CHAPTER 39 ‑ ADULT HEALTH
SUBCHAPTER 39A ‑ CHRONIC DISEASE
SECTION .0100 ‑ MIGRANT HEALTH
10A NCAC 39A .0101 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .0102 DEFINITIONS
The following definitions shall apply throughout this
Section:
(1) "Agriculture" means farming of the land
in all its branches including cultivation, tillage, growing, harvesting,
preparation, and processing for market or storage.
(2) "Migrant" means an individual present in
North Carolina whose principal employment is agriculture on a seasonal basis,
as opposed to year‑round employment, and who establishes a temporary
abode for seasonal employment. The term includes an individual who has been so
employed within the past 24 months and the individual's dependents.
(3) "Migrant Health Clinic" means a health
department, physician's office, or other entity that, under contract with the
North Carolina Farmworker Health Program, provides health or dental services to
migrants on a regularly scheduled basis, pursuant to the Migrant Health
Program.
(4) "Migrant Health Program" means the
program described in the rules of this Section.
(5) "Primary Care" means preventive,
diagnostic, treatment, consultant, referral, and other services rendered by
physicians, physician assistants and nurse practitioners; routine associated
laboratory services; diagnostic radiologic services; and emergency health
services.
(6) "North Carolina Farmworker Health Program"
means the program within the Office of Research, Demonstrations, and Rural
Health Development that administers the Migrant Health Program.
(7) "Migrant Health Entry Point" means an
entity designated by the North Carolina Farmworker Health Program to certify
migrants for participation in the fee-for-service component of the Migrant
Health Program. In designating Migrant Health Entry Points, the program shall
consider the following criteria: density of farmworkers in the agency's
service area; number of farmworker patients served by the agency; and the
agency's ability to offer linguistically appropriate services, night or weekend
hours, and outreach services. A list of designated Migrant Health Entry Points
can be obtained by writing to the North Carolina Farmworker Health Program,
Office of Research, Demonstrations, and Rural Health Development, 2009 Mail
Service Center, Raleigh, NC 27699-2009.
History Note: Authority G.S. 130A‑223; Sec. 329,
95 Stat 569;
Eff. January 1, 1983;
Amended Eff. June 1, 2004.
10A NCAC 39A .0103 MIGRANT HEALTH PROGRAM SERVICES
(a) The North Carolina Farmworker Health Program may
contract with local health departments, public or private agencies or providers
to provide the following health services to migrants:
(1) primary care services;
(2) dental services;
(3) outreach services;
(4) health status assessments;
(5) referrals for medical and dental care; and
(6) other services as specified in the
contract.
(b) A local health department, public or private agency or
provider interested in contracting for migrant health services may submit a
brief proposal to the North Carolina Farmworker Health Program. The proposal
shall include:
(1) a description of service area;
(2) a statement of needs to be addressed,
expressed in quantitative terms to the extent possible;
(3) a statement of specific goals and
objectives for addressing needs;
(4) an outline of methodology and activities
for achieving goals and objectives;
(5) a statement of monitoring methods to be
used in measuring outcome of activities; and
(6) a projected detailed budget.
(c) Contracts may be renewed on an annual basis based upon
determination of a continuing need for these services in the area served by the
provider and the need for services in other areas of the State and the
availability of funds.
History Note: Authority G.S. 130A‑223; Sec. 329,
Public Health Services Act, 95 Stat. 569(42 U.S.C. 254b);
Eff. January 1, 1983;
Amended Eff. June 1, 2004; September 1, 1990.
10A NCAC 39A .0104 CO-PAYMENTS
(a) Migrant Health Clinics shall adopt a schedule of
co-payments for all covered services provided to migrants. Patients shall be
charged for covered services based on that schedule. Copies of the schedule of
co-payments shall be sent to the North Carolina Farmworker Health Program and
may be inspected at or obtained from that agency. No one shall be denied
service at a sponsored Migrant Health Clinic based solely on an inability or
failure to pay.
(b) The patient co-payment for the fee-for-service
component of the Migrant Health Program shall be in accordance with 10A NCAC
45A.
History Note: Authority G.S. 130A‑223; Sec. 329,
Public Health Services Act, 95 Stat. 569(42 U.S.C. 259B); 42 C.F.R. 56.302(f);
Eff. January 1, 1983;
Amended Eff. June 1, 2004; April 1, 1995; September 1,
1990.
10A NCAC 39A .0105 FEE-FOR-SERVICE REIMBURSEMENT
The North Carolina Farmworker Health Program shall purchase
medical care for migrants on a fee‑for‑service basis in accordance
with the rules of this Section and the rules contained in 10A NCAC 45A.
History Note: Authority G.S. 130A‑223; Sec. 329,
95 Stat 569;
Eff. January 1, 1983;
Amended Eff. June 1, 2004.
10A NCAC 39A .0106 ELIGIBLE MIGRANTS
All migrants are eligible for participation in the fee‑for‑service
component of the Migrant Health Program. A farmworker's migrant status shall
be determined by a Migrant Health Entry Point and documented on a Migrant
Health Eligibility Application (form DHHS 3753) signed by the patient, a person
responsible for the patient, or the provider. There are no financial
eligibility requirements.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1983;
Amended Eff. June 1, 2004; April 1, 1999; October 1,
1990.
10A NCAC 39A .0107 ELIGIBLE PROVIDERS
Migrant and Community Health Centers funded directly from
Section 329 or 330 of the United States Public Health Service Act, Independent
National Service Corps sites, local health departments and mental health
centers are not eligible for reimbursement under the fee-for-service component
of the Migrant Health Program. All other providers licensed by the State of
North Carolina to provide covered services are eligible to participate in the
reimbursement program.
History Note: Authority G.S. 130A‑223; Sec. 329,
95 Stat 569;
Eff. January 1, 1983;
Amended Eff. June 1, 2004; April 1, 1995; January 1,
1986.
10A NCAC 39A .0108 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .0109 COVERED SERVICES
(a) The following services are covered by the Migrant
Health Program when provided to eligible migrant farmworkers:
(1) Ambulatory care services that are necessary
and essential for immediate health needs in the form of:
(A) primary care services;
(B) hospital outpatient services;
(C) basic preventive, simple restorative, and simple
surgical dental services that are specifically listed in a Dental Guide
established by the North Carolina Farmworker Health Program based upon the
following factors: the most urgent dental needs of migrant patients; the cost
of effectiveness of the procedure; and the need to maximize the benefits to
patients utilizing finite program dollars. A copy of the Dental Guide may be
obtained free of charge by writing to the North Carolina Farmworker Health
Program, Office of Research, Demonstrations, and Rural Health Development, 2009
Mail Service Center, Raleigh, NC 27699-2009;
(D) laboratory tests, diagnostic X-rays;
(E) drugs on a formulary established by the North
Carolina Farmworker Health Program based upon the following factors: the
medical needs of migrant patients, the cost effectiveness of the drugs, the
availability of generic or other less costly alternatives, and the need to
maximize the benefits to patients utilizing finite program dollars. A copy of
this formulary may be obtained free of charge by writing to the NCFHP, Office
of Research, Demonstrations, and Rural Health Development, 2009 Mail Service
Center, Raleigh, North Carolina, 27699-2009;
(F) mental health services; and
(G) medical supplies necessary for administering covered
drugs.
(2) The following services must receive
approval from the Program Director before being considered for reimbursement,
and shall be reviewed on a case-by-case basis considering the extent to which
the services are necessary and essential for the immediate health care needs of
the patient, the total cost of the plan of treatment, and the probability of
the patient completing the course of therapy:
(A) home health services;
(B) physical therapy and occupational therapy; and
(C) rental or purchase of durable medical equipment.
(b) Services not covered by the Migrant Health Program include
the following:
(1) inpatient care, custodial care, hospice
care;
(2) any elective procedure;
(3) routine physical exams, routine vision or
hearing exams;
(4) eyeglasses or hearing aids;
(5) speech therapy;
(6) chiropractic therapy;
(7) emergency room services;
(8) ground and air ambulance transportation;
and
(9) medical supplies (except those necessary
for administering covered drugs).
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1983;
Amended Eff. October 1, 1990; January 1, 1986;
Temporary Amendment Eff. July 6, 1992 for a Period of 180
Days to Expire on January 2, 1993;
Amended Eff. October 1, 2006; June 1, 2004; April 1,
1995; October 1, 1992.
10A NCAC 39A .0110 CLAIMS FOR PAYMENT
Claims for reimbursement shall be submitted in
accordance with rules found in 10A NCAC 45A.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1983;
Amended Eff. October 1, 1990.
10A NCAC 39A .0111 PAYMENT LIMITATIONS
Other payment limitations applicable to the fee-for-service
component of the Migrant Health Program are found in 10A NCAC 45A.
History Note: Authority G.S. 130A‑223; Sec. 329,
95 Stat 569;
Eff. January 1, 1983;
Amended Eff. June 1, 2004.
SECTION .0200 ‑ HOME HEALTH SERVICES
10A NCAC 39A .0201 GENERAL
10A NCAC 39A .0202 DEFINITIONS
10A NCAC 39A .0203 REIMBURSEMENT FUNDS
10A NCAC 39A .0204 PATIENT FINANCIAL ELIGIBILITY
10A NCAC 39A .0205 COVERED SERVICES
10A NCAC 39A .0206 BILLING THE PROGRAM
10A NCAC 39A .0207 RATES OF REIMBURSEMENT
10A NCAC 39A .0208 REIMBURSEMENT FUNDS: THIRD PARTY PAYORS
10A NCAC 39A .0209 MONITORING
10A NCAC 39A .0210 AUDITS
History Note: Authority G.S. 130A-5(3); 130A-223;
Eff. July 1, 1983;
Amended Eff. October 1, 1990; September 1, 1990; January 1, 1986; July 1, 1985;
Repealed Eff. July 1, 2014.
10A NCAC 39A .0211 SPECIAL PROVISION
History Note: Authority G.S. 130A-5(3); 130A-223;
Eff. August 1, 1991;
Repealed Eff. July 1, 2014.
SECTION .0300 ‑ CHRONIC RENAL DISEASE CONTROL PROGRAM
10A NCAC 39A .0301 GENERAL
(a) The chronic renal disease control program, hereinafter
referred to as the kidney program, shall assist eligible persons who require
treatment for end stage renal diseases (ESRD). The kidney program shall:
(1) Develop criteria for determining medical
and financial eligibility;
(2) Provide financial assistance for eligible
patients in obtaining essential medical and technical services, and in
obtaining pharmaceutical and incidental supplies;
(3) Assist in the development and expansion of
programs for the care and treatment of persons having ESRD, including
dialysis, renal transplantation and other medical procedures and techniques
which will have a lifesaving effect in the care and treatment of such persons;
and
(4) Develop and implement programs for the
prevention of chronic renal diseases.
