North Carolina § 108A-54 - 1A. Amendments to Medicaid State Plan and Medicaid Waivers.

§ 108A-54. 1A. Amendments to Medicaid State Plan and Medicaid Waivers.

The Department of Health and Human Services is expressly authorized and required to take any and all necessary action to amend the State Plan and waivers in order to keep the program within the certified budget, except as provided in G.S. 108A-54(f). For purposes of this section, the term "amendments to the State Plan" includes State Plan amendments, Waivers, and Waiver amendments. , (c) Repealed by Session Laws 2015-245, s. 18, effective September 23, 2015. No fewer than 10 days prior to submitting an amendment to the State Plan to the federal government, the Department shall post the amendment on its Web site and notify the members of the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division that the amendment has been posted. For any amendments to the State Plan that add or eliminate an optional service, the notice required by this subsection shall be 90 days. This notice requirement shall not apply to draft or proposed amendments submitted to the federal government for comments but not submitted for approval. Repealed by Session Laws 2015-245, s. 18, effective September 23, 2015. Any public notice required under 42 C.F.R. 447.205 shall, in addition to any other posting requirements under federal law, be posted on the Department's Web site. Upon posting such a public notice, the Department shall notify the members of the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division that the public notice has been posted. Public notices shall remain posted on the Department's Web site. History (2013-360, s. 12H.2(a); 2014-100, s. 12H.21(a); 2015-245, s. 18.) Primary Care Case Management for Dual Eligibles. - Session Laws 2014-100, s. 12H.20(a), provides: "The Department of Health and Human Services, Division of Medical Assistance, shall draft one or more waivers that would expand primary care case management and that are designed to accomplish the following: "(1) Medicare and Medicaid dual eligibles shall be required to enroll in primary care case management to the maximum extent allowed by the Centers for Medicare and Medicaid Services (CMS). "(2) Primary care case management shall be provided for enrolled dual eligibles. "(3) Primary care case management for dual eligibles with a primary diagnosis of mental illness or intellectual or developmental disability may be administered by the LME/MCOs. "The Department may submit drafts of the waivers to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waivers for CMS approval until authorized by the General Assembly." Session Laws 2014-100, s. 12H.20(b), provides: "No later than March 1, 2015, the Department shall submit to the House Appropriations Subcommittee on Health and Human Services and the Senate Appropriations Committee on Health and Human Services a copy of the draft waivers and a report, which shall include the following: "(1) The anticipated increase in number of dual eligibles that will enroll in primary care case management. "(2) The costs associated with serving the increased number of enrolled dual eligibles. "(3) The anticipated savings to the Medicaid program." Drug Ingredient Pricing Methodology. - Session Laws 2014-100, s. 12H.8(a)-(c), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall adopt an average acquisition cost methodology for brand and generic drug ingredient pricing to be effective beginning on January 1, 2015. The drug ingredient pricing methodology shall be consistent with new federal requirements or, if the new federal requirements have not yet been finalized by October 1, 2014, consistent with the draft federal requirements. In adopting a new drug ingredient pricing methodology, the Department shall also do all of the following: "(1) Raise dispensing fees so that the average acquisition cost ingredient pricing plus the dispensing fees, net of any drug rebates, generates nine hundred seventy-five thousand dollars ($975,000) in savings in General Fund appropriations. "(2) Maintain a distinction between the dispensing fees for preferred and brand drugs. "(3) Ensure that ingredient prices are updated at least monthly. "(b) The Department of Health and Human Services, Division of Medical Assistance, shall issue a request for proposals (RFP) for a contractor to perform a statewide drug dispensing fee study to begin on March 1, 2015. The Department shall use the one hundred thousand dollars ($100,000) appropriated in this budget for this study as the State share to draw down additional federal Medicaid funds for this study. "(c) The Department of Health and Human Services, Division of Medical Assistance, shall follow the procedures in G.S. 108A-54.1 A in submitting the State plan amendment required to implement this section." Session Laws 2015-241, s. 12H.19(a), (b), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, (Department) shall adopt an average acquisition cost methodology for brand and generic drug ingredient pricing to be effective beginning on January 1, 2016. The drug ingredient pricing methodology shall be consistent with new federal requirements or, if the new federal requirements have not yet been finalized by July 1, 2015, consistent with the most recent draft federal requirements. In adopting a new drug ingredient pricing methodology, the Department shall also do all of the following: "(1) Raise the average dispensing fee to a weighted average amount that does not exceed twelve dollars and forty cents ($12.40). "(2) Set actual dispensing fees that maintain a higher dispensing fee for preferred and generic drugs and a lower dispensing fee for brand and nonpreferred drugs. "(3) Ensure that ingredient prices are updated at least monthly. "(b) In order to implement this section, the Department shall either amend the State plan amendment request submitted to the Centers for Medicare and Medicaid Services (CMS) pursuant to Section 12H.8 of S.L. 2014-100 so that it conforms with the requirements of this section or shall withdraw that State plan amendment and submit a new State plan amendment request to CMS that conforms with the requirements of this section. Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1 A(e) [repealed] but shall be submitted by January 1, 2016." Graduate Medical Education. - Session Laws 2015-241, s. 12H.23(a)-(d), as amended by Session Laws 2015-264, s. 88, provides: "(a) The Department of Health and Human Services shall submit a State Plan amendment to modify Section 4.19-A of the Medicaid State Plan, such that, effective January 1, 2016, no Medicaid provider may receive reimbursement for Graduate Medical Education (GME) in addition to their DRG Unit Value (Base) rate under the methodology as defined in the current Medicaid State Plan. "(b) The modification to the Medicaid State Plan required by subsection (a) of this section shall be implemented upon approval by the Centers for Medicare & Medicaid Services (CMS). "(c) The Department of Health and Human Services, Division of Medical Assistance, shall be exempt from the 90-day prior submission requirement in G.S. 108A-54.1 A(e) [repealed] in order to submit to CMS the State Plan amendment required to implement this section but shall submit the State Plan amendment by January 1, 2016. "(d) The Department of Health and Human Services, Division of Medical Assistance, shall submit a report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division by March 1, 2016, identifying options for alternative funding streams to replace the GME reimbursement eliminated by this section." Session Laws 2020-88, s. 9, repealed Session Laws 2015-241, s. 12H.23(a)-(d), as amended by Session Laws 2015-264, s. 88, effective July 2, 2020. Editor's Note. - Session Laws 2013-360, s. 12H.2(c), provides: "The Department of Health and Human Services shall take any and all action necessary to amend the Medicaid State Plan, Attachment 4.19-B, Section 5, Page 2, which pertains to supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical professional providers, in order to limit the definition of eligible medical professional providers to only physicians employed by the East Carolina University School of Medicine or the University of North Carolina at Chapel Hill School of Medicine as academic faculty. The supplemental payments shall be made only for services provided at these schools of medicine." Session Laws 2013-360, s. 1.1, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2013.'" Session Laws 2013-360, s. 38.2, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2013-2015 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2013-2015 fiscal biennium." Session Laws 2013-360, s. 38.5 is a severability clause. Session Laws 2013-363, s. 4.14(a), provides: "The Department of Health and Human Services shall take any and all action necessary to amend the Medicaid State Plan, Attachment 4.19-B, Section 5, Page 2, which pertains to supplemental payments that increase reimbursement to the average commercial rate for certain eligible medical professional providers, in order to limit the definition of eligible medical professional providers to only eligible medical professional providers who were receiving such supplemental payments as of May 22, 2013." Session Laws 2014-100, s. 12H.21(c), provides: "By repealing language in subsection (b) of this section related to giving to the General Assembly notice of a public notice, it is not the intent of the General Assembly to remove the required notice of the changes to reimbursement amounts for services, equipment, or supplies. Rather, it is the intent that those notices be given pursuant to G.S. 108A-54.1 A(f), rather than pursuant to both G.S. 108A-54.1 A(f) and G.S. 108A-55(c) ." Session Laws 2014-100, s. 12H.21(d), made the amendment to subsection (e) by Session Laws 2014-100, s. 12H.21(a), applicable to State Plan Amendments with effective dates on or after December 1, 2014. Session Laws 2014-100, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2014.'" Session Laws 2014-100, s. 38.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2014-2015 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2014-2015 fiscal year." Session Laws 2014-100, s. 38.7, is a severability clause. Session Laws 2015-241, s. 12H.20(a), (b), provides: "(a) The Department of Health and Human Services, Division of Medical Assistance, shall submit a State Plan amendment request to the Centers for Medicare and Medicaid Services to assure that all State-operated dental schools receive the same reimbursement for dental services provided to North Carolina Medicaid beneficiaries. "(b) The State Plan amendment required by this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1 A(e) [repealed]." Session Laws 2015-241, s. 12H.22(a), (b), provides: "(a) Effective January 1, 2016, the Department of Health and Human Services, Division of Medical Assistance, shall increase by ten percent (10%) the rate paid for private duty nursing services provided pursuant to Clinical Coverage Policy 3G. "(b) Any State plan amendments required to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1 