reglab/statecodes huggingface dataset:
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-54.2 - Procedures for changing medical policy.

§ 108A-54.2. Procedures for changing medical policy.
(a) The Department shall adopt rules to develop, amend, and adopt medical coverage policy for Medicaid in accordance with this section.
(b) 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:
(1) 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.
(2) At least 45 days prior to the adoption of new or amended medical coverage policy, the Department shall:
a. Publish the proposed new or amended medical coverage policy on the Department's Web site;
b. Notify all Medicaid providers of the proposed, new, or amended policy; and
c. Upon request, provide persons copies of the proposed medical coverage policy.
(3) 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.
(4) 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:
a. Notify all Medicaid providers of the proposed policy;
b. Upon request, provide persons notice of amendments to the proposed policy; and
c. Accept additional oral or written comments during this 15-day period.
(c) 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.
(d) Repealed by Session Laws 2015-245, s. 19, effective September 23, 2015. (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; 2022-74, s. 9D.15(z).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-54.3C - NC Health Works federal financial participation.

§ 108A-54.3C. NC Health Works federal financial participation.
If the federal medical assistance percentage for Medicaid coverage provided to the category of individuals described in G.S. 108A-54.3A(a)(24) falls below ninety percent (90%), then Medicaid coverage for this category of individuals shall be discontinued as expeditiously as possible but no earlier than the date the lower federal medical assistance percentage takes effect. Upon receipt of information indicating that the federal medical assistance percentage will be lower than ninety percent (90%), the Secretary shall promptly do all of the following:
(1) Notify the Joint Legislative Oversight Committee on Medicaid, the Office of State Budget and Management, and the Fiscal Research Division of the determination and post this notice on the Department's website. The notice must include the proposed effective date of the discontinuation of coverage.
(2) Submit all documents to the Centers for Medicare and Medicaid Services necessary to discontinue Medicaid coverage for the category of individuals described in G.S. 108A-54.3A(a)(24). (2023-7, s. 1.2(a); 2023-134, s. 9E.23(c2).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-54.4 - Income disregard for federal cost-of-living adjustments.

§ 108A-54.4. Income disregard for federal cost-of-living adjustments.
An increase in a Medical Assistance Program recipient's income due solely to a cost-of-living adjustment to federal Social Security and Railroad Retirement payments shall be disregarded when determining income eligibility for the Medical Assistance Program. This section shall not be deemed to render a recipient eligible for the Medical Assistance Program if all other eligibility requirements are not met. (2012-142, s. 10.6(a); 2016-94, s. 12H.7.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-54.5 - Maintenance of waivers for dependents of members of Armed Forces.

§ 108A-54.5. Maintenance of waivers for dependents of members of Armed Forces.
The Department of Health and Human Services shall ensure that the eligibility criteria for Medicaid home- and community-based waivers allow the dependent of a member of the Armed Forces of the United States to maintain the dependent's waiver status upon the transfer of the service member to an assignment outside of North Carolina, so long as the service member maintains the State of North Carolina as the legal residence to which the service member intends to return following completion of military service and the dependent meets Medicaid eligibility criteria and all other waiver eligibility criteria upon returning to North Carolina. Consequently, a dependent who is on the waiting list for a waiver slot shall maintain the dependent's position on the waiting list. A dependent who was receiving waiver services prior to the service member's transfer, upon the dependent's return to North Carolina, shall be reinstated to the dependent's waiver slot, if the slot remains available, or shall receive a priority position on the waiting list for the next available waiver slot. This section shall not be construed to authorize the provision of waiver services outside of North Carolina. (2016-71, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-55.1 - Medicare enrollment required.

§ 108A-55.1. Medicare enrollment required.
The Department shall require State Medical Assistance Program recipients who qualify for Medicare to enroll in Medicare, in accordance with Title XIX of the Social Security Act, in order to pay medical expenditures that qualify for payment under Medicare Parts B and D, except that enrollment in Part D is not required if the recipient has creditable prescription drug coverage as defined by federal law.
Failure to enroll in Medicare shall result in nonpayment of these expenditures under the State Medical Assistance Program. A provider may seek payment for services from Medicaid enrollees who are eligible for but not enrolled in Medicare Parts B and D. (2003-284, s. 10.27; 2006-66, s. 10.6.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-55.2 - Collaboration among agencies to ensure Medicaid-related services payments to eligible students with disabilities in public schools.