(b) The chronic renal disease control program is
administered by the Health Care Section, Division of Adult Health, 1915 Mail Service Center, Raleigh, NC 27699-1915
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. September 1, 1990; January 1, 1986; July 1, 1985; July 1, 1984.
10A NCAC 39A .0302 MEDICAL ELIGIBILITY
Any person who is diagnosed as having ESRD, and who requires
dialysis or transplantation to sustain life, or who has received a transplant,
is medically eligible.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. January 1, 1986; July 1, 1984; March 31, 1980.
10A NCAC 39A .0303 FINANCIAL ELIGIBILITY
Financial eligibility shall be determined in accordance with
rules found in 15A NCAC 45A.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. July 1, 1984; July 1, 1981; March 31, 1980.
10A NCAC 39A .0304 APPLICATION PROCESS
(a) Application for assistance must include a completed
statement of financial eligibility and a completed request for authorization of
services in accordance with the attending physician's directions. Requests for
additional services shall require a completed authorization request form. All
necessary forms may be obtained from the Division of Public Health.
(b) Notification of application approval or reason for
denial shall be sent to the interested parties within 45 days of the date the
application is received by the Department. The effective date of coverage and
the date of termination shall be indicated on the approved application.
Coverage shall not precede the initiation of ESRD therapy, which shall be stated
on the authorization request.
(c) Applications must be renewed annually for the fiscal
year beginning July 1, and ending June 30.
(d) New authorizations for pharmaceutical and incidental
supply purchases shall be given an effective date of coverage corresponding to
the first day of the month in which the application is received and will expire
June 30 of the same fiscal year. Changes of patient ‑ selected pharmacy
during the course of the fiscal year require the approval of the program. The
effective date of the change will be established by the program at the time of
approval. Interested parties will be notified of the change and its effective
date.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. September 1, 1990; January 1, 1986; July 1, 1984; March 31, 1980.
10A NCAC 39A .0305 CLAIMS FOR REIMBURSEMENT
(a) Reimbursement for services provided to eligible
patients shall be based on a valid authorization on file with the Division of
Adult Health.
(b) All claims for reimbursement shall be submitted in
accordance with rules found in 10A NCAC 45A.
(c) Reimbursement shall be based on rates outlined in Rule
.0306 of this Section. The following procedures must be met when billing the
kidney program:
(1) All charges for dialysis shall be billed on
forms acceptable to the program.
(2) Vendors providing home dialysis supplies or
equipment to Medicare Method II patients shall submit claims on their own
billing statements. The following support information must accompany each
billing:
(A) photocopy of Form HCFA‑382‑u3 (5‑83)
bearing the signature of the patient who is both Medicare and kidney program‑eligible,
which shows selection of Method II;
(B) itemized list of supplies which were shipped to the
patient;
(C) individual unit and extended prices for item
quantities; and
(D) copy of the Explanation of Medicare Benefits (EOMB).
(3) Pharmacy reimbursement shall be permitted
only when a valid authorization is in effect. Only one pharmacy of the
patient's choice shall be authorized to receive reimbursement at any given time.
Claims for payment shall be submitted on DEHNR Form 3058, Pharmacy Claim.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. September 1, 1990; January 1, 1986; July 1, 1984; April 1, 1982.
10A NCAC 39A .0306 COVERED SERVICES
The kidney program shall provide financial assistance to
eligible patients for the following covered services:
(1) Center Dialysis.
(a) Chronic maintenance dialysis.
(i) For patients who have no other coverage for
this service, reimbursement is limited to one hundred dollars ($100.00), or
the Medicaid rate, whichever is lower, per treatment, not to exceed 149
treatments per year.
(ii) For patients who have other coverage for
this service, no reimbursement will be provided.
(b) Home training dialysis.
(i) For patients who have no other coverage for
this service, reimbursement is limited to one hundred twenty dollars
($120.00), or the Medicaid rate, whichever is lower, per treatment, not to
exceed 5 training treatment sessions.
(ii) For eligible patients with no other third
party coverage beyond Medicare, the program will reimburse the facilities
fifteen percent of their Medicare home training rate, not to exceed 5 training
treatment sessions.
(iii) For eligible patients who are not covered
by Medicare and do have other coverage for this service, reimbursement is
limited to the extent that full payment (including all third‑party
payments) does not exceed one hundred twenty dollars ($120.00), or the Medicaid
rate, whichever is lower, per treatment, not to exceed 5 training sessions.
(2) Home Dialysis.
(a) Medicare Method I home dialysis.
(i) For patients who have no other coverage for
this service, reimbursement is limited to one hundred dollars ($100.00), or
the Medicaid rate, whichever is lower, per treatment, not to exceed 149
treatments per year.
(ii) For patients with no other party coverage
beyond Medicare, the program will reimburse the facilities fifteen percent of
their Medicare rate per treatment, not to exceed 149 treatments per year.
(iii) For eligible patients who are not covered
by Medicare an do have other coverage for this service, reimbursement is
limited to the extent that full payment (including all third‑party
payments) does not exceed one hundred dollars ($100.00), or the Medicaid rate,
whichever is lower, per treatment, not to exceed 149 treatments per year.
(b) Medicare Method II home dialysis.
(i) Reimbursement to vendors for supplies and
equipment shall be fifteen percent of the Medicare‑approved claims not
to exceed two thousand seven hundred and fifty dollars ($2,750) during the
fiscal year.
(ii) Reimbursement to vendors is limited to
payment for services provided to Medicare‑eligible patients. Non‑Medicare
patients must be treated by their respective dialysis facilities as though
under Method I, or they will be responsible for their own financial
arrangements.
(3) Inpatient Hospital Dialysis.
(a) For patients who have no other coverage for
this service, reimbursement is limited to one hundred dollars ($100.00), or the
Medicaid rate, whichever is lower, per treatment for those patients
hospitalized due to medical complications, pre‑ or post‑transplant
dialysis, or any other medical reason.
(b) For patients who have other coverage for
this service, no reimbursement will be provided.
(4) Pharmaceuticals and Incidental Supplies.
(a) Payments shall be made to patient selected
pharmacies for legend or non‑legend drugs and incidental supplies related
to the ESRD diagnosis purchased by eligible patients upon receipt by the kidney
program of claims submitted on DEHNR Form 3058, Pharmacy Claim. Reimbursement
for legend drugs shall not exceed the Medicaid rate for those drugs.
(b) Payments made to participating pharmacies
for pharmaceuticals and incidental supplies shall not exceed three hundred
dollars ($300.00) per eligible patient per fiscal year.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. September 1, 1990; January 1, 1986; July 1, 1984; July 1, 1983.
10A NCAC 39A .0307 CONSULTATIVE SERVICES
Kidney program staff shall provide consultation to
physicians, hospital and public health department staff, and the public
concerning chronic renal diseases. Educational and training programs will be
conducted by kidney program staff for allied health professionals concerning
prevention, and methods for the care and treatment of persons suffering from
chronic renal diseases.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. March 31, 1980.
10A NCAC 39A .0308 ASSISTANCE AGREEMENTS
(a) Any participating provider, educational institution, or
other corporation may enter into agreements with the kidney program for
financial assistance. The agreements are contingent upon the availability of state
funds. Requests for payment under these agreements shall be made in accordance
with current policy and procedures of the Department.
(b) Agreements with other agencies or organizations may
include, at least, the following areas:
(1) provision of funds for assisting eligible
patients with costs incidental to center or home dialysis, or preparation for,
or care following, kidney transplant;
(2) instituting and carrying on education
programs among physicians, hospitals, public health departments, and the public
concerning chronic renal diseases and the transplantation of human organs and
tissues;
(3) dissemination of information concerning the
prevention of chronic renal diseases and the methods for the care and treatment
of persons having these diseases, and dissemination of information concerning
procurement and transplantation of human organs and tissue; and
(4) participation in and funding of scientific
studies of chronic renal diseases, and improvement of methodology in the
procurement of human organs and tissue for transplantation.
History Note: Authority G.S. 130A‑220;
Eff. February 1, 1976;
Readopted Eff. December 5, 1977;
Amended Eff. September 1, 1990; January 1, 1986; July 1, 1984; March 31, 1980.
10A NCAC 39A .0309 VENDOR REQUIREMENTS
(a) Shipping. Items within each hemo‑ or peritoneal
dialysis kit are not intended to restrict home training centers from
prescribing appropriate substitutions as medically required. However,
substitutes costing more than the quoted contract amount must be approved by
the kidney program manager before authorized payment can be made.
(b) Terms and Conditions. Vendors must maintain adequate
stock to insure against back orders. In addition, vendors must comply with the
following terms and conditions of the contract:
(1) Automatic shipment of supply order to the
patient's home with residential and inside delivery;
(2) Split billing of contracted prices to third
party payee, agreeing not to bill patient for supplies;
(3) Furnish mechanism for pick‑up and
issuance of credit to the kidney program for unopened and unused supplies in
the event of the patient's death, transplantation, return to center, or
overshipment;
(4) Provide collect or toll free telephone
service to patients on a twenty‑four hour per day basis;
(5) Provide letter to patient with each
shipment explaining procedure for reporting and/or returning damaged or missing
supplies;
(6) Contact each patient by telephone at least
monthly to discuss and eliminate any problems experienced by the patient;
(7) Provide back‑up supplies for emergencies
and deliver as necessary;
(8) Submit invoice statements to kidney program
showing balance due after payment by other third party carriers and explanation
of Medicare benefits; Include provided purchase order number on each billing;
(9) Notify kidney program of the patient's
death, transplant, or return to center.
(c) The State of North Carolina reserves the right to
require a performance bond from the successful supply bidder as provided by
law. In case of default by the contractor, the State may procure the articles
or services from other sources and hold the contractor responsible for any
excess costs occasioned thereby.
History Note: Authority G.S. 130A‑220;
Eff. March 31, 1980;
Amended Eff. September 1, 1990.
10A NCAC 39A .0310 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .0311 APPEALS PROCEDURE
Appeals concerning the interpretation and enforcement of the
rules in this Section shall be made in accordance with G.S. 150B.
