reglab/housing_qa huggingface dataset:
NC Gen Stat § 108D-5.1 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 1A - Disenrollment from Prepaid Health Plans.|§ 108D-5.1 - General provisions.

 108D-5.1. General provisions.(a) Nothing in this Article shall be construed to limit or prevent the Department from disenrolling, from a PHP, an enrollee who (i) is no longer eligible to receive services through the Medicaid or NC Health Choice programs or (ii) becomes a member of a population of beneficiaries that is not required to enroll in a PHP under State law.(b) Nothing in this Article shall be construed to exclude a Medicaid or NC Health Choice beneficiary who is otherwise required by State law to enroll in a PHP from enrolling in a PHP, or to prevent a beneficiary who is otherwise exempted from enrollment in a PHP from disenrolling from a PHP and receiving services through the fee-for-service program.  (2019-81, s. 1(a).)
NC Gen Stat § 108D-5.5 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 1A - Disenrollment from Prepaid Health Plans.|§ 108D-5.5 - PHP requests for disenrollment.

 108D-5.5. PHP requests for disenrollment.(a) In General. - A PHP requesting disenrollment of an enrollee from the PHP shall submit a written request for disenrollment to the enrollment broker.(b) Limitations on PHP Requests for Disenrollment. - A PHP shall not request disenrollment of an enrollee from the PHP for any reason prohibited by 42 C.F.R. 438.56(b)(2). A PHP may request disenrollment of an enrollee only when both of the following criteria are met:(1) The enrollee's behavior seriously hinders the PHP's ability to care for the enrollee or other enrollees of the PHP.(2) The PHP has documented efforts to resolve the issues that form the basis of the request for disenrollment of the enrollee.  (2019-81, s. 1(a).)
NC Gen Stat § 108D-5.7 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 1A - Disenrollment from Prepaid Health Plans.|§ 108D-5.7 - Notices.

 108D-5.7. Notices.(a) Notices of Resolution. - For each disenrollment request by an enrollee or a PHP, the Department shall issue a written notice of resolution approving or denying the request by mail to the enrollee before the first day of the second month following the month in which the enrollee or PHP requested disenrollment. For expedited enrollee requests for disenrollment made under G.S. 108D-5.3(d), the Department shall issue the written notice of resolution approving or denying the expedited request within three calendar days of receipt of the request. In the same mailing as the notice, the Department shall also provide the enrollee with an appeal request form that includes all of the following:(1) A statement that, in order to request an appeal, the enrollee must file the form with OAH no later than 30 days after the mailing date of the notice of resolution, and the form may be filed by either (i) sending the form by mail or fax to the address or fax number listed on the form or (ii) calling the telephone number on the form and providing the information requested on the form.(2) The enrollee's name, address, telephone number, and Medicaid or NC Health Choice identification number.(3) A preprinted statement that indicates that the enrollee would like to appeal the specific adverse disenrollment determination identified in the notice of resolution.(4) A statement informing the enrollee of the right to be represented at the contested case hearing by a lawyer, a relative, a friend, or other spokesperson.(5) A space for the enrollee's signature and date.(b) Notices Pertaining to Expedited Enrollee Requests for Disenrollment. - If the Department determines that an enrollee's request for disenrollment does not meet the criteria for an expedited request, the Department shall do the following:(1) No later than three calendar days after receiving the enrollee's request for disenrollment, make reasonable efforts to give the enrollee and all other affected parties oral notice of the denial and follow up with a written notice of the denial. The denial is not appealable.(2) Issue the notice of resolution within the time limits established for standard disenrollment requests under subsection (a) of this section.  (2019-81, s. 1(a); 2021-62, ss. 2.1(d), 2.2(e).)
NC Gen Stat § 108D-5.9 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 1A - Disenrollment from Prepaid Health Plans.|§ 108D-5.9 - Appeals of adverse disenrollment determinations.