§ 108A-55.2. Collaboration among agencies to ensure Medicaid-related services payments to eligible students with disabilities in public schools.
The Department shall work with the Department of Public Instruction and local education agencies to develop efficient, effective, and appropriate administrative procedures and guidelines to provide maximum funding for Medicaid-related services for Medicaid-eligible students with disabilities. The procedures and guidelines shall be streamlined to ensure that local education agencies receive Medicaid reimbursement in a timely manner for Medicaid-related services and administrative outreach to Medicaid-eligible students with disabilities. (2003-284, s. 10.29A.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-56 - Acceptance of federal grants.

§ 108A-56. Acceptance of federal grants.
All of the provisions of the federal Social Security Act providing grants to the states for medical assistance are accepted and adopted, and the provisions of this Part shall be liberally construed to effectuate compliance with the act, except to the extent the applicability of federal law or rules have been waived by agreement between the State and the U.S. Department of Health and Human Services. Nothing in this Part or the regulations made under its authority shall be construed to deprive a recipient of assistance of the right to choose the licensed provider of the care or service made available under this Part within the provisions of the federal Social Security Act, or valid waiver agreement. This section shall not be construed to prohibit a PHP from (i) requiring its enrollees to obtain services from providers that are under contract with the PHP or (ii) imposing utilization management criteria to a request for services, to the extent these actions are not otherwise prohibited by State or federal law or regulation, or by the Department. (1965, c. 1173, s. 1; 1969, c. 546, s. 1; 1981, c. 275, s. 1; 2019-81, s. 4.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-57.1 - Rules governing transfer of medical assistance benefits between counties.

§ 108A-57.1. Rules governing transfer of medical assistance benefits between counties.
Any recipient of medical assistance who moves from one county to another county of this State shall continue to receive medical assistance if eligible. The county director of social services of the county from which the recipient has moved shall transfer all necessary records relating to the recipient to the county director of social services of the county to which the recipient has moved. The county from which the recipient has moved shall pay the county portion of the nonfederal share of medical assistance payments paid for services provided to the recipient during the month following the recipient's move. Thereafter, the county to which the recipient has moved shall pay the county portion of the nonfederal share of medical assistance payments paid for the services provided to the recipient. (1998-212, s. 12.6.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-59 - Acceptance of medical assistance constitutes assignment to the State of right to third party benefits; recovery procedure.

§ 108A-59. Acceptance of medical assistance constitutes assignment to the State of right to third party benefits; recovery procedure.
(a) Notwithstanding any other provisions of the law, by accepting medical assistance, the recipient shall be deemed to have made an assignment to the State of the right to third party benefits, contractual or otherwise, to which he may be entitled.
It shall be the responsibility of the county attorney of the county from which the medical assistance benefits are received or an attorney retained by that county and/or the State to enforce this subsection, and said attorney shall be compensated for his services in accordance with the attorneys' fee arrangements approved by the Department of Health and Human Services.
(b) The responsible State agency will establish a third party resources collection unit that is adequate to assure maximum collection of third party resources.
(c) Notwithstanding any other law to the contrary, in all actions brought pursuant to subsection (a) of this section to obtain reimbursement for payments for medical services, liability shall be determined on the basis of the same laws and standards, including bases for liability and applicable defenses, as would be applicable if the action were brought by the individual on whose behalf the medical services were rendered. (1977, c. 664; 1979, 2nd Sess., c. 1312, ss. 3-5; 1981, c. 275, s. 1; 1995, c. 508, s. 2; 1997-443, s. 11A.118(a).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-60 - Protection of patient property.

