Bill Summary – FastDemocracy

FILED SENATE
                                                                                          Feb 25, 2021
                          GENERAL ASSEMBLY OF NORTH CAROLINA
                                                                 S.B. 159
                                      SESSION 2021           PRINCIPAL CLERK
     S                                                                    D
                               SENATE BILL DRS15049-MR-70
     Short Title:   State Health Plan Administrative Changes.-AB                                (Public)
     Sponsors:      Senators Krawiec, Burgin, and Perry (Primary Sponsors).
     Referred to:
                                     A BILL TO BE ENTITLED
 AN ACT TO MAKE TECHNICAL, CLARIFYING, AND ADMINISTRATIVE CHANGES
      TO LAWS RELATING TO THE STATE HEALTH PLAN FOR TEACHERS AND STATE
      EMPLOYEES.
 The General Assembly of North Carolina enacts:
              SECTION 1. G.S. 135-48.33(a) reads as rewritten:
      "(a) The Board of Trustees must approve all Plan contracts in excess of five hundred
 thousand dollars ($500,000), five million dollars ($5,000,000), including contracts with an initial
 cost of less than five hundred thousand dollars ($500,000), five million dollars ($5,000,000) but
 that may exceed five hundred thousand dollars ($500,000) five million dollars ($5,000,000)
 during the term of the contract."
              SECTION 2. G.S. 135-48.41 reads as rewritten:
 "§ 135-48.41. Additional eligibility provisions.
      …
      (b)     A dependent child shall not be eligible for coverage under the Plan if the dependent
 child is eligible for employer based health care outside of the State Health Plan for Teachers and
 State Employees, other than a parent's claim. Coverage Notwithstanding the age requirement
 under G.S. 135-48.1(9), coverage of a dependent child may be extended continued beyond the
 dependent child's 26th birthday if the dependent child is physically or mentally incapacitated to
 the extent that he or she is incapable of earning a living and (i) such handicap developed or began
 to develop before the dependent's 19th birthday, or (ii) such handicap developed or began to
 develop before the dependent's 26th birthday disabled and if the dependent was covered by the
 Plan in accordance with G.S. 135-48.40(d)(7).on the dependent child's 26th birthday.
 Verification of the dependent child's disability shall be provided to the Plan no later than 60 days
 after the dependent child's 26th birthday.
      (c)     No person shall be eligible for coverage as a dependent if eligible as an employee or
 retired employee, except when a spouse is eligible on a fully contributory basis. basis or when
 the person is a disabled dependent child. In addition, no person shall be eligible for coverage as
 a dependent of more than one employee or retired employee at the same time.
      …."
              SECTION 3.(a) G.S. 135-48.24 reads as rewritten:
 "§ 135-48.24. Administrative review.
      (a)     If, after exhaustion of internal appeal handling as outlined in the contract with the
 Claims Processor Processor, any person is aggrieved, then the Claims Processor shall bring the
 matter to the attention of the Executive Administrator and Board of Trustees, which
 Administrator. The Executive Administrator shall promptly decide whether the subject matter of
                                    *DRS15049-MR-70*
     General Assembly Of North Carolina                                                    Session 2021
 the internal appeal is a determination subject to external review under Part 4 of Article 50 of
 Chapter 58 of the General Statutes. The following shall apply to decisions made under this
 subsection:
             (1)     The Executive Administrator and Board of Trustees shall inform the
                     aggrieved person and the aggrieved person's provider of the decision and shall
                     provide the aggrieved person notice of the aggrieved person's right to appeal
                     that decision as provided in this subsection.
             (2)     If the Executive Administrator and Board of Trustees decide decides that the
                     subject matter of the raised on internal appeal is not a determination subject
                     to external review, then the Executive Administrator and Board of Trustees
                     may shall have the authority to make a binding decision on the matter in
                     accordance with procedures established by the Executive Administrator and
                     Board of Trustees. The Executive Administrator and Board of Trustees shall
                     provide a written summary of the decisions made pursuant to this section to
                     all employing units, all health benefit representatives, all relevant health care
                     providers affected by a decision, and to any other parties requesting a written
                     summary and approved by the Executive Administrator and Board of Trustees
                     to receive a summary immediately following the issuance of a decision.matter.