 108D-5.9. Appeals of adverse disenrollment determinations.(a) Appeals. - An enrollee, or the enrollee's authorized representative, who is dissatisfied with an adverse disenrollment determination may request a hearing to appeal the determination by filing the appeal request form provided under G.S. 108D-5.7(a) with the Office of Administrative Hearings within 30 calendar days of the date on the notice of resolution. The form may be filed by either (i) sending the form by mail or fax to the address or fax number listed on the form or (ii) calling the telephone number on the form and providing the information requested on the form. A request for a hearing to appeal an adverse disenrollment determination of the Department under this section is a contested case subject to the provisions of Article 3 of Chapter 150B of the General Statutes. The appeal shall be conducted in accordance with the procedures in Part 6A of Article 2 of Chapter 108A of the General Statutes.(b) Parties. - The Department shall be the respondent for purposes of appeals under this section.  (2019-81, s. 1(a); 2021-62, s. 2.1(e).)
NC Gen Stat § 108D-11 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 2 - Enrollee Grievances and Appeals.|§ 108D-11 - Managed care entity grievance and appeal procedures, generally.

 108D-11. Managed care entity grievance and appeal procedures, generally.(a) Each managed care entity shall establish and maintain internal grievance and appeal procedures that (i) comply with the Social Security Act and 42 C.F.R. Part 438, Subpart F, and (ii) afford enrollees and their authorized representatives constitutional rights to due process and a fair hearing.(b) An enrollee, or the enrollee's authorized representative, may file grievances and managed care entity level appeals orally or in writing.(c) A managed care entity shall not attempt to influence, limit, or interfere with an enrollee's right or decision to file a grievance, request for a managed care entity level appeal, or a contested case hearing. However, nothing in this Chapter shall be construed to prevent a managed care entity from doing any of the following:(1) Offering an enrollee alternative services.(2) Engaging in clinical or educational discussions with enrollees or providers.(3) Engaging in informal attempts to resolve enrollee concerns prior to the issuance of a notice of grievance disposition or notice of resolution.(d) A managed care entity shall not take punitive action against a provider for any of the following:(1) Filing a grievance on behalf of an enrollee or supporting an enrollee's grievance.(2) Requesting a managed care entity level appeal on behalf of an enrollee or supporting an enrollee's request for a managed care entity level appeal.(3) Requesting an expedited managed care entity level appeal on behalf of an enrollee or supporting an enrollee's request for a managed care entity level expedited appeal.(4) Requesting a contested case hearing on behalf of an enrollee or supporting an enrollee's request for a contested case hearing.(e) The appeal procedures set forth in this Article shall not apply to instances in which the sole basis for the managed care entity's decision is a provision in the State Plan or in federal or State law requiring an automatic change adversely affecting some or all beneficiaries.  (2013-397, s. 1; 2019-81, s. 1(a); 2021-62, s. 2.1(f).)
NC Gen Stat § 108D-12 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 2 - Enrollee Grievances and Appeals.|§ 108D-12 - Managed care entity grievances.

 108D-12. Managed care entity grievances.(a) Filing of Grievance. - An enrollee, or the enrollee's authorized representative, has the right to file a grievance with a managed care entity at any time to express dissatisfaction about any matter other than an adverse benefit determination. Upon receipt of a grievance, a managed care entity shall cause a written acknowledgment of receipt of the grievance to be sent by mail.(b) Notice of Grievance Disposition. - The managed care entity shall resolve the grievance and cause a notice of grievance resolution to be sent by mail to the enrollee and all other affected parties as expeditiously as the enrollee's health condition requires, but no later than 30 days after receipt of the grievance, provided that the managed care entity may extend such time frame to the extent permitted under 42 C.F.R. 438.408(c).(c) Right to Appeal. - There is no right to appeal the resolution of a grievance to OAH or any other forum.  (2013-397, s. 1; 2019-81, s. 1(a).)
NC Gen Stat § 108D-13 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 2 - Enrollee Grievances and Appeals.|§ 108D-13 - Standard managed care entity level appeals.