§ 108A-60. Protection of patient property.
(a) It shall be unlawful for any person:
(1) To willfully commingle or cause or solicit the commingling of the personal funds or moneys of a recipient resident of a provider health care facility with the funds or moneys of such facility; or
(2) To willfully embezzle, convert, or appropriate or cause or solicit the embezzlement, conversion or appropriation of recipient personal funds or property to his own use or to the use of any provider or other person or entity.
(b) A violation of subdivision (a)(1) of this section shall be a Class 1 misdemeanor. A violation of subdivision (a)(2) of this section shall be a Class H felony.
(c) For purposes of this section:
(1) "Health care facility" shall include skilled nursing facilities, intermediate care facilities, rest homes, or any other residential health care facility; and
(2) "Person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization; and
(3) "Recipient" shall include current resident recipients, deceased recipients and recipients who no longer reside at such facility. (1979, c. 510, s. 1; 1981, c. 275, s. 1; 1993, c. 539, ss. 816, 1300; 1994, Ex. Sess., c. 24, s. 14(c).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-61.1 - Financial responsibility of a parent for a child under age 21 in a medical institution.

§ 108A-61.1. Financial responsibility of a parent for a child under age 21 in a medical institution.
Notwithstanding any other provisions of the law, for the purpose of determining eligibility for medical assistance under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., the income and financial resources of the natural or adoptive parents of a person who is under the age of 21 and who requires Medicaid covered services in a medical institution shall not be counted if the patient's physician certifies, and the Division of Health Benefits or its agents approve, that continuous care and treatment are expected to exceed 12 months. For purposes of this subsection, "medical institution" means licensed acute care inpatient medical facilities providing medical, surgical, and psychiatric or substance abuse treatment, or facilities providing skilled or intermediate care, including intermediate care for individuals with intellectual disabilities. (1993, c. 386, s. 1; 2019-81, s. 15(a); 2021-62, s. 4.1; 2021-88, s. 9(c).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-62 - Therapeutic leave for medical assistance patients.

§ 108A-62. Therapeutic leave for medical assistance patients.
(a) A medical assistance beneficiary at an intermediate care facility or skilled nursing facility may take therapeutic leave in accordance with this section without the facility losing reimbursement under the medical assistance program.
(b) The maximum amount of therapeutic leave days that may be taken in a calendar year by a medical assistance beneficiary are as follows:
(1) Ninety days for a beneficiary in an intermediate care facility.
(2) Sixty days for a beneficiary in a skilled nursing facility.
(c) No more than 15 consecutive days of therapeutic leave may be taken by a medical assistance beneficiary without the approval of one of the following:
(1) The Division of Health Benefits of the Department.
(2) The local management entity/managed care organization with which the beneficiary is enrolled under Chapter 122C of the General Statutes.
(3) The prepaid health plan with which the beneficiary is enrolled under Chapter 108D of the General Statutes. (1979, c. 925; 1981, c. 275, s. 1; 1985 (Reg. Sess., 1986), c. 1014, s. 120; 1991, c. 126, s. 1; 1997-443, s. 11A.118(a); 2019-81, s. 15(a); 2021-62, s. 3.1(a).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-63.1 - Health care fraud subpoena to produce documents.

§ 108A-63.1. Health care fraud subpoena to produce documents.
(a) The Attorney General, acting through the Medicaid Investigations Unit of the Department of Justice, may, when engaged in an investigation of an alleged violation of G.S. 108A-63 and prior to the arrest of a suspect, issue in writing and cause to be served a subpoena to produce documents upon any corporation or governmental entity requiring the production of any records, books, papers, electronic media, objects, or other documents which may be relevant to a criminal investigation of a violation of G.S. 108A-63.
(b) A subpoena under this section may require the custodian of records of the corporation or governmental entity to produce an affidavit certifying that the custodian made a thorough and diligent search for the documents requested and that the documents produced constitute all the records requested to the best of the custodian's knowledge, information, and belief.
(c) A subpoena under this section shall describe the documents required to be produced and prescribe a return date within a reasonable period of time, of no less than 20 days from the date of service, within which the documents can be assembled and made available.
(d) A corporation or governmental entity may comply with a subpoena issued under this section by delivering the documents to the Medicaid Investigations Unit by any of the following methods:
(1) By hand delivery.
(2) By mailing the documents by certified mail.
(3) By making the documents reasonably available for transfer to an agent of the Medicaid Investigations Unit at a place of business of the corporation or governmental entity.
(4) If agreed to by the Medicaid Investigations Unit and the corporation or governmental entity, by any other means.
(e) A corporation or governmental entity may move to quash or modify a subpoena issued under this section if it is oppressive or unreasonable or does not comply with the requirements of this section. The motion must be made before the time specified in the subpoena for production and may be made before a judge of the superior court.
(f) In the case of failure by any corporation or governmental entity without adequate excuse to obey a subpoena issued under this section, the Attorney General may invoke the aid of a judge of the superior court. The court may issue an order requiring the subpoenaed corporation or governmental entity to appear before the Attorney General to produce records. Failure to obey the order of the court may be punished as contempt of court. (2009-554, s. 2.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-64 - Medical assistance recipient fraud.

