§ 108D-21 – LME/MCO 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. (2019-81, s. 1(a).)
§ 108D-5.3 – Enrollee requests for disenrollment.
108D-5.3. 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 allowed to disenroll from the PHP without […]
§ 108D-5.5 – PHP requests for disenrollment.
108D-5.5. 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 prohibited by […]
§ 108D-1 – Definitions.
108D-1. Definitions. The following definitions apply in this Chapter: (1) 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. (2) Adverse disenrollment determination. – A determination by the Department of […]
§ 108D-2 – (Effective until contingency met see note) Scope; applicability of this Chapter.
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 […]
§ 108D-3 – Conflicts; severability.
108D-3. 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 […]
§ 108D-5.1 – (Effective until contingency met see note) General provisions.
108D-5.1. 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 or NC Health Choice programs or (ii) becomes a member of a population of beneficiaries that is not required […]