History Note: Authority G.S. 130A‑220;
Eff. March 31, 1980;
Amended Eff. September 1, 1990; February 1, 1987; July 1, 1984.
SECTION .0400 - RESERVED FOR FUTURE CODIFICATION
SECTION .0500 ‑ ADULT HEALTH PROMOTION AND DISEASE
PREVENTION PROGRAM
10A NCAC 39A .0501 GENERAL
The Adult Health Promotion and Disease Prevention Program is
administered by the Health Promotion Section, Division of Public Health, 1915 Mail Service Center, Raleigh, NC 27699-1915.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985;
Amended Eff. September 1, 1990.
10A NCAC 39A .0502 DEFINITIONS
The following definitions shall apply throughout this
Section:
(1) "Health promotion and disease prevention"
means program activities intended to develop and promote community and
individual measures which help individuals to develop lifestyles that can
maintain and enhance the state of well being and to develop and promote
strategies that protect the population from the consequences of the threat of
disease, disability or death.
(2) "Intervention activity" means a specific planned
strategy designed to bring about a change of health status in an individual or
target population. Intervention activities are provided to a defined target
population and are designed to address at least one specific health risk or
problem. Intervention activities may be designed to address:
(a) hypertension,
(b) cancer,
(c) diabetes,
(d) glaucoma,
(e) arthritis,
(f) epilepsy and neurological disorders,
(g) nutrition,
(h) weight control,
(i) physical fitness,
(j) accident prevention,
(k) stress management as related to other health
care,
(l) chronic disease detection,
(m) health assessments, and
(n) health education.
(3) "Program" means the Division of Adult
Health, Adult Health Promotion and Disease Prevention Program.
(4) "Programmatic approach to health promotion and
disease prevention" means a community‑based initiative characterized
as follows:
(a) a community is a definable geographic area,
(b) a lead agency or organization within the
community is identified and liaisons are established among community agencies
to:
(i) determine the prevalence of risk factors
for populations in the community;
(ii) establish health promotion and disease
prevention objectives to address the needs of populations at risk;
(iii) develop and implement specific intervention
activities in pursuit of established objectives;
(iv) perform a periodic reassessment and
evaluation of the community‑based health promotion and disease prevention
intervention activities.
(5) "Target population" means a defined group
of persons toward which health promotion and disease prevention services and
programs will be directed as part of an intervention activity.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985;
Amended Eff. September 1, 1990.
10A NCAC 39A .0503 ROLE OF THE PROGRAM
The Adult Health Promotion and Disease Prevention Program
shall:
(1) Coordinate and administer funding contracts for
providing health promotion and disease prevention services.
(2) Update and maintain an inventory of ongoing
existing health promotion and disease prevention activities in the state.
(3) Maintain working liaisons and relationships
directed toward developing cooperative strategies with other state agencies and
institutions, voluntary health agencies, professional organizations, and other
entities which have potential for affecting health promotion and disease
prevention objectives.
(4) Develop and improve surveillance and data systems
to identify and record morbidity and mortality of chronic diseases and their
related risk factors.
(5) Provide technical and management consultation to
contractors and communities to establish, maintain and improve programmatic
approaches to health promotion and disease prevention. Such consultation may:
(a) Assist contractors and community
organizations in nurturing mutual interests and complementary efforts.
(b) Identify resources which may assist local
efforts.
(c) Provide assistance to determine the
prevalence of risks within the community or specific target population, develop
local objectives and work plans, and select health promotion and disease
prevention methods.
(6) Stimulate and provide program funds to local
entities to develop, implement, and maintain health promotion and disease
prevention activities and programs.
(7) Document efforts to stimulate intervention activity
proposals which address high risk populations and minority target populations.
(8) Monitor contractors to assure that funded
activities are adequately carried out.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985.
10A NCAC 39A .0504 PROVIDER ELIGIBILITY
(a) Any local health department is eligible to apply for
program funds to provide health promotion and disease prevention services.
(b) Non‑profit or governmental groups such as public
health, educational, and voluntary organizations may apply for program funds to
provide health promotion and disease prevention services.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985.
10A NCAC 39A .0505 APPLICATIONS FOR PROGRAM FUNDS
(a) Applications for program funds shall be accepted,
reviewed, and approved or disapproved two times each fiscal year on a schedule
established by the program.
(b) An application for program funds must include a brief
plan which describes clearly and concisely information on:
(1) Background and Need:
(A) Political subdivisions included in the project.
(B) Structure of the applicant agency.
(C) Current population demographic data.
(D) Morbidity and mortality data.
(E) Rationale for selection of specific target
populations.
(F) Facilities and resources which are or will be
available to implement the program.
(G) Interrelationship with other state assisted
programs, and other appropriate groups and agencies.
(2) Project Objectives:
(A) Identify objectives which the applicant proposes to
be included as an addendum to the contract between the program and the
contractor.
(B) The objectives, where possible, must be specific,
measurable, and realistic.
(C) The objectives must relate to outcomes which can be
described on a community level or specific target group.
(3) Intervention Activities:
(A) A list of all intervention activities to be provided
by the applicant and a description of any contractual or other arrangements
entered into or planned for the provision of intervention activities.
(B) Client eligibility criteria, if any is planned.
(C) The schedule of fees or payments and schedule of
discounts for services provided by the applicant, if any is planned.
(D) Proposed protocols for intervention activity
services, if applicable. Such protocols shall include, at a minimum:
(i) identification and recruitment of target
populations;
(ii) screening;
(iii) diagnosis;
(iv) treatment;
(v) referral.
(4) Quality Assurance. The applicant must set
forth a plan to periodically monitor and evaluate the implementation and
effectiveness of applied methodologies. The plan must describe:
(A) Organizational arrangements, including a focus of
responsibility, to support the quality assurance program and the provision of
high quality health promotion and disease prevention services.
(B) Periodic assessment of the appropriateness and the
quality of services provided to persons and to the community served by the
applicant. Such assessments shall:
(i) Be conducted by qualified health professionals
or under the supervision of such professionals.
(ii) Be based on a systematic collection and
evaluation of client records and administrative and management information and
recordkeeping.
(iii) Identify and document needed changes in the
provision of services and shall identify steps for implementing programmatic
change, where indicated.
(5) Budget:
(A) Itemized budget.
(B) Allocation of shared personnel costs.
(C) Narrative description and justification of all
budget items.
(c) The program may provide program funds for health
promotion and disease prevention services which best promote the purposes of
the program. In making the determination of which applications to approve for
funding, each proposal will be judged on its own merits in competition with all
the other proposals submitted to the program. The application will have the
best opportunity of success if the need for the activity has been carefully
assessed and if the activity can be successfully completed in a reasonable
period of time. Proposals will be judged according to the following criteria:
(1) Are the program objectives specific,
measurable, and realistic?
(2) Do proposed activities follow a logical
pattern to achieve the stated program objectives?
(3) Are the program objectives and intervention
strategies based upon well‑defined problems derived from baseline data
and other available information?
(4) Does the request for program funds provide
a clear understanding of whom the program will serve and who is responsible for
various activities?
(5) Is there conformity and linkage with the
program and other appropriate voluntary organizations, professional societies,
etc. and are there plans to effectively utilize their resources?
(6) Will achievement of the program objectives
result in new knowledge, techniques, and services that can be utilized by the
state and community programs?
(7) Is the quality assurance plan adequate to
monitor and control program outcomes, impacts, and processes?
(8) Other pertinent factors.
(d) Final decisions shall be made and communicated to
applicants within 45 days of the deadline established for submission of
applications for program funds.
(e) A contract shall be signed with each applicant who is
approved for funding. The number and type of services to be provided under the
contract will be negotiated annually with each contractor, approved by the
program, and included as an addendum to the contract. Contracts may be renewed
upon expiration of the contract period upon determination of a continuing need
for services in the area served, contractor performance, and the availability
of funds. Continuation applications must include completed performance reports
as required by the program.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985;
Amended Eff. September 1, 1990.
10A NCAC 39A .0506 MONITORING AND REPORTING PROGRAM
PERFORMANCE
(a) The program shall develop, implement, and maintain
monitoring and reporting program performance procedures designed to place
reliance on contractors to plan, manage, and control the day‑to‑day
operations of funded activities.
(b) Contractors shall monitor the quality and performance
of all funded activities. Contractors shall establish, implement, and maintain
a quality assurance program and review each activity, function, and service to
assure that adequate progress is being made towards achieving negotiated
project objectives.
(c) Applications for continuing support shall include a
performance report which covers a reporting period designated by the program.
The content of the performance report shall conform to instructions issued by
the program including a brief presentation of the following for each activity,
service, or negotiated objective:
(1) A comparison of actual accomplishments to
the negotiated objectives established for the period. Where the output of the
project or program can be readily expressed in numbers, a computation of cost
per unit of output may be required if that information will be useful.
(2) The reasons and justification for the
difference between actual accomplishments and negotiated objectives if such
objectives were not met.
(3) Other pertinent information including, when
appropriate, analysis and explanation of unexpectedly high overall or unit
costs.
(d) The program may conduct site visits as necessary to:
(1) Review contractor program accomplishments
and management, administrative, and fiscal control systems.
(2) Provide such technical assistance and
consultation as may be required.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985;
Amended Eff. September 1, 1990.
10A NCAC 39A .0507 USE OF PROGRAM FUNDS
(a) Program funds provided pursuant to these Rules shall be
expended solely for the purposes for which the funds were made available in
accordance with the approved application, negotiated project objectives and budget,
the rules in this Section, the terms and conditions of the award, and the
applicable state costs principles.
(b) A contractor that consistently fails to meet acceptable
levels of performance as determined through site visits, review of performance
reports, data submitted by the contractor, and other appropriate and generally
accepted performance standards and has been offered program consultation and
technical assistance, may have program funds reduced or discontinued.
Recommendations to reduce or discontinue funding must be reviewed and approved
by the State Health Director.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985;
Amended Eff. September 1, 1990.
10A NCAC 39A .0508 CLIENT AND THIRD PARTY FEES
(a) A contractor may impose fees for funded adult health
promotion and disease prevention services. Such fees shall:
(1) Be applied according to a plan approved by
the local board of health and board of county commissioners or governing body
as appropriate.
(2) Not be imposed on persons unable to pay for
services.
(3) Be adjusted to reflect the income,
resources, and family size of the person receiving the services.