             (3)     A decision by If the Executive Administrator and Board of Trustees decides
                     that a the subject matter raised on internal appeal is a determination subject to
                     external review as provided in subsection (b) of this section review, as
                     provided for under subsection (b) of this section, then that decision may be
                     contested by the aggrieved person under Chapter 150B of the General
                     Statutes. The person contesting the decision may proceed with external review
                     pending a decision in the contested case under Chapter 150B of the General
                     Statutes.
     (b)     The State Treasurer, in consultation with the Board of Trustees, shall adopt and
 implement utilization review and internal grievance procedures that are substantially equivalent
 to those required under G.S. 58-50-61 and G.S. 58-50-62. External review of determinations
 shall be conducted in accordance with Part 4 of Article 50 of Chapter 58 of the General Statutes.
 As used in this section, "determination" is a decision by the State Treasurer, or the Plan's
 designated utilization review organization administrated by or under contract with the Plan that
 an admission, availability of care, continued stay, or other health care service has been reviewed
 and, based upon information provided, does not meet the Plan's benefit offerings, or requirements
 for medical necessity, appropriateness, health care setting, or level of care or care, or
 effectiveness, and the requested service is therefore denied, reduced, or terminated.
     (c)     Repealed by Session Laws 2011-398, s. 49, effective January 1, 2012, and applicable
 to contested cases commenced on or after that date."
             SECTION 3.(b) G.S. 135-48.22(3) is repealed.
             SECTION 3.(c) G.S. 150B-1(e) reads as rewritten:
     "(e) Exemptions From Contested Case Provisions. – The contested case provisions of this
 Chapter apply to all agencies and all proceedings not expressly exempted from the Chapter. The
 contested case provisions of this Chapter do not apply to the following:
             …
             (13) The State Health Plan for Teachers and State Employees with respect to
                     determinations (i) decisions by the Executive Administrator and Board of
                     Trustees, that an internal appeal is not subject to external review under
                     G.S. 135-48.24, or (ii) a determination by the Executive Administrator, the
                     Plan's designated utilization review organization, or a self-funded health
                     maintenance organization under contract with the Plan that an admission,
                     availability of care, continued stay, or other health care service has been
     Page 2                                                                          DRS15049-MR-70
     General Assembly Of North Carolina                                                    Session 2021
                    reviewed and, based upon the information provided, does not meet the Plan's
                    benefits offering, or requirements for medical necessity, appropriateness,
                    health care setting, or level of care care, or effectiveness, and the requested
                    service is therefore denied, reduced, or terminated.
              …."
              SECTION 4. G.S. 135-48.27 reads as rewritten:
 "§ 135-48.27. Reports to the General Assembly; General Assembly access to information.
     In addition to the reports required by G.S. 135-48.23(d), the The State Treasurer, the
 Executive Administrator, and Board of Trustees shall report to the General Assembly at such
 times and in such forms as shall be designated as requested, and in the manner designated, by the
 President Pro Tempore of the Senate and the Speaker of the House of Representatives.
 Employees of the Legislative Services Commission designated by the Legislative Services
 Officer (i) shall have access to all records related to the Plan of the State Treasurer, the Board of
 Trustees, the Executive Administrator, the Claims Processor, and the Plan and (ii) shall be
 entitled to attend all meetings, including executive sessions, of the Board of Trustees."
              SECTION 5. G.S. 135-48.1(14) reads as rewritten:
              "(14) Plan or State Health Plan. – The North Carolina State Health Plan for Teachers
                     and State Employees. Depending on the context, the term may refer to the
                     entity created in G.S. 153-48.2 G.S. 135-48.2 or to the health benefit plans
                     offered by the entity, in which case "Plan" includes all comprehensive health
                     benefit plans offered under the Plan."
              SECTION 6. This act is effective when it becomes law.
     DRS15049-MR-70                                                                               Page 3
Statutes affected: 
Filed: 135-48.33, 135-48.41, 135-48.24, 135-48.22, 150B-1, 135-48.27, 135-48.1
Edition 1: 135-48.33, 135-48.41, 135-48.24, 135-48.22, 150B-1, 135-48.27, 135-48.1
Edition 2: 135-48.33, 135-48.41, 135-48.24, 135-48.22, 150B-1, 135-48.27, 135-48.1
Ratified: 135-48.33, 135-48.41, 135-48.24, 135-48.22, 150B-1, 135-48.27, 135-48.1
SL 2021-125: 135-48.33, 135-48.41, 135-48.24, 135-48.22, 150B-1, 135-48.27, 135-48.1