Senate Bill 548: Medicaid Changes for Transformation

• Restructures Chapter 108D to establish managed care procedures for Medicaid and NC Health Choice programs, including definitions, grievance processes, appeals, and provider networks for prepaid health plans (PHPs).

• Creates new Article 1A establishing disenrollment procedures for PHPs, allowing enrollees to disenroll without cause during specified times or with documented cause at any time, with expedited requests for urgent medical needs resolved within 3 calendar days.

• Modifies appeal timeframes from 90 days to 30 days for grievance disposition, from 45 days to 30 days for standard managed care entity appeals, and from 3 working days to 72 hours for expedited appeals.

• Extends contested case hearing appeal deadlines from 30 days to 120 days after notice of resolution and establishes mandatory mediation through the Mediation Network of North Carolina before OAH hearings.

• Codifies portions of S.L. 2015-245 (Medicaid transformation legislation) into new Article 4 of Chapter 108D covering PHP services, populations, and contract requirements; establishes minimum medical loss ratio of 88% for PHPs.