§ 108A-64. Medical assistance recipient fraud.
(a) It shall be unlawful for any person to knowingly and willfully and with intent to defraud make or cause to be made a false statement or representation of a material fact in an application for assistance under this Part, or intended for use in determining entitlement to such assistance.
(b) It shall be unlawful for any applicant, recipient or person acting on behalf of such applicant or recipient to knowingly and willfully and with intent to defraud, conceal or fail to disclose any condition, fact or event affecting such applicant's or recipient's initial or continued entitlement to receive assistance under this Part.
(b1) It is unlawful for any person knowingly, willingly, and with intent to defraud, to obtain or attempt to obtain, or to assist, aid, or abet another person, either directly or indirectly, to obtain money, services, or any other thing of value to which the person is not entitled as a recipient under this Part, or otherwise to deliberately misuse a Medicaid identification card. This misuse includes the sale, alteration, or lending of the Medicaid identification card to others for services and the use of the card by someone other than the recipient to receive or attempt to receive Medicaid program coverage for services rendered to that individual.
Proof of intent to defraud does not require proof of intent to defraud any particular person.
(c) (1) A person who violates a provision of this section shall be guilty of a Class I felony if the value of the assistance wrongfully obtained is more than four hundred dollars ($400.00).
(2) A person who violates a provision of this section shall be guilty of a Class 1 misdemeanor if the value of the assistance wrongfully obtained is four hundred dollars ($400.00) or less.
(d) For purposes of this section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization. (1981, c. 275, s. 1; 1993, c. 539, s. 817; 1994, Ex. Sess., c. 24, s. 14(c); 1995, c. 317, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-64.1 - Incentives to counties to recover fraudulent Medicaid expenditures.

§ 108A-64.1. Incentives to counties to recover fraudulent Medicaid expenditures.
The Department of Health and Human Services, Division of Health Benefits, shall provide incentives to counties that successfully recover fraudulently spent Medicaid funds by sharing State savings with counties responsible for the recovery of the fraudulently spent funds. (2013-360, s. 12H.5; 2019-81, s. 15(a).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-67 - Medicare/Qualified Disabled Working Individuals.

§ 108A-67. Medicare/Qualified Disabled Working Individuals.
Qualified disabled working individuals are eligible for the payment of the Medicare Part A premium. An individual is qualified for this payment:
(1) If the Social Security Administration determines the individual to be a "Disabled Working Individual";
(2) If the individual's income is less than two hundred percent (200%) of the current federal poverty level, as revised annually; and
(3) If the individual is less than 65 years of age. (1991, c. 127.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-68 - Drug Use Review Program; rules.

§ 108A-68. Drug Use Review Program; rules.
Notwithstanding the provisions of Chapter 90 of the General Statutes or of any other provision of law, the Division of Health Benefits, Department of Health and Human Services, shall adopt rules implementing the drug use review provisions of the Omnibus Budget Reconciliation Act of 1990, as amended. (1991 (Reg. Sess., 1992), c. 900, s. 128; 1997-443, s. 11A.118(a); 2019-81, s. 15(a).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-68.1 - Certain prescription drugs exempt from prior authorization requirements.

§ 108A-68.1. Certain prescription drugs exempt from prior authorization requirements.
Prior authorization shall not be required or utilized for any antihemophilic factor drugs prescribed for the treatment of hemophilia and blood disorders where there is no generically equivalent drug available. Nothing in this section shall prohibit the Secretary from implementing a disease management program. (2003-179, s. 1; 2005-83, s. 1; 2009-210, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-69 - Employer obligations.

