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Section .0100 ‑ Migrant Health


Published: 2015

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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.