. Requesting a contested case hearing on behalf of an enrollee or supporting an enrollee’s request for a contested case hearing.
The appeal procedures set forth in this Article shall not apply to instances in which the sole basis for the managed care entity’s decision is a provision in the State Plan or in federal or State law requiring an automatic change adversely affecting some or all beneficiaries.

History. 2013-397, s. 1; 2019-81, s. 1(a); 2021-62, s. 2.1(f).

Editor’s Note.

Session Laws 2013-397, s. 1, enacted this Article as G.S. 108D-4 through 108D-9. It was renumbered as G.S. 108D-11 through 108D-16 at the direction of the Revisor of Statutes.

This section was enacted as G.S. 108D-4. It has been renumbered as G.S. 108D-11 at the direction of the Revisor of Statutes.

Session Laws 2017-57, s. 11H.8(a), (b), provides: “(a) The Department of Health and Human Services (Department) shall continue to ensure that local management entities/managed care organizations (LME/MCOs) utilize an out-of-network agreement that contains standardized elements developed in consultation with LME/MCOs. The out-of-network agreement shall be a streamlined agreement between a single provider of behavioral health or intellectual/developmental disability (IDD) services and an LME/MCO to ensure access to care in accordance with 42 C.F.R. § 438.206(b)(4), reduce administrative burden on the provider, and comply with all requirements of State and federal laws and regulations. LME/MCOs shall use the 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 an in-network provider.

“(2) The behavioral health or IDD provider’s site of service delivery is located outside of the geographical catchment area of the LME/MCO, and the LME/MCO is not accepting applications or the provider does not wish to apply for membership in the LME/MCO closed network.

“(3) The behavioral health or IDD provider is not excluded from participation in the Medicaid program, the NC Health Choice program, or 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, unless the agreement is for inpatient hospitalization, in which case the LME/MCO may, but shall not be required to, enter into more than five such out-of-network agreements with a single hospital or health system in any 12-month period.

“(b) Medicaid providers providing 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.”

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 2021-62, s. 2.1(i), made the deletion of the former second sentence of subsection (b) of this section by Session Laws 2021-62, s. 2.1(f), 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.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), effective October 1, 2019, rewrote the section. For effective date and applicability, see Editor’s note.

Session Laws 2021-62, s. 2.1(f), deleted the former second sentence of subsection (b), which read: “However, unless the enrollee, or the enrollee’s authorized representative, requests an expedited appeal, the oral appeal must be followed by a written, signed appeal.” For effective date and applicability, see editor’s note.

§ 108D-12. Managed care entity grievances.

Filing of Grievance. — An enrollee, or the enrollee’s authorized representative, has the right to file a grievance with a managed care entity at any time to express dissatisfaction about any matter other than an adverse benefit determination. Upon receipt of a grievance, a managed care entity shall cause a written acknowledgment of receipt of the grievance to be sent by mail.
Notice of Grievance Disposition. — The managed care entity shall resolve the grievance and cause a notice of grievance resolution to be sent by mail to the enrollee and all other affected parties as expeditiously as the enrollee’s health condition requires, but no later than 30 days after receipt of the grievance, provided that the managed care entity may extend such time frame to the extent permitted under 42 C.F.R. § 438.408(c).
Right to Appeal. — There is no right to appeal the resolution of a grievance to OAH or any other forum.

History. 2013-397, s. 1; 2019-81, s. 1(a).

Editor’s Note.

This section was enacted as G.S. 108D-5. It has been renumbered as G.S. 108D-12 at the direction of the Revisor of Statutes.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), rewrote the section. For effective date and applicability, see Editor’s note.

§ 108D-13. Standard managed care entity level appeals.

