Chapter 108D

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 mad…

(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 rights to due process a…

(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 ma…

(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 contra…

(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 enrollee…

(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 Administrative Remedy. - Notwiths…

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, maintai…

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 forward a copy of it t…

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)…

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, intell…

(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 geogra…

(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…

(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 from tha…

(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 acco…

(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 Servi…

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 g…

(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 secti…

(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 cost sharing. (2) Repealed…

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 contracts between the Divis…

(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:…

(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 requir…

(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 b…

(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 r…

(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 enroll…

(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 Administ…

The new delivery system and capitated PHP contracts shall be built on defined measures and goals for risk-adjusted health outcomes, quality of care, patient satisfaction, access, and cost. Each component shall be subject to specific accountability measures, including penalties. T…

PHPs shall be responsible for all administrative functions for recipients enrolled in their plan, including, but not limited to, claims processing, care and case management, grievances and appeals, and other necessary administrative services. (2015-245, s. 4; 2019-81, s. 14(a).)

(a) BH IDD tailored plans shall be defined as capitated PHP contracts that meet all requirements in this Article pertaining to capitated PHP contracts, except as specifically provided in this section. With regard to BH IDD tailored plans, the following shall occur: (1) In the eve…

(a) The following definitions apply in this section: (1) Caretaker relative. - As defined in 42 C.F.R. § 435.4. (2) Child. - A person who is under the age of 18, is not married, and has not been legally emancipated. (3) Custodian. - As defined in G.S. 7B-101, or a comparable trib…

(a) The role and responsibility of the Department during Medicaid transformation shall include the following activities and functions: (1) Submit to CMS a demonstration waiver application pursuant to Section 1115 of the Social Security Act and any other waivers and State Plan ame…

PHPs shall be required to implement an Advanced Medical Home care management program but shall not be required to contract with any particular entity as an Advanced Medical Home. A PHP may contract with any entity to serve as an Advanced Medical Home or may create its own Advance…