§ 108D-70 – Advanced Medical Homes.
108D-70. Advanced Medical Homes. 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 Advanced Medical Home […]
§ 108D-22 – PHP provider networks.
108D-22. PHP provider networks. (a) 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 […]
§ 108D-23 – BH IDD tailored plan networks.
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. (2019-81, s. 1(a); 2021-62, s. 4.7(b).)
§ 108D-30 – (Effective until contingency met see note) Intent and Goals.
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 […]
§ 108D-35 – (Effective until contingency met see note) Services covered by PHPs.
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: (1) Medicaid […]
§ 108D-40 – (Effective until contingency met see note) Populations covered by PHPs.
108D-40. Populations covered by PHPs. (a) Capitated PHP contracts shall cover all Medicaid and NC Health Choice 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) Qualified aliens subject to […]
§ 108D-45 – (Effective until contingency met see note) Number and nature of capitated PHP contracts.
108D-45. Number and nature of capitated PHP contracts. The number and nature of the contracts required under G.S. 108D-65(3) shall be as follows: (1) Four contracts between the Division of Health Benefits and PHPs to provide coverage to Medicaid and NC Health Choice recipients statewide. (2) Up to 12 contracts between the Division of Health […]
§ 108D-50 – Defined measures and goals.
108D-50. Defined measures and goals. 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. The Division of Health Benefits may use organizations such as National […]
§ 108D-55 – Administrative functions.
108D-55. Administrative functions. 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).)
§ 108D-60 – BH IDD tailored plans.
108D-60. BH IDD tailored plans. (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 event of the discontinuation of […]