Notice of Adverse Benefit Determination. — A managed care entity shall provide an enrollee with a written notice of an adverse benefit determination by mail as required under 42 C.F.R. § 438.404. The notice will employ a standardized form included as a provision in the contract between the managed care entity and the Department.
Request for Appeal. — An enrollee, or the enrollee’s authorized representative, has the right to file a request for a managed care entity level appeal of a notice of adverse benefit determination no later than 60 days after the mailing date of the notice of adverse benefit determination. Upon receipt of a request for a managed care entity level appeal, a managed care entity shall acknowledge receipt of the request for appeal in writing by mail.
Continuation of Benefits. — A managed care entity shall continue the benefits of a Medicaid enrollee during the pendency of a managed care entity level appeal to the same extent required under 42 C.F.R. § 438.420. In accordance with 42 C.F.R. § 457.1260, NC Health Choice enrollees shall not be entitled to continuation of benefits.
Notice of Resolution. — The managed care entity shall resolve the appeal as expeditiously as the enrollee’s health condition requires, but no later than 30 days after receiving the request for appeal, provided that the managed care entity may extend such time frame as permitted under 42 C.F.R. § 438.408. The managed care entity shall provide the enrollee and all other affected parties with a written notice of resolution by mail within this 30-day period.
Right to Request Contested Case Hearing. — An enrollee, or the enrollee’s authorized representative, may file a request for a contested case hearing under G.S. 108D-15 as long as (i) the enrollee, or the enrollee’s authorized representative, has exhausted the appeal procedures described in this section or G.S. 108D-14 or (ii) the enrollee has been deemed, under 42 C.F.R. § 438.408(c)(3), to have exhausted the managed care entity level appeals process.
Request Form for Contested Case Hearing. — In the same mailing as the notice of resolution, the managed care entity shall also provide the enrollee with an appeal request form for a contested case hearing that meets the requirements of G.S. 108D-15(f).

History. 2013-397, s. 1; 2019-81, s. 1(a).

Editor’s Note.

This section was enacted as G.S. 108D-6. It has been renumbered as G.S. 108D-13 at the direction of the Revisor of Statutes.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), rewrote the section. For effective date and applicability, see Editor’s note.

§ 108D-14. Expedited managed care entity level appeals.

Request for Expedited Appeal. — When the time limits for completing a standard managed care entity level appeal under G.S. 108D-13 could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, an enrollee, or the enrollee’s authorized representative, has the right to file a request for an expedited appeal of an adverse benefit determination no later than 60 days after the mailing date of the notice of adverse benefit determination. In determining whether the enrollee qualifies for an expedited appeal, the managed care entity shall presume an expedited appeal is necessary when the expedited appeal is made by a network provider as an enrollee’s authorized representative or when a network provider has otherwise indicated to the managed care entity that an expedited appeal is necessary.
Notice of Denial for Expedited Appeal. — If the managed care entity denies a request for an expedited managed care entity level appeal, then (i) the managed care entity shall make reasonable efforts to give the enrollee and all other affected parties oral notice of the denial and follow up with a written notice of denial by mail no later than 72 hours after receiving the request for an expedited appeal and (ii) the managed care entity shall resolve the appeal within the time limits established for standard managed care entity level appeals in G.S. 108D-13. The denial is not appealable.
Continuation of Benefits. — A managed care entity shall continue the benefits of a Medicaid enrollee during the pendency of an expedited managed care entity level appeal to the extent required under 42 C.F.R. § 438.420. In accordance with 42 C.F.R. § 457.1260, NC Health Choice enrollees shall not be entitled to continuation of benefits.
Notice of Resolution. — If the managed care entity grants a request for an expedited managed care entity level appeal, the managed care entity shall resolve the appeal as expeditiously as the enrollee’s health condition requires, and no later than 72 hours after receiving the request for an expedited appeal, provided that the managed care entity may extend such time frame as permitted under 42 C.F.R. § 438.408. The managed care entity shall provide the enrollee and all other affected parties with a written notice of resolution by mail within this 72-hour period.
Right to Request Contested Case Hearing. — An enrollee, or the enrollee’s authorized representative, may file a request for a contested case hearing under G.S. 108D-15 as long as (i) the enrollee, or the enrollee’s authorized representative, has exhausted the appeal procedures described in G.S. 108D-13 or this section or (ii) the enrollee has been deemed, under 42 C.F.R. § 438.408(c)(3), to have exhausted the managed care entity level appeals process.
Reasonable Assistance. — A managed care entity shall provide the enrollee with reasonable assistance in completing forms and taking other procedural steps necessary to file an appeal, including providing interpreter services and toll-free numbers that have adequate teletypewriter/telecommunications devices for the deaf (TTY/TDD) and interpreter capability.
Request Form for Contested Case Hearing. — In the same mailing as the notice of resolution, the managed care entity shall also provide the enrollee with an appeal request form for a contested case hearing that meets the requirements of G.S. 108D-15(f).