 108D-13. Standard managed care entity level appeals.(a) Notice of Adverse Benefit Determination. - A managed care entity shall provide an enrollee with a written notice of an adverse benefit determination by mail as required under 42 C.F.R. 438.404. The notice will employ a standardized form included as a provision in the contract between the managed care entity and the Department.(b) Request for Appeal. - An enrollee, or the enrollee's authorized representative, has the right to file a request for a managed care entity level appeal of a notice of adverse benefit determination no later than 60 days after the mailing date of the notice of adverse benefit determination. Upon receipt of a request for a managed care entity level appeal, a managed care entity shall acknowledge receipt of the request for appeal in writing by mail.(c) Continuation of Benefits. - A managed care entity shall continue the benefits of a Medicaid enrollee during the pendency of a managed care entity level appeal to the same extent required under 42 C.F.R. 438.420. In accordance with 42 C.F.R. 457.1260, NC Health Choice enrollees shall not be entitled to continuation of benefits.(d) Notice of Resolution. - The managed care entity shall resolve the appeal as expeditiously as the enrollee's health condition requires, but no later than 30 days after receiving the request for appeal, provided that the managed care entity may extend such time frame as permitted under 42 C.F.R. 438.408. The managed care entity shall provide the enrollee and all other affected parties with a written notice of resolution by mail within this 30-day period.(e) Right to Request Contested Case Hearing. - An enrollee, or the enrollee's authorized representative, may file a request for a contested case hearing under G.S. 108D-15 as long as (i) the enrollee, or the enrollee's authorized representative, has exhausted the appeal procedures described in this section or G.S. 108D-14 or (ii) the enrollee has been deemed, under 42 C.F.R. 438.408(c)(3), to have exhausted the managed care entity level appeals process.(f) Request Form for Contested Case Hearing. - In the same mailing as the notice of resolution, the managed care entity shall also provide the enrollee with an appeal request form for a contested case hearing that meets the requirements of G.S. 108D-15(f).  (2013-397, s. 1; 2019-81, s. 1(a).)
NC Gen Stat § 108D-15.1 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 2 - Enrollee Grievances and Appeals.|§ 108D-15.1 - Expedited contested case hearings on disputed adverse benefit determinations.

 108D-15.1. Expedited contested case hearings on disputed adverse benefit determinations.In accordance with 42 C.F.R. 431.224, an enrollee, or an enrollee's authorized representative, may request that an appeal under G.S. 108D-15(d) be expedited if the time otherwise permitted for a hearing could jeopardize the enrollee's life, health, or ability to attain, maintain, or regain maximum function. With regard to a request for an expedited appeal, all of the following apply:(1) The enrollee shall submit any additional documentation from a licensed health care professional with relevant excerpts from the enrollee's medical record that was not already provided with regard to the adverse benefit determination to demonstrate the need for an expedited appeal.(2) The Department shall determine if the enrollee's request meets the criteria for an expedited appeal.(3) If the Department determines that the enrollee's request does not meet the criteria for an expedited appeal, then (i) the Department shall make reasonable efforts to give the enrollee, or the enrollee's authorized representative, oral notice of the denial as expeditiously as possible and shall follow up with a written notice of denial and (ii) the enrollee's appeal shall not be subject to the expedited time frame in subdivision (4) of this subsection. The denial is not appealable.(4) If the Department determines that the enrollee's request meets the criteria for an expedited appeal, then (i) the mediation procedure under G.S. 108D-15(i) shall not apply to the appeal request and (ii) the decision required under G.S. 108D-16 shall be made as expeditiously as possible.  (2021-62, s. 2.2(i).)
NC Gen Stat § 108D-16 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 2 - Enrollee Grievances and Appeals.|§ 108D-16 - Notice of final decision and right to seek judicial review.

