FILED SENATE
Feb 23, 2023
GENERAL ASSEMBLY OF NORTH CAROLINA
S.B. 156
SESSION 2023 PRINCIPAL CLERK
S D
SENATE BILL DRS35065-MR-27
Short Title: Medicaid Children & Families Specialty Plan. (Public)
Sponsors: Senators Krawiec, Burgin, and Corbin (Primary Sponsors).
Referred to:
1 A BILL TO BE ENTITLED
2 AN ACT AUTHORIZING THE CHILDREN AND FAMILIES SPECIALTY PLAN AS AN
3 ADDITIONAL MEDICAID MANAGED CARE PLAN AND MAKING OTHER
4 CHANGES TO RELATED STATUTES GOVERNING MEDICAID MANAGED CARE.
5 The General Assembly of North Carolina enacts:
6 SECTION 1.(a) The Department of Health and Human Services (DHHS) shall issue
7 an initial request for proposals (RFP) to procure a single statewide children and families (CAF)
8 specialty plan contract with services to begin no later than December 1, 2024. The RFP shall be
9 subject to the requirements in G.S. 108D-62, as enacted by Section 10 of this act. DHHS shall
10 define the services available under the CAF specialty plan and the Medicaid and NC Health
11 Choice beneficiaries who are eligible to enroll in the CAF specialty plan, except as otherwise
12 specified in this act or in law. For the purposes of this section, the CAF specialty plan shall be as
13 defined under G.S. 108D-1, as amended by Section 2 of this act.
14 SECTION 1.(b) DHHS shall request approval from the Centers for Medicare and
15 Medicaid Services (CMS) to require that a child who is automatically enrolled in the children
16 and families specialty plan under G.S. 108D-62(f) may not elect to enroll instead in a standard
17 benefit plan or a behavioral health and intellectual/developmental disabilities tailored plan unless
18 doing so is in the best interest of the child, as determined by the county department of social
19 services after consultation with the entity operating a CAF specialty plan.
20 SECTION 2. G.S. 108D-1 reads as rewritten:
21 "§ 108D-1. Definitions.
22 The following definitions apply in this Chapter:
23 …
24 (4) Behavioral health and intellectual/developmental disabilities tailored plan or
25 BH IDD tailored plan. – A capitated prepaid health plan contract under the
26 Medicaid transformation demonstration waiver that meets all of the
27 requirements of Article 4 of this Chapter, including the requirements
28 pertaining to BH IDD tailored plans.plans, but excluding the requirements
29 pertaining only to the CAF specialty plan.
30 …
31 (5a) Children and families specialty plan or CAF specialty plan. – A statewide
32 capitated prepaid health plan contract under the Medicaid transformation
33 demonstration waiver that meets all of the requirements of Article 4 of this
34 Chapter, including the requirements pertaining to the CAF specialty plan, but
35 excluding the requirements only pertaining to BH IDD tailored plans.
36 …
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 General Assembly Of North Carolina Session 2023
1 (30) Prepaid health plan or PHP. – A prepaid health plan, as defined in
2 G.S. 58-93-5, that is under a capitated contract with the Department for the
3 delivery of Medicaid and NC Health Choice services, or a local management
4 entity/managed care organization that is under a capitated PHP contract with
5 the Department to operate a BH IDD tailored plan.Department.
6 …
7 (36) Standard benefit plan. – A capitated prepaid health plan contract under the
8 Medicaid transformation demonstration waiver that meets all of the
9 requirements of Article 4 of this Chapter except for the requirements
10 pertaining only to a BH IDD tailored plan.plan and only to the CAF specialty
11 plan."
12 SECTION 3. G.S. 108D-5.3 reads as rewritten:
13 "§ 108D-5.3. Enrollee requests for disenrollment.
14 …
15 (b) Without Cause Enrollee Requests for Disenrollment. – An enrollee shall be allowed
16 to disenroll request disenrollment from the PHP without cause only during the times specified in
17 42 C.F.R. § 438.56(c)(2), except that enrollees who are in any of the following groups may
18 request to disenroll at any time:
19 (1) Beneficiaries who meet the definition of Indian under 42 C.F.R. § 438.14(a).
20 (2) Beneficiaries who are enrolled in the foster care system.described in
21 G.S. 108D-40(a)(14).
22 (3) Beneficiaries who are in the former foster care Medicaid eligibility category.
23 (4) Beneficiaries who receive Title IV-E adoption assistance.