History. 2013-397, s. 1; 2019-81, s. 1(a); 2021-62, s. 2.2(f), (g).

Editor’s Note.

This section was enacted as G.S. 108D-7. It has been renumbered as G.S. 108D-14 at the direction of the Revisor of Statutes.

Session Laws 2021-62, s. 2.2(j), made the amendments to subsections (a) and (b) of this section by Session Laws 2021-62, s. 2.2(f), (g), 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 2019-81, s. 1(a), rewrote the section. For effective date and applicability, see Editor’s note.

Session Laws 2021-62, s. 2.2(f), (g) substituted “standard managed care entity level appeal under G.S. 108D-13” for “standard appeal” in the first sentence of subsection (a); and, in subsection (b), in the first sentence, inserted “then (i)” near the beginning, and substituted “expedited appeal and (ii)” for “expedited appeal. In addition,” near the middle, and added the second sentence. For effective date and applicability, see editor’s note.

§ 108D-15. Contested case hearings on disputed adverse benefit determinations.

Jurisdiction of the Office of Administrative Hearings. — The Office of Administrative Hearings does not have jurisdiction over a dispute concerning an adverse benefit determination, except as expressly set forth in this Chapter.
Exclusive Administrative Remedy. — Notwithstanding any provision of State law or rules to the contrary, this section is the exclusive method for an enrollee to contest a notice of resolution of an adverse benefit determination issued by a managed care entity. G.S. 108A-70.9A, 108A-70.9B, and 108A-70.9C do not apply to enrollees contesting an adverse benefit determination.
Request for Contested Case Hearing. — A request for an administrative hearing to appeal a notice of resolution of an adverse benefit determination issued by a managed care entity is a contested case subject to the provisions of Article 3 of Chapter 150B of the General Statutes. An enrollee, or the enrollee’s authorized representative, has the right to file a request for appeal to contest a notice of resolution as long as (i) the enrollee, or the enrollee’s authorized representative, has exhausted the appeal procedures described in G.S. 108D-13 or G.S. 108D-14 or (ii) the enrollee has been deemed, under 42 C.F.R. § 438.408(c)(3), to have exhausted the managed care entity level appeals process.
Filing Procedure. — An enrollee, or the enrollee’s authorized representative, may file a request for an appeal by filing an appeal request form that meets the requirements of subsection (f) of this section with OAH by no later than 120 days after the mailing date of the notice of resolution. 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. Upon receipt of a timely filed appeal request form, information contained in the notice of resolution is no longer confidential, and the managed care entity shall immediately forward a copy of the notice of resolution to OAH electronically. OAH may dispose of these records after one year.
Parties. — The managed care entity shall be the respondent for purposes of this appeal. The managed care entity, the enrollee, or the enrollee’s authorized representative may move for the permissive joinder of the Department under Rule 20 of the North Carolina Rules of Civil Procedure. The Department may move to intervene as a necessary party under Rules 19 and 24 of the North Carolina Rules of Civil Procedure.
Appeal Request Form. — In the same mailing as the notice of resolution, the managed care entity shall also provide the enrollee with an appeal request form for a contested case hearing which shall be no more than one side of one page. The form shall include at least all of the following:
1. A statement that, in order to request an appeal, the enrollee must file the form with OAH no later than 120 days after the mailing date of the notice of resolution, 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 enrollee’s name, address, telephone number, and Medicaid or NC Health Choice identification number.
3. A preprinted statement that indicates that the enrollee would like to appeal the specific adverse benefit determination identified in the notice of resolution.
4. The option for the enrollee to request an expedited appeal.
5. A statement informing the enrollee of the right to be represented at the contested case hearing by a lawyer, a relative, a friend, or other spokesperson.
6. A space for the enrollee’s signature and date.
Continuation of Benefits. — A managed care entity shall continue the benefits of a Medicaid enrollee during the pendency of an appeal to the same extent required under 42 C.F.R. § 438.420. In accordance with 42 C.F.R. § 457.1260, NC Health Choice enrollees shall not be entitled to continuation of benefits. Notwithstanding any other provision of State law, the administrative law judge does not have the power to order and shall not order a managed care entity to continue benefits in excess of what is required by 42 C.F.R. § 438.420.
Simple Procedures. — Notwithstanding any other provision of Article 3 of Chapter 150B of the General Statutes, the chief administrative law judge of OAH may limit and simplify the administrative hearing procedures that apply to contested case hearings conducted under this section in order to complete these cases as expeditiously as possible. Any simplified hearing procedures approved by the chief administrative law judge under this subsection must comply with all of the following requirements:
1. OAH shall schedule and hear cases by no later than 55 days after receipt of a request for a contested case hearing.
2. OAH shall conduct all contested case hearings telephonically or by video technology with all parties, unless the enrollee requests that the hearing be conducted in person before the administrative law judge. An in-person hearing shall be conducted in the county that contains the headquarters of the managed care entity unless the enrollee’s impairments limit travel. For enrollees with impairments that limit travel, an in-person hearing shall be conducted in the enrollee’s county of residence. OAH shall provide written notice to the enrollee of the use of telephonic hearings, hearings by video conference, and in-person hearings before the administrative law judge, as well as written instructions on how to request a hearing in the enrollee’s county of residence.
3. The administrative law judge assigned to hear the case shall consider and rule on all prehearing motions prior to the scheduled date for a hearing on the merits.
4. The administrative law judge may allow brief extensions of the time limits imposed in this section only for good cause shown and to ensure that the record is complete. The administrative law judge shall only grant a continuance of a hearing in accordance with rules adopted by OAH for good cause shown and shall not grant a continuance on the day of a hearing, except for good cause shown. If an enrollee fails to make an appearance at a hearing that has been properly noticed by OAH by mail, OAH shall immediately dismiss the case, unless the enrollee moves to show good cause by no later than three business days after the date of dismissal. As used in this section, “good cause shown” includes delays resulting from untimely receipt of documentation needed to render a decision and other unavoidable and unforeseen circumstances.
5. OAH shall include information on at least all of the following in its notice of hearing to an enrollee:
  1. The enrollee’s right to examine at a reasonable time before and during the hearing the contents of the enrollee’s case file and any documents to be used by the managed care entity in the hearing before the administrative law judge.
  2. The enrollee’s right to an interpreter during the hearing process.
  3. The circumstances in which a medical assessment may be obtained at the managed care entity’s expense and made part of the record, including all of the following:
    1. A hearing involving medical issues, such as a diagnosis, an examining physician’s report, or a decision by a medical review team.
    2. A hearing in which the administrative law judge considers it necessary to have a medical assessment other than the medical assessment performed by an individual involved in any previous level of review or decision making.
Mediation. — Upon receipt of an appeal request form as provided by G.S. 108D-15(f) or other clear request for a hearing by an enrollee, OAH shall immediately notify the Mediation Network of North Carolina, which shall contact the enrollee 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 managed care entity 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 case involving a dispute of an adverse benefit determination until it has received notice from the mediator assigned that either (i) the mediation was unsuccessful, (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 enrollee has the burden of proof on all issues submitted to OAH for a contested case hearing under this section 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 in the case.
New Evidence. — The enrollee shall be permitted to submit evidence regardless of whether it was obtained before or after the managed care entity’s adverse benefit determination and regardless of whether the managed care entity had an opportunity to consider the evidence in resolving the managed care entity level appeal. Upon the receipt of new evidence and at the request of the managed care entity, the administrative law judge shall continue the hearing for a minimum of 15 days and a maximum of 30 days in order to allow the managed care entity to review the evidence. Upon reviewing the evidence, if the managed care entity decides to reverse the adverse benefit determination, it shall immediately inform the administrative law judge of its decision.
Issue for Hearing. — For each adverse benefit determination, the administrative law judge shall determine whether the managed care entity substantially prejudiced the rights of the enrollee and whether the managed care entity, 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.
To the extent that anything in this Chapter, Chapter 150B of the General Statutes, or any rules or policies adopted under these Chapters is inconsistent with the Social Security Act or 42 C.F.R. Part 438, Subpart F, federal law prevails and applies to the extent of the conflict, except when 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. All rules, rights, and procedures for contested case hearings concerning adverse benefit determinations shall be construed so as to be consistent with applicable federal law and shall provide the enrollee with rights that are no less than those provided under federal law.