 108D-16. Notice of final decision and right to seek judicial review.The administrative law judge assigned to conduct a contested case hearing under G.S. 108D-15 shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision that includes findings of fact and conclusions of law and send it to the parties in accordance with G.S. 150B-37. The written decision shall notify the parties of the final decision and of the right of the enrollee and the managed care entity to seek judicial review of the decision under Article 4 of Chapter 150B of the General Statutes.  (2013-397, s. 1; 2019-81, s. 1(a).)
NC Gen Stat § 108D-21 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 3 - Managed Care Entity Provider Networks.|§ 108D-21 - LME/MCO provider networks.

 108D-21. LME/MCO provider networks.Each LME/MCO operating the combined 1915(b) and (c) waivers shall develop and maintain a closed network of providers to furnish mental health, intellectual or developmental disabilities, and substance abuse services to its enrollees.  (2019-81, s. 1(a).)
NC Gen Stat § 108D-22 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 3 - Managed Care Entity Provider Networks.|§ 108D-22 - PHP provider networks.

 108D-22. PHP provider networks.(a) Except as provided in G.S. 108D-23, each PHP shall develop and maintain a provider network that meets access to care requirements for its enrollees. A PHP may not exclude providers from their networks except for failure to meet objective quality standards or refusal to accept network rates. Notwithstanding the previous sentence, a PHP must include all providers in its geographical coverage area that are designated essential providers by the Department in accordance with subdivision (b) of this section, unless the Department approves an alternative arrangement for securing the types of services offered by the essential providers.(b) The Department shall designate Medicaid and NC Health Choice providers as essential providers if, within a region defined by a reasonable access standard, the provider either (i) offers services that are not available from any other provider in the region or (ii) provides a substantial share of the total units of a particular service utilized by Medicaid and NC Health Choice beneficiaries within the region during the last three years and the combined capacity of other service providers in the region is insufficient to meet the total needs of the Medicaid and NC Health Choice enrollees. The Department shall not classify physicians and other practitioners as essential providers. At a minimum, providers in the following categories shall be designated essential providers:(1) Federally qualified health centers.(2) Rural health centers.(3) Free clinics.(4) Local health departments.(5) State Veterans Homes.  (2019-81, s. 1(a).)
NC Gen Stat § 108D-23 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 3 - Managed Care Entity Provider Networks.|§ 108D-23 - BH IDD tailored plan networks.

 108D-23. BH IDD tailored plan networks.Entities operating BH IDD tailored plans shall develop and maintain a closed network of providers only for the provision of behavioral health, intellectual and developmental disability, and traumatic brain injury services.  (2019-81, s. 1(a); 2021-62, s. 4.7(b).)
NC Gen Stat § 108D-30 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 4 - Prepaid Health Plans.|§ 108D-30 - Intent and Goals.

 108D-30. Intent and Goals.It is the intent of the General Assembly to transform the State's current Medicaid and NC Health Choice programs to programs that provide budget predictability for the taxpayers of this State while ensuring quality care to those in need. The new Medicaid and NC Health Choice programs shall be designed to achieve the following goals:(1) Ensure budget predictability through shared risk and accountability.(2) Ensure balanced quality, patient satisfaction, and financial measures.(3) Ensure efficient and cost-effective administrative systems and structures.(4) Ensure a sustainable delivery system.  (2015-245, s. 1; 2019-81, s. 14(a).)
NC Gen Stat § 108D-35 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 4 - Prepaid Health Plans.|§ 108D-35 - Services covered by PHPs.