§ 108A-69. Employer obligations.
(a) As used in this section and in G.S. 108A-70:
(1) "Health benefit plan" means an accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscriber contract; a plan provided by a multiple employer welfare arrangement; the State Health Plan for Teachers and State Employees under Chapter 135 of the General Statutes; or a plan provided by another benefit arrangement. "Health benefit plan" does not mean a Medicare supplement policy as defined in G.S. 58-54-1(5).
(2) "Health insurer" means any health insurance company subject to Articles 1 through 63 of Chapter 58 of the General Statutes, including a multiple employee welfare arrangement, and any corporation subject to Articles 65 and 67 of Chapter 58 of the General Statutes; a group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974; and the State Health Plan for Teachers and State Employees under Chapter 135 of the General Statutes.
(b) If a parent is required by a court or administrative order to provide health benefit plan coverage for a child, and the parent is eligible for family health benefit plan coverage through an employer, the employer:
(1) Must allow the parent to enroll, under family coverage, the child if the child would be otherwise eligible for coverage without regard to any enrollment season restrictions.
(2) Must enroll the child under family coverage upon application of the child's other parent or upon receipt of notice from the Department of Health and Human Services in connection with its administration of the Medical Assistance or Child Support Enforcement Program if the parent is enrolled but fails to make application to obtain coverage for the child.
(3) May not disenroll or eliminate coverage of the child unless:
a. The employer is provided satisfactory written evidence that:
1. The court or administrative order is no longer in effect; or
2. The child is or will be enrolled in comparable health benefit plan coverage that will take effect not later than the effective date of disenrollment; or
b. The employer has eliminated family health benefit plan coverage for all of its employees.
(4) Must withhold from the employee's compensation the employee's share, if any, of premiums for health benefit plan coverage, not to exceed the maximum amount permitted to be withheld under section 303(b) of the federal Consumer Credit Protection Act, as amended; and must pay this amount to the health insurer; subject to regulations, if any, adopted by the Secretary of the U.S. Department of Health and Human Services. (1993 (Reg. Sess., 1994), c. 644, s. 3; 1995, c. 193, s. 44; 1997-433, s. 3.2; 1997-443, s. 11A.118(a); 1998-17, s. 1; 1999-293, s. 8; 2007-323, s. 28.22A(o); 2007-345, s. 12.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70 - Recoupment of amounts spent on medical care.

§ 108A-70. Recoupment of amounts spent on medical care.
(a) To the extent necessary to reimburse the Department or a PHP for expenditures for costs under this Part, and provided that claims for current and past due child support shall take priority over claims for those expenditures, the Department may garnish the wages, salary, or other employment income of, and the Secretary of Revenue shall withhold amounts from State tax refunds to, any person who meets all of the following criteria:
(1) Is required by court or administrative order to provide health benefit plan coverage for the cost of health care services to a child eligible for medical assistance under Medicaid.
(2) Has received payment from a third party for the costs of such services.
(3) Has not used such payments to reimburse, as appropriate, either the other parent or guardian of the child or the provider of the services.
(b) To the extent that payment for covered services has been made under G.S. 108A-55 for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the Department of Health and Human Services is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. (1993 (Reg. Sess., 1994), c. 644, s. 3; 1997-443, s. 11A.118(a); 2019-81, s. 5.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.9C - Informal review permitted.

§ 108A-70.9C. Informal review permitted.
Nothing in this Part shall prevent the Department from engaging in an informal review of a contested Medicaid case with a recipient prior to issuing a notice of adverse determination under G.S. 108A-70.9A(c) or a notice of resolution under G.S. 108D-5.7. (2010-31, s. 10.30(a); 2019-81, s. 6.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.11 - Definitions.

§ 108A-70.11. Definitions.
Definitions. - As used in this Part:
(1) "Attorney General" means the Attorney General or any Deputy, Assistant, or Associate Attorney General.
(2) "Claim" means an application for payment or approval or for use in determining entitlement to payment presented to the Medical Assistance Program in any form, including written, electronic, or magnetic, which identifies a service, good, or accommodation as reimbursable under the Medical Assistance Program.
(3) "Damages" means the difference between what the Medical Assistance Program paid a provider and the amount it would have paid the provider in the absence of a violation of this section and may be established by statistical sampling methods.
(4) "Knowingly" means that a provider, with respect to the information:
a. Has actual knowledge of the information;
b. Acts in deliberate ignorance of the truth or falsity of the information; or
c. Acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
(5) "Medical Assistance Program" means the Division of Health Benefits and its fiscal agent. (1997-338, s. 1; 2019-81, s. 15(a).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.15 - Employee remedies.