History. 2013-397, s. 1; 2014-100, s. 12H.27(c); 2019-81, s. 1(a); 2021-62, ss. 2.1(g), (h), 2.2(h).

Editor’s Note.

This section was enacted as G.S. 108D-8. It has been renumbered as G.S. 108D-15 at the direction of the Revisor of Statutes.

Session Laws 2014-100, s. 12H.27(d), made the amendment to subsection (i) by Session Laws 2014-100, s. 12H.27(c), 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.

Session Laws 2021-62, s. 2.1(i), made the amendments to this section by Session Laws 2021-62, s. 2.1(g), (h), 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 (f)(3a) of this section, as added by Session Laws 2021-62, s. 2.2(h), 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 2014-100, s. 12H.27(c), effective October 1, 2014, substituted the present last sentence of subsection (i) for the former, which read: “Nothing in this subsection shall restrict the right to a contested case hearing.” See Editor’s note for applicability.

Session Laws 2019-81, s. 1(a), rewrote the section. For effective date and applicability, see Editor’s note.

Session Laws 2021-62, ss. 2.1(g), (h), rewrote subsections (d), and (f)(1). For effective date and applicability, see editor’s note.

Session Laws 2021-62, s. 2.2(h), added subdivision (f)(3a). For effective date and applicability, see editor’s note.

§ 108D-15.1. Expedited contested case hearings on disputed adverse benefit determinations.

In accordance with 42 C.F.R. § 431.224, an enrollee, or an enrollee’s authorized representative, may request that an appeal under G.S. 108D-15(d) be expedited if the time otherwise permitted for a hearing could jeopardize the enrollee’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:

The enrollee shall submit any additional documentation from a licensed health care professional with relevant excerpts from the enrollee’s medical record that was not already provided with regard to the adverse benefit determination to demonstrate the need for an expedited appeal.
The Department shall determine if the enrollee’s request meets the criteria for an expedited appeal.
If the Department determines that the enrollee’s request does not meet the criteria for an expedited appeal, then (i) the Department shall make reasonable efforts to give the enrollee, or the enrollee’s authorized representative, oral notice of the denial as expeditiously as possible and shall follow up with a written notice of denial and (ii) the enrollee’s appeal shall not be subject to the expedited time frame in subdivision (4) of this subsection. The denial is not appealable.
If the Department determines that the enrollee’s request meets the criteria for an expedited appeal, then (i) the mediation procedure under G.S. 108D-15(i) shall not apply to the appeal request and (ii) the decision required under G.S. 108D-16 shall be made as expeditiously as possible.

History. 2021-62, s. 2.2(i).

Editor’s Note.

Session Laws 2021-62, s. 2.2(j), made this section, as added by Session Laws 2021-62, s. 2.2(i), 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.

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

The administrative law judge assigned to conduct a contested case hearing under G.S. 108D-15 shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision that includes findings of fact and conclusions of law and send it to the parties in accordance with G.S. 150B-37. The written decision shall notify the parties of the final decision and of the right of the enrollee and the managed care entity to seek judicial review of the decision under Article 4 of Chapter 150B of the General Statutes.

History. 2013-397, s. 1; 2019-81, s. 1(a).

Editor’s Note.