(b) The contractor must make reasonable effort to collect
fees from the client or third party payors. Fees charged and collected must be
reported to the program and may be expended only with the prior written
approval of the program and used only to reduce the program portion of the
contract amount or to expand services according to an approved plan.
History Note: Authority G.S. 130A‑223;
Eff. January 1, 1985.
SECTION .0600 ‑ MEDICATION ASSISTANCE PROGRAM FOR THE
DISABLED
10A NCAC 39A .0601 GENERAL
(a) The purpose of the Medication Assistance Program for
the Disabled (MAPD) is to provide financial assistance to help defray the cost
of prescribed medications for persons removed from the Social Security
Disability Program between the dates of March 1, 1981 and September 30, 1983.
(b) The MAPD is administered by the Division of Public
Health, 1915 Mail Service Center, Raleigh, NC 27699-1915
History Note: Authority: S.L. 1985, c. 791, s. 19(a);
Temporary Rule Eff. October 29, 1985 for a Period of 120 Days to Expire on February 26, 1986;
Eff. February 26, 1986;
Amended Eff. September 1, 1990.
10A NCAC 39A .0602 CLIENT ELIGIBILITY
(a) To be eligible for financial assistance from the MAPD,
a person shall:
(1) Have been terminated from the Social
Security Disability Program between March 1, 1981 and September 30, 1983;
(2) Be a resident of North Carolina;
(3) Not have an average gross monthly income in
excess of nine hundred and seventeen dollars ($917.00);
(4) Not be receiving Medicaid (Title XIX)
benefits;
(5) Not be receiving Social Security Disability
payments;
(6) Have a current requirement for prescribed
medications; and
(7) Complete, sign, and file a declaration of
eligibility, which includes an estimate of monthly medication costs, on a form
provided by the program.
(b) If a change occurs in the client's self‑declared
eligibility status, the client shall report the change to the program
immediately.
History Note: Authority: S.L. 1985, c. 791, s. 19(a);
Temporary Rule Eff. October 29, 1985 for a Period of 120 Days to Expire on February 26, 1986;
Eff. February 26, 1986;
Temporary Amendment Eff. October 21, 1987, for a Period of 180 Days to Expire on April 17, 1988;
Amended Eff. May 1, 1988.
10A NCAC 39A .0603 FINANCIAL ASSISTANCE PAYMENTS
(a) Financial assistance payments will be made on a
quarterly basis to clients eligible for benefits at any time during the
quarter, subject to the availability of funds.
(b) In the absence of a physician's verification of the
medication prescribed, the program will pay a benefit of no more than one
hundred dollars ($100.00) per month to eligible persons. In order to receive a
benefit of more than one hundred dollars ($100.00) per month, a physician's
verification must be provided to the program.
History Note: Authority: S.L. 1985, c. 791, s. 19(a);
Temporary Rule Eff. October 29, 1985 for a Period of 120 Days to Expire on February 26, 1986;
Eff. February 26, 1986;
Temporary Amendment Eff. October 21, 1987, for a Period of 180 Days to Expire on April 17, 1988;
Amended Eff. May 1, 1988.
SECTION .0700 ‑ HEALTH CARE SERVICES IN THE HOME
DEMONSTRATIONPROGRAM
10A NCAC 39A .0701 GENERAL
The Demonstration Program is administered by the Division of
Public Health, 1915 Mail Service Center, Raleigh, NC 27699-1915.
History Note: Authority G.S. 130A‑223;
Temporary Rule Eff. March 20, 1989 for a Period of 180 Days to Expire on September 16, 1989;
Eff. August 1, 1989;
Amended Eff. September 1, 1990.
10A NCAC 39A .0702 DEFINITIONS
The following definitions shall apply throughout this
Section:
(1) "In Home Health Care Services" are
skilled nursing, home health aide, therapy, medical social services, ancillary
medical supplies, durable medical equipment, home mobility aids, telephone
alert, physician services, nurse practitioner services, psychologists'
services, nutritionists' services, respiratory therapy services, personal care
services, self‑care education services for persons with diabetes or
hypertension, and case management; these services are provided at the patient's
place of residence as a part of an agency approved plan of care.
(2) "Home Health Agency" is a public, private
non‑profit or private proprietary home health agency certified by
Medicaid and Medicare.
(3) "Demonstration Program" means the Health
Care Services in the Home Demonstration Program.
(4) "Skilled Nursing Services" are skilled
nursing services as defined in Home Health Medicaid Manual (HHMM) Section
5202.1 which is adopted by reference in accordance with G.S. 150B‑14(c).
Copies of the HHMM may be inspected at or obtained from the Demonstration
Program Office.
(5) "Home Health Aides Services" are home
health aide services as defined in HHMM Section 5202.2.
(6) "Personal Care Services" are personal
care services as defined in the Medicaid Provider Manual, which is adopted by
reference in accordance with G.S. 150B‑14(c), copies of which may be
inspected at or obtained from the Demonstration Program Office.
(7) "Therapy Services" are therapy services
defined in HHMM Section 5202.3.
(8) "Medical Social Services" are medical
social services as defined in HCFA‑Pub. 11 Section 206.1, which is
adopted by reference in accordance with G.S. 150B‑14(c). Copies of which
may be inspected at or obtained from the Demonstration Program Office.
(9) "Durable Medical Equipment (DME)" is
durable medical equipment as defined in HHMM Section 5202.5 which is adopted by
reference in accordance with G.S. 150B‑14(c). Copies may be inspected at
or obtained from the Demonstration Program Office.
(10) "Medical Supplies" are medical supplies as
defined in HHMM Section 5202.4 which is adopted by reference in accordance with
G.S. 150B‑14(c), copies of which may be inspected at or obtained from the
Demonstration Program Office.
(11) "Assessment Evaluations" are evaluations
that identify individuals who are likely to be at risk of institutionalization
or prolonged or frequent recurring hospitalization and are likely to need but
are unable to afford skilled medical or related health services in order to
avoid institutionalization. Assessment evaluations are divided into two parts:
(a) The pre‑assessment screening to
establish presumptive eligibility for the assessment; and
(b) The comprehensive assessment to:
(i) determine the degree of risk for
institutionalization or hospitalization if the individual does not receive or
continue to receive skilled medical, health and related services in the home;
and
(ii) conduct comprehensive in‑home health,
social, and environmental assessments to determine those who need skilled
medical or related health services, those who need both, those who need other
in‑home services, those who have no need, and those whose needs cannot be
met in the home.
(12) "Case Management" is the use of multiple
and varied services including social, rehabilitative, skilled medical and
related health services that are located, coordinated and monitored to meet the
needs of eligible clients. Case management may only be provided in conjunction
with at least one additional in home health care service.
(13) "Home Mobility Aids" are the provision of
minor renovations or minor physical adaptations to the client's home when these
adaptations are considered necessary to enable clients to remain in the home.
(14) "Telephone Alert" is a system that uses
telephone lines to alert a central monitoring facility that there is a medical
emergency in the household.
(15) "Physician Services" are services provided
by a person licensed to practice medicine as required by North Carolina
statute.
(16) "Physicians Assistant Services" are
services provided by an individual authorized to perform medical acts under the
supervision of a physician pursuant to G.S. 90‑18.1.
(17) "Nurse Practitioners Services" are
services provided by a Registered Nurse who has met the requirements of the
regulations adopted by the Board of Medical Examiners and the Board of Nursing
pursuant to G.S. 90‑18.2.
(18) "Psychologists Services" are services
provided by a person licensed to perform psychological analysis, therapy or
research.
(19) "Nutritionists Services" are services
provided by a registered dietician.
(20) "Respiratory Therapy Services" are
services for the treatment of disease by using breathing devices to restore
maximum bodily function and preventing disability following disease. These
services must be provided by a registered, certified respiratory therapist.
(21) "Self‑care Education Services" are
those services that provide self‑care skill development to enable
patients diagnosed with chronic conditions to integrate such skills into their
daily lives. Self care skills include, but are not limited to compliance with
medication regimen; ability to administer the medication correctly; ability to
follow meal plans and portion exchanges; ability to perform tests, including
the ability to monitor blood glucose and blood pressure; and the ability to use
exercise as a therapeutic modality.
(22) "Demonstration Program Reimbursement Rate"
is the:
(a) agency rate or the maximum Medicaid rate,
whichever is lower, for nursing services, home health aide services and therapy
services, and home mobility aides and telephone alert systems;
(b) interim Medicare rate for medical social
services, durable medical equipment and ancillary medical supplies; and
(c) schedule of payments that shall be developed
by the Division of Adult Health for assessment evaluation services, self‑care
education services, nutrition services, case management services, physicians
services, physician assistant services, family nurse practitioner services,
psychologist services and other covered services for which neither Medicaid nor
Medicare has an established reimbursement rate.
(23) "Third Party Payor" is any person or
entity that is or may be indirectly liable for the cost of service furnished to
a patient. Third party payors include, without limitation, Medicaid, Medicare,
private insurance, Veterans Administration, Children's Special Health Services
and Workers' Compensation.
History Note: Authority G.S. 130A‑223;
Temporary Rule Eff. March 20, 1989 for a Period of 180 Days to Expire on September 16, 1989;
Eff. August 1, 1989;
Amended Eff. August 1, 1991; February 1, 1990.
10A NCAC 39A .0703 ELIGIBLE PROVIDERS
The Demonstration Program may contract with local health
departments, public and private certified home health agencies, and any other
public or private organization, institution, and agency in order to carry out
the Demonstration Program. Only home health agencies participating in the home
health services program under 10A NCAC 39A .0200 shall be eligible to contract
for Demonstration Program reimbursement funds.
History Note: Authority G.S. 130A‑223;
Temporary Rule Eff. March 20, 1989 for a Period of 180 Days to Expire on September 16, 1989;
Eff. August 1, 1989.
10A NCAC 39A .0704 FINANCIAL ELIGIBILITY
(a) Demonstration Program reimbursement funds shall be used
to pay for in home health care services and assessment evaluations provided to
financially eligible patients. Financial eligibility shall be determined by
the home health agency by a signed declaration of gross income and family size
by the patient or a person responsible for the patient. A patient whose gross
family income is 125 percent or less of Federal Poverty Guidelines shall be
financially eligible for full coverage under the program. A patient whose
gross family income is between 125 percent and 200 percent of Federal Poverty
Guidelines shall be eligible for partial coverage as defined in Rule .0706 of
this Section under the program. A patient whose gross family income is 200
percent or more of Federal Poverty Guidelines is not eligible for coverage
under the program. The Federal Poverty Guidelines are adopted by reference in
accordance with G.S. 150B‑14(c). Copies of the Federal Poverty Guidelines
may be inspected at or obtained from the Demonstration Program.