 108D-35. Services covered by PHPs.Capitated PHP contracts shall cover all Medicaid and NC Health Choice services, including physical health services, prescription drugs, long-term services and supports, and behavioral health services for NC Health Choice recipients, except as otherwise provided in this section. The capitated contracts required by this section shall not cover:(1) Medicaid services covered by the local management entities/managed care organizations (LME/MCOs) under the combined 1915(b) and (c) waivers shall not be covered under a standard benefit plan, except that all capitated PHP contracts shall cover the following services:a. Inpatient behavioral health services.b. Outpatient behavioral health emergency room services.c. Outpatient behavioral health services provided by direct-enrolled providers.d. Mobile crisis management services.e. Facility-based crisis services for children and adolescents.f. Professional treatment services in a facility-based crisis program.g. Outpatient opioid treatment services.h. Ambulatory detoxification services.i. Nonhospital medical detoxification services.j. Partial hospitalization.k. Medically supervised or alcohol and drug abuse treatment center detoxification crisis stabilization.l. Research-based intensive behavioral health treatment.m. Diagnostic assessment services.n. Early and Periodic Screening, Diagnosis, and Treatment services.o. Peer support services.In accordance with this subdivision, 1915(b)(3) services shall not be covered under a standard benefit plan.(2) Dental services.(3) Services provided through the Program of All-Inclusive Care for the Elderly (PACE).(4) Services documented in an individualized education program, as defined in G.S. 115C-106.3, or other document described in the Medicaid State Plan, and provided or billed by a local education agency, as defined in G.S. 115C-106.3.(5) Services documented in an individualized family service plan under the Individuals with Disabilities Education Act, 20 U.S.C. 1436, that are provided and billed by a Children's Developmental Services Agency or by a provider contracted with a Children's Developmental Services Agency to provide those services.(6) Services for Medicaid program applicants during the period of time prior to eligibility determination.(7) The fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses, and ophthalmic frames.  (2015-245, s. 4; 2016-121, s. 2(b); 2017-57, s. 11H.17(a); 2017-186, s. 4; 2018-48, s. 1; 2019-81, ss. 12, 14(a); 2021-62, ss. 3.2, 4.9(a).)
NC Gen Stat § 108D-45 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 4 - Prepaid Health Plans.|§ 108D-45 - Number and nature of capitated PHP contracts.

 108D-45. Number and nature of capitated PHP contracts.The number and nature of the contracts required under G.S. 108D-65(3) shall be as follows:(1) Four contracts between the Division of Health Benefits and PHPs to provide coverage to Medicaid and NC Health Choice recipients statewide.(2) Up to 12 contracts between the Division of Health Benefits and PLEs for coverage of regions specified by the Division of Health Benefits pursuant to G.S. 108D-65(2). Regional contracts shall be in addition to the four statewide contracts required under subdivision (1) of this section. Each regional contract shall provide coverage throughout the entire region for the Medicaid and NC Health Choice services required by G.S. 108D-35. A PLE may bid for more than one regional contract, provided that the regions are contiguous.(3) The limitations on the number of contracts established in this section shall not apply to BH IDD tailored plans described in G.S. 108D-60.(4) Initial capitated PHP contracts may be awarded on staggered terms of three to five years in duration to ensure against gaps in coverage that may result from termination of a contract by the PHP or the State.  (2015-245, s. 4; 2016-121, s. 2(b); 2018-48, s. 1; 2019-81, s. 14(a).)
NC Gen Stat § 108D-50 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 4 - Prepaid Health Plans.|§ 108D-50 - Defined measures and goals.

 108D-50. Defined measures and goals.The new delivery system and capitated PHP contracts shall be built on defined measures and goals for risk-adjusted health outcomes, quality of care, patient satisfaction, access, and cost. Each component shall be subject to specific accountability measures, including penalties. The Division of Health Benefits may use organizations such as National Committee for Quality Assurance (NCQA), Physician Consortium for Performance Improvement (PCPI), or any others necessary to develop effective measures for outcomes and quality.  (2015-245, s. 4; 2019-81, s. 14(a).)
NC Gen Stat § 108D-55 (2021)
2021 North Carolina General Statutes|Chapter 108D - Medicaid and NC Health Choice Managed Care Programs|Article 4 - Prepaid Health Plans.|§ 108D-55 - Administrative functions.

 108D-55. Administrative functions.PHPs shall be responsible for all administrative functions for recipients enrolled in their plan, including, but not limited to, claims processing, care and case management, grievances and appeals, and other necessary administrative services.  (2015-245, s. 4; 2019-81, s. 14(a).)