North Carolina § 108A-54 - 2. Procedures for changing medical policy.

§ 108A-54. 2. Procedures for changing medical policy.

The Department shall adopt rules to develop, amend, and adopt medical coverage policy for Medicaid and NC Health Choice in accordance with this section. Medical coverage policy is defined as those policies, definitions, or guidelines utilized to evaluate, treat, or support the health or developmental conditions of a recipient so as to determine eligibility, authorization or continued authorization, medical necessity, course of treatment and supports, clinical outcomes, and clinical supports treatment practices for a covered procedure, product, or service. Medical coverage policy is subject to the following: During the development of new medical coverage policy or amendment to existing medical coverage policy, the Department shall consult with and seek the advice of the Physician Advisory Group and other organizations the Secretary deems appropriate. The Secretary shall also consult with and seek the advice of officials of the professional societies or associations representing providers who are affected by the new medical coverage policy or amendments to existing medical coverage policy. At least 45 days prior to the adoption of new or amended medical coverage policy, the Department shall: Publish the proposed new or amended medical coverage policy on the Department's Web site; Notify all Medicaid and NC Health Choice providers of the proposed, new, or amended policy; and Upon request, provide persons copies of the proposed medical coverage policy. During the 45-day period immediately following publication of the proposed new or amended medical coverage policy, the Department shall accept oral and written comments on the proposed new or amended policy. If, following the comment period, the proposed new or amended medical coverage policy is modified, then the Department shall, at least 15 days prior to its adoption: Notify all Medicaid and NC Health Choice providers of the proposed policy; Upon request, provide persons notice of amendments to the proposed policy; and Accept additional oral or written comments during this 15-day period. If the adoption of new or amended medical coverage policies is necessitated by an act of the General Assembly or a change in federal law, then the 45- and 15-day time periods specified in subsection (b) of this section shall instead be 30- and 10-day time periods. Repealed by Session Laws 2015-245, s. 19, effective September 23, 2015. History (2006-66, s. 10.4; 2009-451, s. 10.68A(b); 2011-399, s. 4; 2013-360, s. 12H.6(a); 2015-245, s. 19.) Cross References. - As to Medicaid and Health Choice provider requirements, see Chapter 108C , G.S. 108C-1 et seq. NC Health Choice Medical Policy. - Session Laws 2011-145, s. 10.27, provides: "Unless required for compliance with federal law, the Department shall not change medical policy affecting the amount, sufficiency, duration, and scope of NC Health Choice health care services and who may provide services until the Division of Medical Assistance has prepared a five-year fiscal analysis documenting the increased cost of the proposed change in medical policy and submitted it for departmental review. If the fiscal impact indicated by the fiscal analysis for any proposed medical policy change exceeds one million dollars ($1,000,000) in total requirements for a given fiscal year, then the Department shall submit the proposed medical policy change with the fiscal analysis to the Office of State Budget and Management and the Fiscal Research Division. The Department shall not implement any proposed medical policy change exceeding one million dollars ($1,000,000) in total requirements for a given fiscal year unless the source of State funding is identified and approved by the Office of State Budget and Management. For medical policy changes exceeding one million dollars ($1,000,000) in total requirements for a given fiscal year that are required for compliance with federal law, the Department shall submit the proposed medical policy or policy interpretation change with a five-year fiscal analysis to the Office of State Budget and Management prior to implementing the change. The Department shall provide the Office of State Budget and Management and the Fiscal Research Division a quarterly report itemizing all medical policy changes with total requirements of less than one million dollars ($1,000,000)." For prior similar provisions, see Session Laws 2009-451, s. 10.33. Editor's Note. - Session Laws 2011-399, s. 6, made the amendment to this section by Session Laws 2011-399, s. 4, applicable to medical coverage policies entered into or amended on or January 1, 2012. 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. 38.5 is a severability clause. Effect of Amendments. - Session Laws 2009-451, s. 10.68A(b), effective July 1, 2009, deleted "of the North Carolina Medical Society" following "Physician Advisory Group" in the first sentence of subdivision (1). Session Laws 2011-399, s. 4, effective January 1, 2012, and applicable to medical coverage policies entered into or amended on or after that date, added the subsection (a) designation, and therein inserted "adopt rules to" and substituted "with this section" for "with the following"; and added the subsection (b) designation, and therein added the introductory paragraph. Session Laws 2013-360, s. 12H.6(a), effective July 1, 2013, added "for Medicaid and NC Health Choice" in subsection (a); added the last sentence in subsection (b); added "the Department shall" in subdivisions (b)(1) and (b)(3); added "and NC Health Choice" in sub-subdivisions (b)(2)b. and (b)(4)a.; added subsections (c) and (d). Session Laws 2015-245, s. 19, effective September 23, 2015, deleted subsection (d).