(b) Once a patient is determined to be financially
eligible, that eligibility shall continue for the duration of the plan of care
for the patient, up to a maximum of one year.
(c) The home health agency shall document each financial
eligibility determination on a form provided by the Demonstration Program.
(d) The home health agency is authorized to require
substantiating documentation when making financial eligibility determinations.
History Note: Authority G.S. 130A‑223;
Temporary Rule Eff. March 20, 1989 for a Period of 180 Days to Expire on September 16, 1989;
Eff. August 1, 1989;
Amended Eff. September 1, 1990.
10A NCAC 39A .0705 MEDICAL ELIGIBILITY
A person determined to be at risk for institutionalization
or prolonged or frequently recurring hospitalization and who is in need of in
home health care services is eligible for services under this program.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0706 BILLING THE DEMONSTRATION PROGRAM
(a) If a patient's gross family income is 125 percent or
less of Federal Poverty Guidelines, the home health agency may bill the
Demonstration Program Reimbursement Rate [Rule .0702(21)]. The agency may not
bill a patient in this income category.
(b) If a patient's gross family income is between 125
percent and 200 percent of Federal Poverty Guidelines, the home health agency
may bill the program as follows:
(1) 85 percent of the Demonstration Program
Reimbursement Rate if the patient's gross family income is between or includes
126 percent and 140 percent of Federal Poverty Guidelines;
(2) 70 percent of the Demonstration Program
Reimbursement Rate if the patient's gross family income is between or includes
141 percent and 155 percent of Federal Poverty Guidelines;
(3) 55 percent of the Demonstration Program
Reimbursement Rate if the patient's gross family income is between or includes
156 percent and 170 percent of Federal Poverty Guidelines;
(4) 40 percent of the Demonstration Program
Reimbursement Rate if the patient's gross family income is between or includes
172 percent and 185 percent of Federal Poverty Guidelines; or
(5) 25 percent of the Demonstration Program
Reimbursement Rate if the patient's gross family income is between or includes
186 percent and 199 percent of Federal Poverty Guidelines.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0707 RATES OF REIMBURSEMENT
(a) Home health agencies that contract for reimbursement
funds shall be reimbursed for in-home health services provided to eligible
patients in an amount and percentage based on the Demonstration Program Reimbursement
Rate in effect at the time service is rendered, as specified in Rule .0702(21)
of this Section.
(b) Claims for reimbursement from Demonstration Program
must be documented and reported on a quarterly basis on a form provided by the
program. No claims for reimbursement will be accepted by the Demonstration
Program more than 180 days after the date of delivery of services. If after
charging the program, the agency receives payment from the patient or other
third party that would result in the agency receiving more than the
Demonstration Program Reimbursement Rate, the agency shall reimburse the
program the difference between the total amount reimbursed from all sources and
the Demonstration Program Reimbursement Rate.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0708 REIMBURSEMENT FUNDS: THIRD PARTY PAYORS
Demonstration Program reimbursement funds shall be used to
pay for services not reimbursed by a third party payor. A contracting home
health agency must take reasonable measures to determine and subsequently
collect the full legal liability of third party payors to pay for services
reimbursed by the program before requesting payment from the Demonstration
Program.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0709 MONITORING
Each home health agency receiving reimbursement funds shall
submit the following information in a form as prescribed by and in the time
frames established in the contract:
(1) Demonstration Program quarterly report;
(2) Demonstration Program annual report;
(3) Quarterly expenditure report;
(4) Report the fairly evaluated cost of unreimbursed
care provided to patients eligible for the Demonstration Program; and
(5) Other information necessary for the effective
administration of the Demonstration Program.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0710 AUDITS
Agency financial and statistical records, patient records,
and any other pertinent information may be audited by the state as part of the
overall monitoring and evaluation effort.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223;
Eff. August 1, 1989.
10A NCAC 39A .0711 SPECIAL PROVISIONS
(a) Each home health agency contracting for reimbursement
funds must provide, by itself or from other non‑federal sources:
(1) A non‑federal contribution in cash or
in kind, fairly evaluated, including plant equipment, or in‑home services
equal to not less than twenty‑five dollars ($25.00) for each seventy‑five
dollars ($75.00) of first year Demonstration Program reimbursement funds
expended under the contract;
(2) A non‑federal contribution in cash or
in kind, fairly evaluated, including plant equipment, or in‑home services
equal to not less than thirty‑five dollars ($35.00) for each sixty‑five
dollars ($65.00) of second year Demonstration Program reimbursement funds
expended under the contract; and
(3) A non‑federal contribution in cash or
in kind, fairly evaluated, including plant equipment, or in‑home services
equal to not less than forty‑five dollars ($45.00) for each fifty‑five
dollars ($55.00) of third year Demonstration Program reimbursement funds expended
under the contract.
(b) Each home health agency contracting for reimbursement
funds shall assure that individuals 65 years of age and over shall comprise not
less than 25 percent of the individuals receiving in‑home health care
services under the contract unless the Demonstration Program contracts with a
home health agency to serve a specific target population identified in a
federal grant for the Demonstration Program.
(c) First year Demonstration Program funds in an amount not
less than 10.5 percent of the total federal financial assistance shall be made
available to support Demonstration Program activities and services for
innovative, integrated, and coordinated ways to serve migrant farm workers and
AIDS patients within their individual living environments.
History Note: Filed as a Temporary Rule Eff. March 20, 1989 For a Period of 180 Days to Expire on September 16, 1989;
Authority G.S. 130A‑223; Sec. 395, 101 STAT. 979
(42 U.S.C. 280c);
Eff. August 1, 1989;
Amended Eff. August 1, 1991.
SECTION .0800 ‑ HOME AND COMMUNITY‑BASED HIV
HEALTH SERVICES PROGRAM
10A NCAC 39A .0801 GENERAL
10A NCAC 39A .0802 DEFINITIONS
10A NCAC 39A .0803 ELIGIBLE PROVIDERS
10A NCAC 39A .0804 FINANCIAL ELIGIBILITY
10A NCAC 39A .0805 MEDICAL ELIGIBILITY
10A NCAC 39A .0806 BILLING THE HIV HEALTH SERVICES PROGRAM
10A NCAC 39A .0807 RATES OF REIMBURSEMENT
10A NCAC 39A .0808 REIMBURSEMENT FUNDS: THIRD PARTY PAYORS
10A NCAC 39A .0809 MONITORING
10A NCAC 39A .0810 AUDITS
History Note: Authority G.S. 130A-223;
Temporary Adoption Eff. January 7, 1991 for a period of 180 Days to Expire on July 6, 1991;
ARRC Objection Lodged January 18, 1991;
Eff. May 1, 1991;
Repealed Eff. July 1, 2014.
SECTION .0900 ‑ RYAN WHITE HIV CARE PROGRAM
10A NCAC 39A .0901 GENERAL
The Ryan White HIV Care Program (RWCP) is administered by
the Division of Public Health, 1915 Mail Service Center, Raleigh, NC 27699-1915.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0902 DEFINITIONS
The following definitions shall apply throughout this
Section:
(1) "Care Consortium" is an association of
one or more public, and one or more nonprofit private health care and support
services providers or community based organizations operating within areas
determined by the RWCP to be most affected by HIV disease.
(2) "Essential Health Services" means
services such as case management services; medical, nursing, and dental care;
diagnostics; monitoring; medical follow‑up services; mental health;
developmental and rehabilitation services; home health; and hospice care.
(3) "Essential Support Services" means
services such as transportation services; attendant care; homemaker services;
day or respite care; benefits advocacy; advocacy services provided through
public and nonprofit private entities; nutrition services; housing referral
services; child welfare and family services (including foster care and adoption
services); and provision of information and counseling on living with HIV
disease.
(4) "Lead Agency" means the agency,
organization, institution or other entity which will assume administrative and
fiscal responsibility for RWCP Care Consortium Funds.
(5) "RWCP Reimbursement Rate" is the:
(a) maximum Medicaid rate, if one exists, for
essential health services and essential support services other than those set
out in Paragraph (5)(b) and (c) of this Rule;
(b) interim Medicare rate for medical social
services; or
(c) schedule of payments that shall be developed
by the Division of Public Health for essential health services and essential
support services other than those set out in Paragraph (5)(a) and (b) of this
Rule.
(6) "Third Party Payor" is any person or
entity that is or may be indirectly liable for the cost of services furnished
to an eligible person. Third party payors include, without limitation,
Medicaid, Medicare, and private insurance.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0903 ELIGIBLE PROVIDERS
(a) The RWCP may contract with a care consortium or a lead
agency designated by a care consortium to provide essential health services and
essential support services for individuals with HIV disease.
(b) The RWCP may contract with public and private
organizations, institutions, agencies, and individuals in order to carry out
the RWCP.
(c) Contracts may be renewed on an annual basis upon
determination by the RWCP of a continuing need for essential health and essential
support services in the care consortium service area; the performance of the
care consortium, the need for services in other areas of the state, and the
availability of funds.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0904 APPLICATIONS FOR RWCP CARE CONSORTIUM
FUNDS
A care consortium interested in contracting for essential
health services and essential support services must submit an application to
the RWCP. The application shall include documentation that the consortium:
(1) consists of one or more public and one or more
nonprofit private health care and support service providers or community‑based
organizations which:
(a) operate within counties in North Carolina
affected by HIV;
(b) represent populations and subpopulations
reflecting the local incidence of HIV; and
(c) have a record of service to populations and
subpopulations with HIV;
(2) has consulted with the following entities in
establishing a plan for the provision of essential health and essential support
services:
(a) public health agencies that provide or
support ambulatory and outpatient HIV‑related health care services within
the geographic areas to be served;
(b) other entity or entities that directly
provide ambulatory and outpatient HIV‑related health care services within
the geographic areas to be served; and
(c) community‑based organizations that
exist solely for the purpose of providing HIV‑related support services to
individuals with HIV disease;
(3) has conducted a needs assessment of the geographic
area to be served and has developed a plan to institute a comprehensive
continuum of services to meet the identified needs;
(4) has included persons with HIV disease in the needs
assessment and planning stages of the consortium's plan;
(5) has the capacity to coordinate, integrate and
expand existing services;
(6) will develop a mechanism to ensure continuity of
services through effective case management;
(7) can provide services which are cost effective
alternatives to hospitalization;
(8) will spend at least 15 percent of its funding to
provide health and/or support services to infants, children, women and families
with HIV disease;
(9) has developed a plan for outreach to rural areas,
low income individuals and families with HIV disease, as well as to special
subpopulations at high risk for HIV infection including but not limited to,
injecting drug users and their partners, gay and bisexual men, homeless people,
and children and adolescents at risk for HIV infection;
(10) will comply with the North Carolina confidentiality
laws;
(11) has created a mechanism to evaluate on a periodic
basis the success of the consortium in responding to identified needs and the
cost effectiveness of the mechanism employed by the consortium to deliver
comprehensive care.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0905 FINANCIAL ELIGIBILITY
All persons with HIV disease are financially eligible to
receive RWCP essential health services and essential support services.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0906 MEDICAL ELIGIBILITY
A person who is determined by a health care professional to
have HIV disease and who is determined to need essential health services or
essential support services is eligible for RWCP services.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0907 BILLING THE RYAN WHITE HIV CARE PROGRAM
(a) If an eligible person's individual/family annual gross
income is 100 percent or below the official Federal Poverty Guidelines, the
care consortium may bill the RWCP the RWCP Reimbursement Rate. The care
consortium must assure that an eligible person in this income category is not
billed.
