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. 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. 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. 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. 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. 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. (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 […]
108D-65. Role of the Department. 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 amendments necessary to accomplish the requirements of this Article […]
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 […]