§ 108A-70.15. Employee remedies.
(a) In the absence of fraud or malice, no person who furnishes information to officials of the State responsible for investigating false claims violations shall be liable for damages in a civil action for any oral or written statement made or any other action that is necessary to supply information required pursuant to this Part.
(b) Any employee of a provider who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by the employee's employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under G.S. 108A-70.12, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under G.S. 108A-70.12, shall be entitled to all relief necessary to make the employee whole. Relief shall include reinstatement with the same seniority status as the employee would have had but for the discrimination, two times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys' fees. An employee may bring an action in the appropriate court for the relief provided in this section. (1997-338, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.16 - Uniformity of interpretation.

§ 108A-70.16. Uniformity of interpretation.
This Part shall be so interpreted and construed as to be consistent with the federal False Claims Act, 31 U.S.C. § 3729, et seq., and any subsequent amendments to that act. (1997-338, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › §§ 108A-70.30: Recodified as Part 33 of Article 7 of Chapter 143B, G.S. 143B-344.46, by Session Laws 2013-360, s. 15.22(h), effective July 1, 2013.

§ 108A-70.30: Recodified as Part 33 of Article 7 of Chapter 143B, G.S. 143B-344.46, by Session Laws 2013-360, s. 15.22(h), effective July 1, 2013.
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.36 - Applicability.

§ 108A-70.36. Applicability.
(a) If a federally recognized Native American tribe within the State has assumed responsibility for the Medicaid program pursuant to G.S. 108A-25(e), then this Part applies to the tribe in the same manner as it applies to county departments of social services.
(b) This Part shall not apply to any eligibility determinations made by the federally facilitated marketplace, also known as the federal health benefit exchange, so long as use of the federally facilitated marketplace for Medicaid eligibility determinations has been authorized by the General Assembly, in accordance with G.S. 143B-24(b). (2016-94, s. 12H.17(b); 2023-7, s. 1.8(d).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.37 - Timely decision standards.

§ 108A-70.37. Timely decision standards.
The county department of social services shall render a decision on an individual's application for Medicaid within 45 calendar days from the date of application, except for applications in which a disability determination has already been made or is needed. For those applications, the county department of social services shall render a decision on an individual's eligibility within 90 calendar days from the date of application. (2016-94, s. 12H.17(b).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.39 - Average processing time standards.

§ 108A-70.39. Average processing time standards.
(a) Average processing time is calculated by finding the processing time for each case that received a disposition during a given month and finding the average of those processing times.
(b) The standard for average processing time is 90 days for cases in which the individual has applied for the Medicaid Aid to the Disabled category (M-AD) and 45 days for all other cases. (2016-94, s. 12H.17(b).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.40 - Percentage processed timely standards.

§ 108A-70.40. Percentage processed timely standards.
(a) Percentage processed timely is the percentage of cases that received a timely disposition in a given month. The percentage processed timely is calculated by expressing the number of cases during a given month with a processing time equal to or less than the standard set in G.S. 108A-70.37 as a percentage of the total cases receiving a disposition during that month. When the deadline for meeting the timely decision standard in G.S. 108A-70.37 falls on a weekend or holiday, an application that receives a disposition on the first workday following the deadline shall be considered timely for purposes of calculating the percentage processed timely.
(b) The Department is authorized to adopt rules to establish a percentage standard for each county department of social services that will be the percentage processed timely standard for that county department of social services. Until the Department adopts rules establishing percentage standards for each county, the percentage processed timely standards are those established in 10A NCAC 23C .0203 as of April 2016. (2016-94, s. 12H.17(b).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.41 - Corrective action.