(b) If an eligible person's individual/family annual gross
income is greater than 100 percent of the Federal Poverty Guidelines, the care
consortium may bill the RWCP as follows:
(1) 85 percent of the RWCP Reimbursement Rate
if the eligible person's gross annual income is between or includes 101 percent
and 130 percent of Federal Poverty Guidelines;
(2) 70 percent of the RWCP Reimbursement Rate
if the eligible person's gross annual income is between or includes 131 percent
and 160 percent of Federal Poverty Guidelines;
(3) 55 percent of the RWCP Reimbursement Rate
if the eligible person's gross annual income is between or includes 161 percent
and 190 percent of Federal Poverty Guidelines;
(4) 40 percent of the RWCP Reimbursement Rate
if the eligible person's gross annual income is between or includes 191 percent
and 220 percent of Federal Poverty Guidelines; or
(5) 25 percent of the RWCP Reimbursement Rate if
the eligible person's gross annual income is equal to or greater than 221
percent of Federal Poverty Guidelines.
(c) An eligible person may be billed for essential health
and support services subject to the limitations as set forth in Rule .0908 of
this Section.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0908 LIMITATIONS ON FEE CHARGES
(a) Individual and aggregate fee charges to eligible
persons receiving essential health and essential support services or any other
Ryan White C.A.R.E. Act services shall conform to the following limitations:
(1) If individual/family annual gross income is
equal to or below 100 percent of the official Federal Poverty Guidelines,
there shall be no charge.
(2) If individual/family annual gross income is
equal to 101 to 200 percent of the official Federal Poverty Guidelines, then
the total allowable annual charges shall be five percent or less of the gross
income level.
(3) If individual/family annual gross income is
201 to 300 percent of the official Federal Poverty Guidelines, then the total
allowable annual charges shall be seven percent or less of the gross income
level.
(4) If individual/family annual gross income is
more than 300 percent of the official Federal Poverty Guidelines, then the
total allowable annual charges shall be 10 percent or less of the gross income
level.
(b) Once the total allowable annual charges to an
individual/family under the entire Ryan White C.A.R.E. Act meet the limitations
as set forth in this Rule, the individual/family may no longer be charged for
RWCP essential health and essential support services. The care consortium may
then bill the RWCP the full RWCP Reimbursement Rate.
(c) Individual/family annual gross income shall be
determined by the care consortium by a signed declaration of gross income and
family size by the medically eligible person or a person responsible for the
eligible person.
(d) Once a person's financial status is determined for the
purpose of assessing fee charges, the determination shall continue for the
duration of the care episode, up to a maximum of one year.
(e) The care consortium shall document each eligible
person's financial status determination on a form provided by the RWCP.
(f) The care consortium shall document individual and
aggregate annual fees charged to an eligible person on a form provided by the
program.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0909 RATES OF REIMBURSEMENT
(a) Care consortia that contract for reimbursement funds
shall be reimbursed for essential health services and essential support
services provided to eligible persons in an amount and percentage based on the
RWCP Reimbursement Rate in effect at the time service is rendered, as specified
in Rule .0902(4) of this Section.
(b) Claims for reimbursement from the RWCP must be
documented and reported on a quarterly basis on a form provided by the
program. No claims for reimbursement will be accepted by the RWCP more than
180 days after the date of delivery of services. If after charging the
program, the care consortium receives payment from the eligible person or other
third party that would result in the care consortium's receiving more than the
RWCP Reimbursement Rate, the consortium shall reimburse the RWCP the difference
between the total amount reimbursed from all sources and the RWCP Reimbursement
Rate.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0910 REIMBURSEMENT FUNDS: THIRD PARTY PAYORS
RWCP reimbursement funds shall be used to pay for services
not reimbursed by a third party payor. A contracting care consortium must take
reasonable measures to determine and subsequently collect the full legal
liability of third party payors to pay for services reimbursed by the program
before requesting payment from the RWCP.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0911 MONITORING
Each care consortium receiving reimbursement funds shall
submit the following information in a form as prescribed by and in the time
frames established in the contract:
(1) RWCP quarterly report;
(2) RWCP annual report;
(3) Quarterly expenditure report;
(4) Other information necessary for the effective
administration of RWC Program.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
10A NCAC 39A .0912 AUDITS
Agency financial and statistical records, patient records,
and any other pertinent information may be audited by the state as part of the
overall monitoring and evaluation effort.
History Note: Authority G.S. 130A‑223;
Eff. December 1, 1991.
SECTION .1000 ‑ HIV MEDICATIONS PROGRAM
10A NCAC 39A .1001 GENERAL
Persons diagnosed by a medical provider to
have HIV disease or HIV seropositivity, and who qualify financially pursuant to
15A NCAC 245 .0202, shall be eligible to have medications paid for through the
HIV Medications Program in accordance with the rules of this Section.
History Note: Authority G.S. 130A‑5(3);
Eff. October 1, 1990;
Transferred and Recodified from 15A NCAC 19A .0701 Eff. August 10, 1992;
Temporary Amendment Eff. July 1, 1995, for a period of
180 days or until the permanent rule becomes effective, whichever is sooner;
Amended Eff. January 1, 1996.
10A NCAC 39A .1002 COVERED MEDICATIONS
(a) Medications covered by the HIV Medication Program shall
be specified on a formulary established by the Program based upon the following
factors: the medical needs of persons living with HIV disease, the cost effectiveness
of the drugs, the availability of generic or other less costly alternatives,
and the need to maximize the benefits to patients using finite Program
dollars. The covered medications include: antiretroviral medications used to
treat HIV infection in accordance with FDA approved indications included in the
official product labeling and other FDA approved medications as approved by the
program, used for the prevention and treatment of the side effects of and
opportunistic infections related to a diagnosis of HIV disease, or to treat the
side effects and toxicities of the other covered medications.
(b) Other medications shall be approved by the program
based on:
(1) the expert input and recommendations
received from a panel of physicians in North Carolina working directly with the
HIV infected community, including physicians at the tertiary care centers, in
community practice, in research, and represented on the AIDS Care Advisory
Committee; and
(2) an evaluation of the availability of
adequate financial resources.
(c) A list of medications on the HIV Medications Program
formulary shall be made available upon request by the Purchase of Medical Care
Services or the Division of Public Health – AIDS Drug Assistance Program, 1902 Mail Service Center, Raleigh, NC 27699-1902. Additionally, as medications are added to the
program, announcements shall be made through the monthly newsletter distributed
by the Purchase of Medical Care Services to participating pharmacies and
through announcements mailed to HIV care consortia, tertiary care centers and
other agencies serving HIV infected individuals by the Division of Public
Health.
History Note: Authority G.S. 130A‑5(3);
Eff. January 1, 1996;
Temporary Amendment Eff. July 1, 2005;
Amended Eff. November 1, 2005.
10A NCAC 39A .1003 MEDICAL ELIGIBILITY
A person who is determined by a physician to
be infected with the human immunodeficiency virus is medically eligible.
History Note: Authority G.S. 130A‑5(3);
Eff. January 1, 1996.
10A NCAC 39A .1004 FINANCIAL ELIGIBILITY
Financial eligibility shall be determined in
accordance with 15A NCAC 45A .0200.
History Note: Authority G.S. 130A‑5(3);
Eff. January 1, 1996.
10A NCAC 39A .1005 APPLICATION PROCESS
(a) Applications for assistance must be
submitted and shall be processed in accordance with 10A NCAC 45A. All
necessary forms may be obtained from the Purchase of Medical Care Services,
Office of the Controller, Department of Health and Human Services, 1904 Mail Service Center, Raleigh, N.C. 27699-1904.
(b) Applications must be renewed at least
annually for the fiscal year beginning July 1, and ending June 30.
History Note: Authority G.S. 130A‑5(3);
Eff. January 1, 1996;
Temporary amendment Eff. July 1, 2005;
Amended Eff. April 1, 2006; January 1, 2006; October 1,
2005.
10A NCAC 39A .1006 PROGRAM OPERATIONS
Medications provided to eligible clients through this HIV
Medication Program shall be dispensed and provided by a pharmacy (or
pharmacies) under contract with the Program.
History Note: Authority G.S. 130A‑5(3);
Temporary Adoption Eff. July 1, 2005;
Eff. November 1, 2005.
SECTION .1100 - CANCER DIAGNOSTIC AND TREATMENT PROGRAM
10A NCAC 39A .1101 GENERAL
(a) The Cancer Diagnosis and Treatment
Program shall provide financial assistance for the medical care of indigent
patients as follows:
(1) diagnostic services for cancer;
and
(2) treatment services for
cancer.
(b) Rules for the Breast and Cervical Cancer
Screening and Follow-up Program are found in 10A NCAC 39A .1200.
(c) The Cancer Diagnosis and Treatment
Program shall be administered by the Division of Public Health, 1915 Mail Service Center, Raleigh, NC 27699-1915.
History Note: Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the permanent rule becomes effective,
whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1102 DEFINITIONS
The
following definitions shall apply throughout this Section:
(1) "Cervical
intraepithelial neoplasia (CIN)" means any condition suggestive of
pre-invasive cervical cancer which for the purpose of these Rules means mild, moderate,
or severe dysplasia or carcinoma in-situ.