24 (5) Beneficiaries who are receiving long-term services and supports in
25 institutional or community-based settings.
26 (6) Any other beneficiaries who are not required to enroll in a PHP under
27 G.S. 108D-40.
28 (7) Beneficiaries who are described in G.S. 108D-40(a)(12).
29 …."
30 SECTION 4. G.S. 108D-22 reads as rewritten:
31 "§ 108D-22. PHP provider networks.
32 (a) Except as provided in G.S. 108D-23, G.S. 108D-23 and G.S. 108D-24, each PHP
33 shall develop and maintain a provider network that meets access to care requirements for its
34 enrollees. A PHP may not exclude providers from their networks except for failure to meet
35 objective quality standards or refusal to accept network rates. Notwithstanding the previous
36 sentence, a PHP must include all providers in its geographical coverage area that are designated
37 essential providers by the Department in accordance with subdivision (b) of this section, unless
38 the Department approves an alternative arrangement for securing the types of services offered by
39 the essential providers.
40 …."
41 SECTION 5. Article 3 of Chapter 108D of the General Statutes is amended by
42 adding a new section to read:
43 "§ 108D-24. Children and families specialty plan networks.
44 The entity operating the children and families specialty plan shall develop and maintain a
45 closed network of providers only for the provision of the following services:
46 (1) Intensive in-home services.
47 (2) Multisystemic therapy.
48 (3) Residential treatment services.
49 (4) Services provided in private residential treatment facilities.
50 A closed network is the network of providers that have contracted with the entity operating
51 the CAF specialty plan to furnish these services to enrollees."
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1 SECTION 6. G.S. 108D-35(b) reads as rewritten:
2 "(b) The capitated contracts required by this section shall not cover any of the following:
3 (1) Medicaid services covered by the local management entities/managed care
4 organizations (LME/MCOs) under the combined 1915(b) and (c) waivers
5 waivers or an approved 1915(i) waiver shall not be covered under a standard
6 benefit plan, except that all capitated PHP contracts shall cover the following
7 services:
8 a. Inpatient behavioral health services.
9 b. Outpatient behavioral health emergency room services.
10 c. Outpatient behavioral health services provided by direct-enrolled
11 providers.
12 d. Mobile crisis management services.
13 e. Facility-based crisis services for children and adolescents.
14 f. Professional treatment services in a facility-based crisis program.
15 g. Outpatient opioid treatment services.
16 h. Ambulatory detoxification services.
17 i. Nonhospital medical detoxification services.
18 j. Partial hospitalization.
19 k. Medically supervised or alcohol and drug abuse treatment center
20 detoxification crisis stabilization.
21 l. Research-based intensive behavioral health treatment.
22 m. Diagnostic assessment services.
23 n. Early and Periodic Screening, Diagnosis, and Treatment services.
24 o. Peer support services.
25 p. Behavioral health urgent care services.
26 q. Substance abuse comprehensive outpatient treatment program
27 services.
28 r. Substance abuse intensive outpatient program services.
29 s. Social settings detoxification services.
30 In accordance with this subdivision, 1915(b)(3) services shall not be covered
31 under a standard benefit plan.
32 …."
33 SECTION 7. G.S. 108D-40 reads as rewritten:
34 "§ 108D-40. Populations covered by PHPs.
35 (a) Capitated PHP contracts shall cover all Medicaid program aid categories except for
36 the following categories:
37 …
38 (12) Recipients with a serious mental illness, a serious emotional disturbance, a
39 severe substance use disorder, an intellectual/developmental disability, or who
40 have survived a traumatic brain injury and who are receiving traumatic brain
41 injury services, who are on the waiting list for the Traumatic Brain Injury
42 waiver, or whose traumatic brain injury otherwise is a knowable fact, until BH
43 IDD tailored plans become operational, at which time this population will be
44 enrolled with a BH IDD tailored plan in accordance with
45 G.S. 108D-60(a)(10). Recipients G.S. 108D-60(a)(10), except as described in
46 subdivision (14) of this subsection. Except as provided in
47 G.S. 108D-60(a)(11), recipients in this category shall have the option to
48 voluntarily enroll with a PHP, PHP operating a standard benefit plan, provided
49 that (i) a recipient electing to enroll with a PHP operating a standard benefit
50 plan would only have access to the behavioral health services covered by
51 PHPs according to G.S. 108D-35(1) standard benefit plans and would no
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1 longer have access to the behavioral health services excluded from standard
2 benefit plans under G.S. 108D-35(1) and (ii) the recipient's informed consent
3 shall be required prior to the recipient's enrollment with a PHP. PHP operating
4 a standard benefit plan. Recipients in this category shall include, at a
5 minimum, recipients who meet any of the following criteria:
6 …
7 (13) Recipients in the following categories shall not be covered by PHPs for a
8 period of time to be determined by the Department that shall not exceed five
9 years after the date that capitated PHP contracts begin:
10 …
11 c. Recipients who are (i) enrolled in the foster care system, (ii) receiving
12 Title IV-E adoption assistance, (iii) under the age of 26 and formerly
13 were in the foster care system, or (iv) under the age of 26 and formerly
14 received adoption assistance.
