SUBCHAPTER 22l ‑ MANAGED CARE AND PREPAID PLANS

 

SECTION .0100 ‑ MANAGED CARE

 

10A NCAC 22l .0101       PROGRAM DEFINITION

Carolina ACCESS will contract with primary care physicians

in participating counties to deliver and coordinate the health care of certain categories

of Medicaid recipients.

 

History Note:        Authority G.S. 108A‑25(b); Section

93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992;

Pursuant to G.S. 150B-21.3A, rule is necessary without

substantive public interest Eff. August 22, 2015.

10a NCAC 22L .0102       COORDINATION FEE

In addition to normal Medicaid payments, the Division of

Medical Assistance has the authority to pay participating physicians a monthly

coordination fee for providing or coordinating the health care services of enrollees

who have selected them as their primary care physician.

 

History Note:        Authority G.S. 108A‑25(b); Section

93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22L .0103       ACCESS TO CARE

Carolina ACCESS enrollees are eligible to receive all health

care services that all Medicaid recipients are eligible for.  They receive

their services through their primary care physician who either provides or coordinates

their health care.  The Division of Medical Assistance has the authority to

deny payment for covered services that are not authorized by the primary care

physician.

 

History Note:        Authority G.S. 108A‑25(b); Section

93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22L .0104       ENROLLMENT

All Medicaid recipients in participating counties who are

eligible for Carolina ACCESS shall enroll in Carolina ACCESS.  Medicaid

recipients eligible for Carolina ACCESS include AFDC, AFDC-related, MIC, Aged,

Blind and Disabled categories, unless exempt due to institutional placement. 

Institutional placement includes nursing home, mental institutions and

domiciliary care.  Medicaid recipients who are Medicaid Pregnant Women, foster

children or who are also on Medicare, have the option to enroll in Carolina

ACCESS.

 

History Note:        Authority G.S. 108A‑25(b); Section

93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992.

 

10A NCAC 22l .0105       EMERGENCY ROOM CARE

 

History Note:        Authority G.S. 108A‑25(b); Section

93(h) of Chapter 689, 1991 North Carolina Session laws;

Eff. August 3, 1992;

Expired Eff. September 1, 2015 pursuant to G.S.

150B-21.3A.

 

SECTION .0200 ‑ PREPAID PLANS

 

10A NCAC 22L .0201       PROGRAM DEFINITION

The Division of Medical Assistance (DMA) may contract with

Federally qualified Health Maintenance Organizations (HMOs) and State licensed

and certified HMOs to provide and coordinate medical services for Medicaid

eligibles.  Prior to DMA awarding a contract to an HMO, the HMO must submit an

application in which it demonstrates its ability to meet all contract

specifications.

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without

substantive public interest Eff. August 22, 2015.

 

10A NCAC 22L .0202       ENROLLMENT

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999;

Expired Eff. September 1, 2015 pursuant to G.S.

150B-21.3A.

 

 

10A NCAC 22L .0203       ACCESS TO CARE

(a)  In-plan and out-of-plan services shall be listed in the

contract between the HMO and DMA.  The HMO shall pay for all in-plan services

when provided in accordance with the HMO's policies and procedures.  DMA shall

pay for all out-of-plan services provided in accordance with Medicaid policies

and procedures.  The Division of Medical Assistance has the authority to deny

payment for in-plan services not provided nor authorized by the HMO.

(b)  HMO members shall receive all in-plan services from

their HMO or its subcontractors except:

(1)           emergency medical services as defined in 42

U.S.C. 1932(b)(2)(B) and (C), which could not be provided by the HMO because

the time to reach the in-plan provider capable of providing such services would

have meant risk of serious damage or injury to the member's health;

(2)           Medicaid-covered family planning services

and supplies;

(3)           services provided by a public health

department for the screening, diagnosis, counseling, or treatment of sexually

transmitted diseases, tuberculosis or HIV; and

(4)           services for which the HMO has referred the

member to an out-of-plan provider.

(c)  The HMO shall make payment for in-plan services in

Paragraph (b), of this Rule, in an amount agreed upon by the provider and the

HMO.  In the absence of such an agreement, payment shall be made in the amount

of the Medicaid allowable fee.

 

History Note:        Authority G.S. 108A-25(b);

Eff. August 3, 1992;

Amended Eff. April 1, 1999.