(2) "Day
of Service" means all covered services provided in one calendar day.
(3) "Program"
means the Cancer Diagnosis and Treatment Program.
(4) "Year"
means the state fiscal year, July 1 ‑ June 30.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993;
Amended Eff. January 1, 1995.
10A NCAC 39A .1103 LIMITATIONS ON DAYS OF SERVICE
(a)
Financial assistance shall be provided for diagnostic services for up to eight
days per year per patient. The Program shall authorize the number of days for
reimbursement based on the medical condition of the patient and the procedure
to be performed.
(1) Applications
for inpatient diagnostic services shall be accompanied by a written, signed
statement from the attending physician that includes the following:
(A) the
medical reason that the inpatient services are required; and
(B) the
medical reason such services cannot be performed on an outpatient basis.
(2) The
statement in Subparagraph (a)(1) of this Rule may be in the form of a workup
protocol, clinical notes, medical history, or other medical document in lieu of
a separately prepared statement.
(3) The
statement in Subparagraph (a)(1) of this Rule shall be reviewed by the Program
which shall assess the medical need for inpatient diagnostic services.
(b)
Financial assistance shall be provided for treatment services for up to 30 days
per year per patient. The Program shall authorize the number of days for
reimbursement based on the medical condition of the patient and the procedure
to be performed.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A-220;
Eff. April 1, 1993;
Amended Eff. August 1, 1995.
10A NCAC 39A .1104 COVERED SERVICES
(a) Covered services shall include diagnostic and treatment
services for cancer or a condition suggestive of cancer. Physical therapy
following surgery, where medically indicated, is an approved treatment service.
(b) Service restrictions:
(1) Dental treatment is not covered except in
cases of head and neck cancer when necessary for the delivery of oncologic
care.
(2) The Program shall not cover late discharge
fees, transportation, telephone calls, or other miscellaneous charges.
(3) Cosmetic surgery shall not be covered.
This does not preclude the coverage of reconstructive surgery for patients for
whom the Program has paid for a treatment service related to their current
diagnosis.
(4) Ancillary diagnostic studies shall be
authorized only when they are determined by the Program to be directly related
to the confirmation of a diagnosis of cancer or are necessary for treatment
planning.
(5) The Program may authorize reimbursement for
up to two follow-up office visits after completion of diagnostic studies or
treatment. These visits shall be included within the days allowed for
diagnostic and treatment services.
(6) Treatment for patients suspected of having
cervical intraepithelial neoplasia shall be performed in accordance with the
guidelines of the American College of Obstetricians and Gynecologists (ACOG)
contained in Technical Bulletin Number 183 - August 1993, which is incorporated
herein by reference in accordance with G.S. 150B-21.6, along with any subsequent
amendments and editions. Copies of the guidelines may be obtained at no cost
by calling (919)715-3369 or by writing to the Cancer Control Program, 1915 Mail
Service Centeer, Raleigh, NC 27699-1915.
(7) The use of any course of treatment not
recognized as having scientifically established medical value nor accepted as
standard medical treatment for the condition being treated, as determined by
the Program, will not be covered.
(8) Inpatient services shall not be authorized
unless the hospital is licensed in the State of North Carolina under General
Statute 131E-5, the Hospital Licensure Act, or under conditions of
participation for Medicare (Title XVIII of the Social Security Act) or Medicaid
(Title XIX of the Social Security Act).
(c) Meals and overnight accommodations, in a motel, home,
boarding house, ambulatory care facility, or similar facility for patients
receiving covered services on an outpatient basis shall be covered by the
Program if the patient's residence is at least 50 miles from the medical
facility providing the outpatient services.
(1) Reimbursement for actual expenses shall not
exceed the maximum allowable subsistence (meals and accommodations) for state
employees in the course of their official duties, found in G.S. 138-6, based on
those rates of reimbursement in effect at the time of the authorization of
these expenses by the Program.
(2) Program authorization of meals and
accommodations shall be limited to the maximum number of days of service
coverage. However, the Program shall cover meals and accommodations for
weekends between the periods during which treatment is authorized.
(3) Authorization Requests for meals and
accommodations shall state the number of days which will be required, as well
as the dates of service on which outpatient diagnostic or treatment services
shall be rendered.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the permanent rule becomes effective,
whichever is sooner;
Authority G.S. 130A‑205;
Eff. April 1, 1993;
Amended Eff. August 1, 2000; August 1, 1995.
10A NCAC 39A .1105 FINANCIAL ELIGIBILITY
Financial eligibility for the Program shall be determined
in accordance with the rules found in 15A NCAC 45A.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A-205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1106 MEDICAL ELIGIBILITY
(a) To be medically eligible for diagnostic authorization,
a patient must have a condition strongly suspicious of cancer which requires
diagnostic services to confirm the preliminary diagnosis. The Program shall authorize
only those services determined by the program to be medically necessary to
confirm a preliminary diagnosis.
(b) Diagnostic services for suspected cervical
intraepithelial neoplasia shall be covered by the Program if there is cytologic
evidence suggestive of cervical intraepithelial neoplasia.
(c) A positive pathology report shall be required before
treatment services can be authorized by the Program.
(d) Before treatment services may be authorized, the
attending physician must certify that there is a 25 percent or better chance of
five-year survival with treatment. The Program shall use the current five-year
relative survival rates published by the National Cancer Institute's
Surveillance, Epidemiology, and End Results (SEER) Program as a guide for
evaluating requests for treatment. These rates are incorporated herein by
reference in accordance with G.S. 150B-21.6, along with any subsequent
amendments and editions. They may be used by physicians to assist with
estimating survival. Copies of the rates may be obtained at no cost by calling
(919)715-3369 or by writing to the Cancer Control Program, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915.
(e) All requests for treatment shall be reviewed by the
Program. Such requests shall be authorized when the Program determines that
there is at least a 25 percent chance of five-year survival with treatment and
that the services to be provided are medically necessary to improve the chance
of survival. In determining medical eligibility, the Program may confer with
the patient's attending physician, members of the Cancer Committee of the North
Carolina Medical Society, and other physicians trained in the treatment of
cancer.
(f) All requests for chemotherapy shall be accompanied by a
protocol describing the treatment being requested.
History Note: Filed as a Temporary Adoption Eff.
December 1, 1992 for a period of 180 days or until the permanent rule becomes
effective, whichever is sooner;
Authority G.S. 130A‑205;
Eff. April 1, 1993;
Amended Eff. August 1, 2000; August 1, 1995.
10A NCAC 39A .1107 PATIENT APPLICATION PROCESS
(a)
Authorization Request and Financial Eligibility Application forms may be
requested by the provider from the Program at the principal address of the
Division.
(b)
The Authorization Request and Financial Eligibility Applications are to be
completed in accordance with the Rules found in 15A NCAC 45A and the directions
printed on the forms.
(c)
Separate Authorization Requests are necessary for diagnosis and for treatment.
History Note: Filed as a Temporary Adoption Eff.
December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205;
Eff. April 1, 1993.
10A NCAC 39A .1108 REIMBURSEMENT PROCESS
All
claims for authorized services rendered shall be processed in accordance with
rules found in 15A NCAC454A.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1109 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1110 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1111 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1112 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1113 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1114 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1115 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1116 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1117 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1118 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1119 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1120 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1121 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1122 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1123 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1124 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1125 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1126 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1127 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1128 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1129 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1130 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1131 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1132 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1133 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1134 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1135 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1136 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1137 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1138 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1139 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1140 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1141 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1142 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1143 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1144 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1145 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1146 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1147 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1148 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1149 RESERVED FOR FUTURE CODIFICATION
10A NCAC 39A .1150 REPORTING OF CANCER
Every
physician shall report cancers as required by G.S. 130A‑209, in the
manner prescribed by 10A NCAC 46.
History Note: Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the permanent rule becomes effective,
whichever is sooner;
Authority G.S. 130A‑209;
Eff. April 1, 1993.
10A NCAC 39A .1151 CANCER REGISTRY
Rules
governing the administration of the Central Cancer Registry are found in 10A
NCAC 46.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205;
Eff. April 1, 1993.
SECTION .1200 - BREAST AND CERVICAL CANCER SCREENING AND
FOLLOW‑UP PROGRAM
10A NCAC 39A .1201 GENERAL
(a) The Breast and Cervical Cancer Screening
and Follow-up Program provides the following services to eligible women:
(1) breast cancer screening and follow-up
services; and
(2) cervical cancer screening
and follow-up services.
(b) The Breast and Cervical Cancer Screening
and Follow-up Program is administered by the Division of Public Health, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915.
(c) Rules for the Cancer Diagnostic and
Treatment Program are found in 10A NCAC 39A .1100.
History Note: Authority G.S. 130A‑205; Sec. 301
& 317, Public Health Services Act, as amended;
Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the permanent rule becomes effective, whichever is sooner;
Eff. April 1, 1993.
10A NCAC 39A .1202 DEFINITIONS
The following
definitions shall apply throughout this Section:
(1) "Breast
cancer screening services" means
(a) a
clinical breast examination and a screening mammogram in accordance with
"The American Cancer Society Guidelines for the Cancer-related Check-up:
Recommendations;"
(b) instruction
in breast self-examination;
(c) documentation
of screening test results in the patient's medical record; and
(d) notification
to the patient of the screening test results.
(2) "Cervical
cancer screening services" means
(a) a
pelvic examination and a Pap test in accordance with "The American Cancer
Society Guidelines for the Cancer-Related Check-up: Recommendations,"
(b) documentation
of the screening test results in the patient's medical record; and
(c) notification
to the patient of the screening test results.
(3) "Follow-up
for breast cancer screening services" means a repeat mammogram and, when
medically appropriate, a diagnostic mammogram.
(4) "Follow-up
for cervical cancer screening services" means a repeat Pap smear and, when
medically appropriate, a colposcopy directed biopsy.
(5) "Program"
means Breast and Cervical Cancer Screening and Follow-up Program;
"The American Cancer Society Guidelines for the
Cancer-Related Check-up: Recommendations" is hereby incorporated by
reference including any subsequent amendments and editions. This material is
available for inspection at the Division of Public Health, 1330 St. Mary's
Street, Raleigh, N.C. A copy may be obtained from the Division of Public
Health, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915.
History Note: Filed as a Temporary Adoption Eff.