§ 108A-70.41. Corrective action.
(a) If for any three consecutive months or for any five months out of a period of 12 consecutive months a county department of social services fails to meet either the average processing time standard or the percentage processed timely standard or both standards, the Department and the county department of social services shall enter into a joint corrective action plan to improve the timely processing of applications.
(b) A joint corrective action plan entered into pursuant to this section shall specifically identify the following components:
(1) The duration of the joint corrective action plan, not to exceed 12 months. If a county department of social services shows measurable progress in meeting the performance requirements in the joint corrective action plan, then the duration of the joint corrective action plan may be extended by six months, but in no case shall a joint corrective action plan exceed 18 months.
(2) A plan for improving timely processing of applications that specifically describes the actions to be taken by the county department of social services and the Department.
(3) The performance requirements for the county department of social services that constitute successful completion of the joint corrective action plan.
(4) Acknowledgement that failure to successfully complete the joint corrective action plan will result in temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.42. (2016-94, s. 12H.17(b).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.43 - Reporting.

§ 108A-70.43. Reporting.
No later than November 1 of each year, the Department shall submit a report for the prior fiscal year to the Joint Legislative Oversight Committee on Medicaid, the Joint Legislative Oversight Committee on Health and Human Services, and the Fiscal Research Division containing the following information:
(1) The annual statewide percentage of Medicaid applications processed in a timely manner for the fiscal year.
(2) The statewide average number of days to process Medicaid applications for each month in the fiscal year.
(3) The annual percentage of Medicaid applications processed in a timely manner by each county department of social services for the fiscal year.
(4) The average number of days to process Medicaid applications for each month for each county department of social services.
(5) The number of months during the fiscal year that each county department of social services met the timely processing standards under G.S. 108A-70.38.
(6) The number of months during the fiscal year that each county department of social services failed to meet the timely processing standards under G.S. 108A-70.38.
(7) A description of all corrective action activities conducted by the Department and county departments of social services in accordance with G.S. 108A-70.36.
(8) A description of how the Department plans to assist county departments of social services in meeting timely processing standards for Medicaid applications, for every county in which the performance metrics for processing Medicaid applications in a timely manner do not show significant improvement compared to the previous fiscal year. (2017-57, s. 11H.21; 2022-74, s. 9D.15(z), (bb).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.45 - Applicability.

§ 108A-70.45. Applicability.
If a federally recognized Native American tribe within the State has assumed responsibility for the Medicaid program pursuant to G.S. 108A-25(e), then this Part applies to the tribe in the same manner as it applies to county departments of social services. (2017-57, s. 11H.22(c).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.46 - Audit of county Medicaid determinations.

§ 108A-70.46. Audit of county Medicaid determinations.
(a) Beginning January 1, 2019, the Department of Health and Human Services, Division of Central Management and Support, shall audit county departments of social services for compliance with the accuracy standards adopted under G.S. 108A-70.47 for Medicaid eligibility determinations made within a 12-month period. This audit shall also include an evaluation of compliance with the quality assurance standards under G.S. 108A-70.48 by the county department of social services. Audits shall be conducted for initial Medicaid eligibility determination applications as well as Medicaid reenrollment determinations. The Department shall ensure that every county is audited no less than once every three years.
(b) Beginning 18 months after the Department has implemented the training and certification program under G.S. 108A-26.5, the Department shall include in its audits required under this section a verification that all county departments of social services are in compliance with the certification program requirements for individuals involved in the Medicaid eligibility determination process. (2017-57, s. 11H.22(c), (h); 2018-5, s. 11H.5(a), (d).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.47 - Medicaid eligibility determination processing accuracy standards.

§ 108A-70.47. Medicaid eligibility determination processing accuracy standards.
(a) The Department shall require county departments of social services to comply with accuracy standards set forth in rule for the processing of Medicaid eligibility determinations. The Department shall set the following standards:
(1) Accuracy standards with regards to errors that caused an ineligible Medicaid recipient to be approved for Medicaid benefits.
(2) Accuracy standards with regards to errors that caused the denial of benefits to an applicant that should have been approved for Medicaid benefits.
(3) Accuracy standards with regards to errors made during the eligibility determination process that did not change the outcome of the eligibility determination.
(b) Standards under this section shall be developed by the Department in consultation with the State Auditor. (2017-57, s. 11H.22(c).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.48 - Quality assurance.