This section was enacted as G.S. 108D-9. It has been renumbered as G.S. 108D-16 at the direction of the Revisor of Statutes.

Effect of Amendments.

Session Laws 2019-81, s. 1(a), substituted “managed care entity” for “LME/MCO” in the third sentence. For effective date and applicability, see Editor’s note.

§§ 108D-17 through 108D-20.

Reserved for future codification purposes.

Article 3. Managed Care Entity Provider Networks.

§ 108D-21. LME/MCO provider networks.

Each LME/MCO operating the combined 1915(b) and (c) waivers shall develop and maintain a closed network of providers to furnish mental health, intellectual or developmental disabilities, and substance abuse services to its enrollees.

History. 2019-81, s. 1(a).

Editor’s Note.

§ 108D-22. PHP provider networks.

Except as provided in G.S. 108D-23, each PHP shall develop and maintain a provider network that meets access to care requirements for its enrollees. A PHP 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, a PHP must include all providers in its geographical coverage area that are designated essential providers by the Department in accordance with subdivision (b) of this section, unless the Department approves an alternative arrangement for securing the types of services offered by the essential providers.
The Department shall designate Medicaid and NC Health Choice providers as essential providers if, within a region defined by a reasonable access standard, the provider either (i) offers services that are not available from any other provider in the region or (ii) provides a substantial share of the total units of a particular service utilized by Medicaid and NC Health Choice beneficiaries 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. The Department shall not classify physicians and other practitioners as essential providers. At a minimum, providers in the following categories shall be designated essential providers:
1. Federally qualified health centers.
2. Rural health centers.
3. Free clinics.
4. Local health departments.
5. State Veterans Homes.

History. 2019-81, s. 1(a).

Editor’s Note.

§ 108D-23. BH IDD tailored plan networks.

Entities operating BH IDD tailored plans shall develop and maintain a closed network of providers only for the provision of behavioral health, intellectual and developmental disability, and traumatic brain injury services.

History. 2019-81, s. 1(a); 2021-62, s. 4.7(b).

Editor’s Note.

Effect of Amendments.

Session Laws 2021-62, s. 4.7(b), effective June 29, 2021, substituted “maintain a closed network of providers” for “maintain closed provider networks.”

§§ 108D-24 through 108D-29.

Reserved for future codification purposes.

Article 4. Prepaid Health Plans.

§ 108D-30. Intent and Goals.

It is the intent of the General Assembly to transform the State’s current Medicaid and NC Health Choice programs to programs that provide budget predictability for the taxpayers of this State while ensuring quality care to those in need. The new Medicaid and NC Health Choice programs shall be designed to achieve the following goals:

Ensure budget predictability through shared risk and accountability.
Ensure balanced quality, patient satisfaction, and financial measures.
Ensure efficient and cost-effective administrative systems and structures.
Ensure a sustainable delivery system.

History. 2015-245, s. 1; 2019-81, s. 14(a).

Editor’s Note.

Session Laws 2015-245, s. 1 was codified as this section by Session Laws 2019-81, s. 14(a)(1), effective October 1, 2019.

In codifying the portions of S.L. 2015-245, as amended, that are specified in subsection (a) of this section, the Revisor of Statutes is authorized to do all of the following:

Replace references to DHHS with references to the Department or the Department of Health and Human Services, as appropriate.
Revise references to subdivision (3) of Section 4 of the session law to instead reference the codified location of the language in subdivision (3) of Section 5 of the session law.

Session Laws 2020-88, s. 11, as amended by Session Laws 2021-62, s. 3.6(a), provides: “For the first five years of the initial standard benefit plan prepaid health plan capitated contracts required under Article 4 of Chapter 108D of the General Statutes, the reimbursement for durable medical equipment and supplies, orthotics, and prosthetics under managed care shall be set at one hundred percent (100%) of the lesser of the supplier’s usual and customary rate or the maximum allowable Medicaid fee-for-service rates for durable medical equipment and supplies, orthotics, and prosthetics.”