December 1, 1992 for a Period of 180 Days or until the permanent rule becomes
effective, whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1203 FINANCIAL ELIGIBILITY
(a) Patients who are at, or are below 200 percent of the
Federal Poverty Guidelines in effect on July 1 of each year are financially
eligible to receive services found in 10A NCAC 39A .1201, subject to the provisions
of 10A NCAC 39A .1207. The Federal Poverty Guidelines are incorporated by
reference including subsequent amendments and editions. This material is
available for inspection at the Department of Environment, Health, and Natural
Resources, Division of Public Health, 1330 St. Mary's Street, Raleigh, North Carolina. A copy of the Federal Poverty Guidelines may be obtained at no cost from
the Division of Public Health, 1915 Mail Service Center, Raleigh, North
Carolina 27699-1915.
(b) Financial eligibility for the Program shall be
determined by participating providers from information contained in a
declaration of gross income and family size signed by the patient or a person
responsible for the patient. The participating provider is authorized to
require substantiating documentation when making financial eligibility
determination.
(c) Once a patient is determined to be financially eligible
for the Program, that eligibility shall continue for one year.
(d) The participating provider shall document each
financial eligibility determination for breast and cervical cancer screening
and follow-up services on a form provided by the Program.
History Note: Filed as a Temporary Adoption Eff.
December 1, 1992 for a Period of 180 Days or until the permanent rule becomes
effective, whichever is sooner;
Authority G.S. 130A-205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1204 MEDICAL ELIGIBILITY
(a) Women who are age 40 or older are
eligible to receive breast cancer screening and follow-up services.
(b) Women less than 40 years of age are
eligible for: clinical breast examination, in accordance with "The American
Cancer Society Guidelines for the Cancer-related Check-up:
Recommendations;" instruction in breast self-examination; and follow-up
services.
(c) Women who have been sexually active or
who are age 18 or older are medically eligible to receive cervical cancer
screening and follow-up services.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1205 PARTICIPATING PROVIDERS
The Program may contract with local health
departments, public and non-profit private entities, institutions, and agencies
in order to carry out the purpose of the Program.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205; Sec. 301 & 317 Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1206 PATIENT APPLICATION PROCESS
Patients may apply for breast and cervical
cancer screening and follow-up services at any participating local health
department or at the office of any other participating provider. A copy of the
list of participating local health departments and other providers may be
obtained from the Division of Public Health, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915at no cost.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A‑205;
Eff. April 1, 1993.
10A NCAC 39A .1207 APPLICATIONS FOR PROGRAM FUNDS
(a) Applications to contract for program
funds shall be accepted, reviewed and approved or disapproved each fiscal year
on a schedule established by the Program.
(b) An application to contract for program
funds must include information stating:
(1) Anticipated number of
persons to receive services provided by the applicant, including any services
provided through contractual or other arrangements under the proposed contract;
(2) Assurance that the applicant
will adhere to medical protocols provided by the Program for cervical and
breast cancer screening and follow-up;
(3) Assurance that the applicant
will participate in educational opportunities provided by the Program, and
other continuing education as appropriate;
(4) Assurance that the applicant
will submit minimum data elements to the Program on a quarterly basis according
to the schedule provided by the Program;
(5) Assurance that no woman at,
or below, 100 percent of the Federal Poverty Guidelines shall be charged for
services provided by this Program. Women between 100 percent and 200 percent
of the Federal Poverty Guidelines may be charged a fee according to the
following sliding scale:
Gross Family
Income As Percent Percent of Fee Patient
Federal Poverty
Guidelines May Be Charged
100% 0%
> 100% ‑
125% 20%
> 125% ‑
150% 40%
> 150% ‑
175% 60%
> 175% ‑
200% 80%
The sliding fee
scale must be posted in order for clients being served to view it; and
(6) Assurance that the contractor
will implement a patient referral and tracking protocol.
(c) A contract shall be signed with each
applicant who is approved for funding. The number of patients to be served
under the contract will be negotiated annually with each contractor, approved
by the Program, and included as an addendum to the contract. Contracts may be
renewed upon expiration of the contract period upon determination of a
continuing need for services in the area served, contractor performance, and
the availability of funds.
History Note: Filed as a Temporary Adoption Eff.
December 1, 1992 for a Period of 180 Days or until the permanent rule becomes
effective, whichever is sooner;
Authority G.S. 130A-205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1208 USE OF PROGRAM FUNDS
(a) Program funds shall be expended solely
for the purposes for which the funds were made available in accordance with the
rules of this Section, the approved application, the negotiated contract
objectives and budget, and the terms and conditions of the award.
(b) A contractor that fails to meet
acceptable levels of performance as determined through site visits, review of
performance reports, data submitted by the contractor, and other requirements
of the rules of this Section and that has been offered program consultation and
technical assistance, may have program funds reduced or discontinued.
(c) Program funds shall be used to pay only
for services not reimbursable by a third party payor. A participating provider
must take reasonable measures to determine and subsequently collect the full
legal liability of third party payors to pay for services covered by the
Program before charging expenditures to the Program.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A-205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
10A NCAC 39A .1209 QUALITY ASSURANCE
(a) Facilities
performing mammograms as a part of breast cancer screening and follow-up
services under this Section shall be certified in accordance with Rules
codified in 10 NCAC 03W .0200 - Mammography Certification. After January 1, 1993, facilities must be accredited by the American College of Radiology for
the performance of mammography. A copy of 10 NCAC 03W .0200 may be obtained
from the Division of Adult Health, 1915 Mail Service Center, Raleigh, North
Carolina 27699-1915 at no cost.
(b) Laboratories
evaluating Pap smears as a part of cervical cancer screening and follow-up
services under this Section shall be certified in accordance with rules
codified in 10 NCAC 03W .0100 - Pap Smear Certification. A copy of 10 NCAC 03W
.0100 may be obtained from the Division of Public Health, 1915 Mail Service
Center, Raleigh, North Carolina 27699-1915 at no cost.
History Note: Filed as a Temporary Adoption Eff. December 1, 1992 for a Period of 180 Days or until the
permanent rule becomes effective, whichever is sooner;
Authority G.S. 130A-205; Sec. 301 & 317, Public
Health Services Act, as amended;
Eff. April 1, 1993.
SECTION .1300 - PRESCRIPTION DRUG ASSISTANCE PROGRAM
10A ncac 39a .1301 GENERAL
The Prescription Drug Assistance Program shall provide
financial assistance for prescription drug costs to eligible and
enrolled persons over the age of 65 years and who have been diagnosed by a
physician as having cardiovascular disease or diabetes and require prescription
medication to treat one or more of these conditions.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39a .1302 DEFINITIONS
(a) "Cardiovascular disease" shall mean diagnoses
of hypertension, angina, arrhythmia, or heart failure.
(b) "Diabetes" shall mean diabetes mellitus.
(c) "Prescription drug" shall mean any drug
product required by federal or state law to include "Rx only" or
"Caution: Federal law prohibits dispensing without prescription" upon
its label prior to dispensing of the product to a patient, or any drug required
by the North Carolina Medicaid Pharmacy Program to be dispensed pursuant to a
prescription.
(d) "Outpatient prescription drug" shall mean any
drug defined in Paragraph (c) of this Rule that is dispensed by a pharmacy
which holds a valid permit issued by the North Carolina Board of Pharmacy to a
patient for use outside of a health or medical inpatient facility such as a
hospital, long-term care facility, or medical clinic.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39a .1303 FINANCIAL ELIGIBILITY
Persons who are not eligible for full Medicaid benefits, who
do not have other insurance coverage for drugs, and whose income is not more
than 150% of the federal poverty level may be enrolled in the program.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39A .1304 LIMITATIONS
Notwithstanding any other provision of the rules of this
Section, enrollment in the program is subject to the following:
(1) A waiting list of eligible persons may be
established by the program. Admission to the list and subsequent enrollment in
the Program shall be on a first-come first-served basis.
(2) Enrollment of eligible persons and reimbursement to
providers shall be subject to the availability of funds.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39a .1305 APPLICATION PROCESS
(a) Applications for enrollment shall be submitted on forms
provided by the Prescription Drug Assistance Program, North Carolina Division
of Public Health, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915.
(b) Notification of approval or denial of enrollment shall
be sent to applicants within 30 calendar days of receipt of application.
(c) Benefits shall be effective upon receipt of a program
identification card by the enrollee.
(d) All program identification cards and benefits shall
expire on June 30 of each year.
(e) In order to continue receiving benefits, enrollees
shall reapply prior to July 1 of each year on forms provided by the
Prescription Drug Assistance Program, North Carolina Division of Public Health,
1915 Mail Service Center, Raleigh, North Carolina 27699-1915, except that
persons receiving Medicaid benefits as Qualified Medicare Beneficiaries or
Specified Low-Income Medicare Beneficiaries shall not be required to reapply.
Applications for enrollment received after July 1 of each year will be
processed on a first-come first served basis subject to the availability of
funds.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39A .1306 COVERED SERVICES
The Prescription Drug Assistance Program shall provide
financial assistance for prescription drug costs on behalf of enrollees as
follows:
(1) Outpatient prescription drugs for the treatment of
hypertension, angina, arrhythmia, heart failure, and diabetes mellitus shall be
authorized and shall be supplied in quantities:
(a) not to exceed a 100 day supply; and
(b) consistent with the prescriber's
instructions for use.
(2) Each prescription order dispensed to the enrollee
shall be subject to a co-payment of six dollars ($6.00), payable by the
enrollee to the pharmacy provider, for quantities up to a 100 day supply.
(3) A prescription drug prescribed by a brand or trade
name for which one or more generically- equivalent drugs are available shall be
considered to be an order for the drug by its generic name, except when the
prescriber personally indicates in his or her own handwriting on the
prescription order, "Brand Medically Necessary" or "Dispense as
Written."
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.
10a ncac 39a .1307 REIMBURSEMENT
(a) Reimbursement for outpatient prescription drugs
dispensed to enrollees shall be made to the pharmacy provider of service at a
rate not to exceed the lesser of:
(1) the applicable North Carolina Medicaid
Pharmacy Program reimbursement rate; or
(2) the pharmacy provider's usual and customary
charge.
(b) Claims for reimbursement shall be submitted in the
manner required by the Prescription Drug Assistance Program and any person or
entity engaged in the processing of claims on behalf of the Program.
History Note: Authority S.L. 1999, c. 237, s. 11.1.(a);
Temporary Adoption Eff. February 10, 2000;
Eff. April 1, 2001.