North Carolina · statute · N.C. Gen. Stat. ch. 108D · 31 active provisions
Definitions. The following definitions apply in this Chapter: (1) Adverse benefit determination. - As defined in 42 C.F.R. § 438.400(b). (2) 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 en…
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 services delivered through the fee-for-service program. (2013-397, s. 1; 2019-81, s. 1(a);…
Conflicts; severability. (a) 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. (b) To the…
General provisions. (a) 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 program or (ii) becomes a member of a population of beneficiaries that is not required to enroll in a PH…
Enrollee requests for disenrollment. (a) 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. (b) Without Cause Enrollee Requests for Disenrollment. - An enrollee shall be a…
PHP requests for disenrollment. (a) In General. - A PHP requesting disenrollment of an enrollee from the PHP shall submit a written request for disenrollment to the enrollment broker. (b) Limitations on PHP Requests for Disenrollment. - A PHP shall not request disenrollment of an enrollee from the PHP for any reason pr…
Notices. (a) 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 disenrollme…
Appeals of adverse disenrollment determinations. (a) 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…
Managed care entity grievance and appeal procedures, generally. (a) 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…
Managed care entity grievances. (a) 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 ca…
Standard managed care entity level appeals. (a) 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 co…
Expedited managed care entity level appeals. (a) 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 enr…
Contested case hearings on disputed adverse benefit determinations. (a) 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. (b) Exclusive Admin…
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,…
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 shall fo…
LME/MCO provider networks. Until the date that BH IDD tailored plans begin operating, each LME/MCO operating the combined 1915(b) and (c) waivers or providing coverage of any services approved under the 1915(i) option shall develop and maintain a closed network of providers to provide mental health, intellectual or dev…
PHP provider networks. (a) Provider Networks. - Except as provided in G.S. 108D-23(c) and G.S. 108D-24(b), each PHP shall develop and maintain an open network of providers that meets access to care requirements for its enrollees. (b) Essential Providers. - A PHP must include all providers in its geographical coverage a…
BH IDD tailored plan provider networks. (a) Each LME/MCO shall operate provider networks with respect to its BH IDD tailored plan contract in accordance with this section and G.S. 108D-22. (b) Repealed by Session Laws 2026-1, s. 3C.12(b), effective April 30, 2026. (c) With regard to services and supports that are exclu…
Children and families specialty plan networks. (a) The entity operating the children and families specialty plan shall operate provider networks in accordance with this section and G.S. 108D-22. (b) The entity operating the children and families specialty plan shall develop a closed network, and may exclude providers f…
Other provider networks. (a) Beginning on the date that BH IDD tailored plans begin operating, each LME/MCO under contract with the Department (i) to provide coverage of services as a PIHP or (ii) to provide coverage of any services approved under the 1915(i) option shall operate a closed network in accordance with thi…
Intent and Goals. It is the intent of the General Assembly to transform the State's current Medicaid program in order to provide budget predictability for the taxpayers of this State while ensuring quality care to those in need. The new Medicaid program shall be designed to achieve the following goals: (1) Ensure budge…
Services covered by PHPs. (a) Capitated PHP contracts shall cover all Medicaid services, including physical health services, prescription drugs, long-term services and supports, and behavioral health services, except as otherwise provided in this section. (b) The capitated contracts required by this section shall not c…
(Effective until October 1, 2026) Populations covered by PHPs. (a) Capitated PHP contracts shall cover all Medicaid program aid categories except for the following categories: (1) Recipients who are enrolled in both Medicare and Medicaid for whom Medicaid coverage is limited to the coverage of Medicare premiums and cos…
Number and nature of contracts for standard benefit plans. The number and nature of the contracts for standard benefit plans required under G.S. 108D-65(6) shall be as follows: (1) Four contracts between the Division of Health Benefits and PHPs to provide coverage to Medicaid recipients statewide. (2) Up to 12 contract…
Consideration of county requests. (a) For purposes of this section, the term "applicable RFP" means any RFP for a BH IDD tailored plan for a contract term subsequent to the initial BH IDD tailored plan contract term. (b) A county may request to realign with another LME/MCO in accordance with all of the following: (1) N…