15 (14) Until the CAF specialty plan becomes operational, recipients who are (i)
16 children enrolled in foster care in this State, (ii) receiving adoption assistance,
17 or (iii) former foster care youth until they reach the age of 26. When the CAF
18 specialty plan becomes operational, recipients described in this subdivision
19 will be enrolled in accordance with G.S. 108D-62.
20 …."
21 SECTION 8. G.S. 108D-45 reads as rewritten:
22 "§ 108D-45. Number and nature of capitated PHP contracts.contracts for standard benefit
23 plans.
24 The number and nature of the contracts for standard benefit plans required under
25 G.S. 108D-65(3) G.S. 108D-65(6) shall be as follows:
26 …
27 (3) The limitations on the number of contracts established in this section shall not
28 apply to BH IDD tailored plans described in G.S. 108D-60.
29 …."
30 SECTION 9. G.S. 108D-60 reads as rewritten:
31 "§ 108D-60. BH IDD tailored plans.
32 (a) BH IDD tailored plans shall be defined as capitated PHP contracts that meet all
33 requirements in this Article pertaining to capitated PHP contracts, except as specifically provided
34 in this section. With regard to BH IDD tailored plans, the following shall occur:
35 …
36 (10) Recipients described in G.S. 108D-40(a)(12) shall be automatically enrolled
37 with an entity operating a BH IDD tailored plan and plan, except that
38 recipients who are also described in G.S. 108D-40(a)(14) shall be enrolled in
39 accordance with G.S. 108D-62. Except as provided in subdivision (11) of this
40 subsection, recipients described in G.S. 108D-40(a)(12) shall have the option
41 to enroll with a PHP operating a standard benefit plan, provided that a
42 recipient electing to enroll with a PHP operating a standard benefit plan would
43 only have access to the behavioral health services covered by the standard
44 benefit plans and would no longer have access to the behavioral health
45 services excluded from standard benefit plan coverage under G.S. 108D-35(1)
46 and provided that the recipient's informed consent shall be required prior to
47 the recipient's enrollment with a PHP operating a standard benefit plan.
48 (11) Recipients described in G.S. 108D-40(a)(12) shall not have the option to
49 voluntarily enroll with a PHP operating a standard benefit plan or the CAF
50 specialty plan while receiving services offered by the programs or in the
51 settings specified below:
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1 a. Recipients enrolled in the Innovations waiver.
2 b. Recipients enrolled in the Traumatic Brain Injury waiver.
3 c. Recipients residing in or receiving respite services at an intermediate
4 care facility for individuals with intellectual/developmental
5 disabilities.
6 d. Recipients enrolled in and being served under Transitions to
7 Community Living.
8 e. Recipients receiving State-funded residential services, including
9 group living, family living, supported living, and residential supports.
10 (b) The Department may contract with entities operating BH IDD tailored plans under a
11 capitated or other arrangement for the management of behavioral health, intellectual and
12 developmental disability, and traumatic brain injury services for any recipients excluded from
13 PHP coverage under G.S. 108D-40(a)(4), (5), (7), (10), (11), (12), and (13).who are not enrolled
14 in a BH IDD tailored plan or the CAF specialty plan."
15 SECTION 10. Article 4 of Chapter 108D of the General Statutes is amended by
16 adding a new section to read:
17 "§ 108D-62. Children and families specialty plan.
18 (a) The following definitions apply in this section:
19 (1) Caretaker relative. – As defined in 42 C.F.R. § 435.4.
20 (2) Child. – A person who is under the age of 18, is not married, and has not been
21 legally emancipated.
22 (3) Custodian. – As defined in G.S. 7B-101.
23 (4) Foster care. – The placement of a child who is described in
24 G.S. 108D-40(a)(14) whose custody has been awarded by court order or
25 pursuant to a voluntary placement agreement from the parent, custodian, or
26