A(e) [repealed] but shall be submitted by January 1, 2016." Session Laws 2015-241, s. 12H.26(c), provides: "Any State Plan amendments required to implement this section shall not be subject to the 90-day prior submission requirements of G.S. 108A-54.1 A(e) [repealed] and G.S. 108A-70.25(b) ." Session Laws 2015-241, s. 12H.27(a), (b), provides: "(a) Notwithstanding any other provision of law, the Department of Health and Human Services, Division of Medical Assistance, (Department) is authorized to use any reimbursement methodology or arrangement to provide Medicaid coverage for blood glucose testing equipment and supplies, provided that the Department's total requirements, net of rebates, for providing blood glucose testing equipment and supplies does not exceed one million nine hundred thirty-three thousand three hundred fifty-seven dollars ($1,933,357) in fiscal year 2015-2016 and two million twenty thousand nine hundred seventy-four dollars ($2,020,974) in fiscal year 2016-2017. "(b) Any state plan amendment submitted to implement this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1 A(e) [repealed]." Session Laws 2015-241, s. 12H.30, as added by Session Laws 2015-264, s. 89, provides: "The Department of Health and Human Services, Division of Medical Assistance, shall submit a Medicaid State Plan amendment request to the Centers for Medicare and Medicaid Services (CMS) to amend the annual cost settlement methodology for local health departments, as defined in Article 2 of Chapter 130A of the General Statutes. The State Plan amendment shall provide a methodology that maximizes identification of allowable Medicaid costs in order to assure that North Carolina is receiving the maximum federal reimbursement for local health departments' treatment of Medicaid-eligible patients consistent with Medicare reimbursement principles. The State Plan amendment required by this section shall not be subject to the 90-day prior submission requirement of G.S. 108A-54.1 A(e) [repealed] but shall be submitted by February 15, 2016 and shall apply to cost reports with a fiscal year beginning July 1, 2016 and thereafter. This section shall not be construed to require the Department to submit to CMS a State Plan amendment that increases State funding requirements." Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'" Session Laws 2015-241, s. 33.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2015-2017 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2015-2017 fiscal biennium." Session Laws 2015-241, s. 33.6, is a severability clause. Session Laws 2016-94, s. 1.2, provides: "This act shall be known as the 'Current Operations and Capital Improvements Appropriations Act of 2016.'" Session Laws 2016-94, s. 12H.12, provides: "It is the intent of the General Assembly to explore all possible funding options to maintain or expand reimbursement for Graduate Medical Education." Session Laws 2016-94, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2016-2017 fiscal year, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2016-2017 fiscal year." Session Laws 2016-94, s. 39.7, is a severability clause. Session Laws 2017-57, s. 11H.13(a)-(c), provides: "(a) For the period of July 1, 2017, through June 30, 2019, the Department of Health and Human Services, Division of Medical Assistance (DMA), shall no longer be required to implement the prohibitions on reimbursement for Graduate Medical Education (GME) payments required by Section 12H.23 of S.L. 2015-241, as amended by Section 88 of S.L. 2015-264. "(b) It is the intent of the General Assembly to continue to appropriate funds to the Department of Health and Human Services in years beyond this fiscal biennium in order to maintain the GME add-on to the DRG Unit Value (Base) rate as part of Medicaid Transformation, as described in S.L. 2015-241. "(c) No later than January 1, 2018, DMA shall report to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice and the Fiscal Research Division on all of the following: "(1) The actual and forecasted total requirements less receipts for payments made for the GME add-on to the DRG Unit Value (Base) rate. "(2) The actual and forecasted total requirements less receipts for all Medicaid spending. "(3) Any specific actions the Department of Health and Human Services has taken or proposes to take to maintain total Medicaid spending within the amounts appropriated for the Medicaid program." Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'" Session Laws 2017-57, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2017-2019 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2017-2019 fiscal biennium." Session Laws 2017-57, s. 39.6, is a severability clause. Effect of Amendments. - Session Laws 2014-100, s. 12H.21(a), effective September 1, 2014, inserted the third sentence in subsection (d); added the last sentence in subsection (e); and added subsection (f). See Editor's note for applicability. Session Laws 2015-245, s. 18, effective September 23, 2015, rewrote the first sentence of subsection (a), which formerly read: "No provision in the Medicaid State Plan or in a Medicaid Waiver may expand or otherwise alter the scope or purpose of the Medicaid program from that authorized by law enacted by the General Assembly"; deleted subsections (b) and (c); in subsection (d), substituted "Medicaid and NC Health Choice" for "Health and Human Services" in the first sentence, inserted the second sentence, inserted "notice" in the present third sentence, and deleted the former last two sentences; and deleted subsection (e).