§ 108A-70.48. Quality assurance.
The Department shall require county departments of social services to comply with quality assurance minimum standards set forth in rule. The quality assurance standards shall be based upon best practices and shall be developed by the Department in consultation with the State Auditor. (2017-57, s. 11H.22(c).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.49 - Corrective action.

§ 108A-70.49. Corrective action.
(a) If the Department's audit under G.S. 108A-70.46 results in a determination that a county department of social services fails to meet any of the standards adopted under G.S. 108A-70.47 or G.S. 108A-70.48, the Department and the county department of social services shall enter into a joint corrective action plan to improve the accurate processing of applications.
(b) A joint corrective action plan entered into pursuant to this section shall specifically identify the following components:
(1) The duration of the joint corrective action plan, not to exceed 24 months. If a county department of social services shows measurable progress in meeting the performance requirements in the joint corrective action plan, then the duration of the joint corrective action plan may be extended by six months, but in no case shall a joint corrective action plan exceed 36 months.
(2) A plan for improving the accurate processing of applications that specifically describes the actions to be taken by the county department of social services and the Department.
(3) The performance requirements for the county department of social services that constitute successful completion of the joint corrective action plan.
(4) Acknowledgment that failure to successfully complete the joint corrective action plan will result in temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.50.
(c) Any county department of social services under a joint corrective action plan shall be audited under G.S. 108A-70.46 on an annual basis until the joint corrective action plan is successfully completed or until the failure to successfully complete the joint corrective action plan results in the temporary assumption of Medicaid eligibility administration by the Department, in accordance with G.S. 108A-70.50. (2017-57, s. 11H.22(c); 2018-5, s. 11H.5(b).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 2 - Programs of Public Assistance. › § 108A-70.51 - Reporting.

§ 108A-70.51. Reporting.
Beginning with the calendar year 2020, no later than March 1 of each year, the Department shall submit a report to the Joint Legislative Oversight Committee on Medicaid, the Fiscal Research Division, and the State Auditor that contains the following information about the prior calendar year:
(1) The percentage of audited county departments of social services that met the accuracy standards adopted under G.S. 108A-70.47 in the prior fiscal year.
(2) The percentage of audited county departments of social services that met the quality assurance standards adopted under G.S. 108A-70.48 in the prior fiscal year.
(3) The audit result for each standard adopted under G.S. 108A-70.47 for each county of department services in the prior fiscal year.
(4) The number of years in the preceding 10-year period that any county department of social services failed to meet the standards in G.S. 108A-70.47 or G.S. 108A-70.48.
(5) A description of all corrective action activities conducted by the Department and county departments of social services in accordance with G.S. 108A-70.49.
(6) For every county in which the performance metrics for processing Medicaid applications in an accurate manner do not show significant improvement compared to the previous audit of that county, a description of how the Department plans to assist county departments of social services in accuracy and quality assurance standards for Medicaid applications. (2017-57, s. 11H.22(c); 2018-5, s. 11H.5(c); 2022-74, s. 9D.15(i).)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 3 - Social Services Programs. › § 108A-71 - Authorization of social services programs.

§ 108A-71. Authorization of social services programs.
The Department is hereby authorized to accept all grants-in-aid available for programs of social services under the Social Security Act, other federal laws or regulations, State appropriations and other non-federal sources. The Department is designated as the single State agency responsible for administering or supervising the administration of such programs. It is the intent of this Article that programs of social services be administered so that the State and its citizens may benefit fully from any grants-in-aid. (1981, c. 275, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 3 - Social Services Programs. › § 108A-72 - Social services checks payable to decedents.

§ 108A-72. Social services checks payable to decedents.
In the event of the death of a recipient of a cash payment service, any check or checks payable to such recipient but not endorsed prior to such recipient's death shall be returned to the issuing agency, made void, and reissued to the provider of the service. (1981, c. 275, s. 1.)
2023 North Carolina General Statutes › Chapter 108A - Social Services › Article 3 - Social Services Programs. › § 108A-73 - Services appeals and confidentiality of records.

§ 108A-73. Services appeals and confidentiality of records.
The provisions of Article 4 on public assistance and social services appeals and confidentiality of records shall be applicable to social services programs authorized under this Article. (1981, c. 275, s. 1.)