Session Laws 2020-88, s. 12(a), provides: “The Department of Health and Human Services may contract with an Indian managed care entity (IMCE) or an Indian health care provider (IHCP), as defined under 42 C.F.R. § 438.14(a), to assist in the provision of health care or health care-related services to Medicaid and NC Health Choice beneficiaries who are members of federally recognized tribes or who are eligible to enroll in an IMCE. Contracts may include health care or health care-related services as agreed upon with the IMCE or IHCP, as approved by the Secretary of the Department of Health and Human Services and as allowed by the Centers for Medicare and Medicaid Services (CMS), including, but not limited to, the following services:

“(1) Primary care case management as a primary care case managed system or entity, as described in 42 C.F.R. § 438.2.

“(2) Utilization management and referrals.

“(3) The management or provision of home- and community-based services under a 1915(c) waiver.

“(4) The management or provision of specialized services covered by a behavioral health and intellectual/developmental disabilities (BH/IDD) tailored plan in accordance with G.S. 108D-60(8).

“Coverage provided by the IMCE or IHCP may be more permissive, but no more restrictive, than Medicaid or NC Health Choice medical coverage policy adopted or amended by the Department of Health and Human Services; however, the coverage shall be in compliance with federal regulations and policies related to the receipt of federal funding for these health care or health care-related services.”

Session Laws 2020-88, s. 12(d), provides: “The Department of Health and Human Services is authorized to seek approval from CMS and submit any necessary State Plan Amendments and waivers, or any amendments thereto, to implement the provisions of this section.”

§ 108D-35. Services covered by PHPs.

Capitated PHP contracts shall cover all Medicaid and NC Health Choice services, including physical health services, prescription drugs, long-term services and supports, and behavioral health services for NC Health Choice recipients, except as otherwise provided in this section. The capitated contracts required by this section shall not cover:

Medicaid services covered by the local management entities/managed care organizations (LME/MCOs) under the combined 1915(b) and (c) waivers shall not be covered under a standard benefit plan, except that all capitated PHP contracts shall cover the following services:
1. Inpatient behavioral health services.
2. Outpatient behavioral health emergency room services.
3. Outpatient behavioral health services provided by direct-enrolled providers.
4. Mobile crisis management services.
5. Facility-based crisis services for children and adolescents.
6. Professional treatment services in a facility-based crisis program.
7. Outpatient opioid treatment services.
8. Ambulatory detoxification services.
9. Nonhospital medical detoxification services.
10. Partial hospitalization.
11. Medically supervised or alcohol and drug abuse treatment center detoxification crisis stabilization.
12. Research-based intensive behavioral health treatment.
13. Diagnostic assessment services.
14. Early and Periodic Screening, Diagnosis, and Treatment services.
15. Peer support services.
16. (For contingency, see editor’s note) Behavioral health urgent care services.
Dental services.
Services provided through the Program of All-Inclusive Care for the Elderly (PACE).
Services documented in an individualized education program, as defined in G.S. 115C-106.3, or other document described in the Medicaid State Plan, and provided or billed by a local education agency, as defined in G.S. 115C-106.3.
Services documented in an individualized family service plan under the Individuals with Disabilities Education Act, 20 U.S.C. § 1436, that are provided and billed by a Children’s Developmental Services Agency or by a provider contracted with a Children’s Developmental Services Agency to provide those services.
Services for Medicaid program applicants during the period of time prior to eligibility determination.
The fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses, and ophthalmic frames.

In accordance with this subdivision, 1915(b)(3) services shall not be covered under a standard benefit plan.

History. 2015-245, s. 4; 2016-121, s. 2(b); 2017-57, s. 11H.17(a); 2017-186, s. 4; 2018-48, s. 1; 2019-81, ss. 12, 14(a); 2021-62, ss. 3.2, 4.9(a); 2021-180, s. 9F.11(c).

Contingent Effective Date.

Session Laws 2021-180, s. 9F.11 made the addition of sub-subdivision (1)o. by Session Laws 2021-180, s. 9F.11(c) contingent upon certain requirements being met. For details on those contingencies, see the note under the heading “Behaviorial Health Urgent Care Pilot Program.”