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.
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
Payment for services in hospital emergency rooms will be limited to an assessment fee unless the assessment indicates need for further emergency room care. If an assessment indicates an emergency condition exists then the full range of Medicaid services may be covered as defined in the State Plan for Medical Assistance and approved by the Health Care Financing Administration.
History Note: Authority G.S. 108A‑25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws;
Eff. August 3, 1992.
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.
10A NCAC 22L .0202 ENROLLMENT
(a) Enrollment is voluntary in all service areas with the exception of Mecklenburg County. In Mecklenburg County, eligibles in the following program aid categories are required to join an HMO if they do not have Medicare coverage:
(1) Work First Family Assistance (WFFA);
(2) Family and Children's Medicaid without deductible (MAF);
(3) Medicaid for Infants and Children (MIC);
(4) Medicaid for Pregnant Women (MPW);
(5) Medicaid for the Blind and Disabled (MAB, MAD and MSB); and
(6) Adult Care Home Residents (SAD).
(b) Each contract shall define eligibles and service areas, according to the provisions in 42 CFR 434, Subpart C, which is hereby incorporated by reference including subsequent amendments and editions. This material is available for inspection at the Department of Health and Human Services, Division of Medical Assistance, 1985 Umstead Drive, Raleigh, North Carolina. Copies of the cited regulation may be obtained from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402 at a cost of twenty-one dollars ($21.00).
History Note: Authority G.S. 108A-25(b);
Eff. August 3, 1992;
Amended Eff. April 1, 1999.
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.