GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2021
SESSION LAW 2021-125
SENATE BILL 159
AN ACT to make TECHNICAL, clarifying, and administrative changes to laws relating to the state health plan for teachers and state employees.
The General Assembly of North Carolina enacts:
SECTION 1. G.S. 135‑48.33(a) reads as rewritten:
"(a) The Board of
Trustees must approve all Plan contracts in excess of five hundred thousand
dollars ($500,000), three million dollars ($3,000,000), including
contracts with an initial cost of less than five hundred thousand dollars
($500,000), three million dollars ($3,000,000), but that may exceed five
hundred thousand dollars ($500,000) three million dollars ($3,000,000) during
the term of the contract."
SECTION 2. G.S. 135‑48.41 reads as rewritten:
"§ 135‑48.41. Additional eligibility provisions.
…
(b) A dependent child
shall not be eligible for coverage under the Plan if the dependent child is
eligible for employer based health care outside of the State Health Plan for
Teachers and State Employees, other than a parent's claim. Coverage Notwithstanding
the age requirement under G.S. 135‑48.1(9), coverage of a
dependent child may be extended continued beyond the dependent
child's 26th birthday if the dependent child is physically or
mentally incapacitated to the extent that he or she is incapable of earning a
living and (i) such handicap developed or began to develop before the
dependent's 19th birthday, or (ii) such handicap developed or began to develop
before the dependent's 26th birthday disabled and if the dependent
was covered by the Plan in accordance with G.S. 135‑48.40(d)(7).on
the dependent child's 26th birthday. Verification of the dependent child's
disability shall be provided to the Plan no later than 60 days after the
dependent child's 26th birthday.
…."
SECTION 3.(a) G.S. 135‑48.24 reads as rewritten:
"§ 135‑48.24. Administrative review.
(a) If, after exhaustion of
internal appeal handling as outlined in the contract with the Claims Processor
Processor, any person is aggrieved, then the Claims Processor
shall bring the matter to the attention of the Executive Administrator and
Board of Trustees, which Administrator. The Executive Administrator shall
promptly decide whether the subject matter of the internal appeal is a
determination subject to external review under Part 4 of Article 50 of Chapter
58 of the General Statutes. The following shall apply to decisions made
under this subsection:
(1) The Executive Administrator and Board of
Trustees shall inform the aggrieved person and the aggrieved person's
provider of the decision and shall provide the aggrieved person notice of the
aggrieved person's right to appeal that decision as provided in this
subsection.
(2) If the Executive Administrator and Board of
Trustees decide decides that the subject matter of the raised
on internal appeal is not a determination subject to external review, then
the Executive Administrator and Board of Trustees may shall have the
authority to make a binding decision on the matter in accordance with
procedures established by the Executive Administrator and Board of Trustees. The
Executive Administrator and Board of Trustees shall provide a written summary
of the decisions made pursuant to this section to all employing units, all
health benefit representatives, all relevant health care providers affected by
a decision, and to any other parties requesting a written summary and approved
by the Executive Administrator and Board of Trustees to receive a summary
immediately following the issuance of a decision.matter.
(3) A decision by If the Executive
Administrator and Board of Trustees decides that a the
subject matter raised on internal appeal is a determination subject to
external review as provided in subsection (b) of this section review,
as provided for under subsection (b) of this section, then that decision may
be contested by the aggrieved person under Chapter 150B of the General
Statutes. The person contesting the decision may proceed with external review
pending a decision in the contested case under Chapter 150B of the General Statutes.
(b) The State Treasurer, in
consultation with the Board of Trustees, shall adopt and implement utilization
review and internal grievance procedures that are substantially equivalent to
those required under G.S. 58‑50‑61 and G.S. 58‑50‑62.
External review of determinations shall be conducted in accordance with Part 4
of Article 50 of Chapter 58 of the General Statutes. As used in this section,
"determination" is a decision by the State Treasurer, or the Plan's
designated utilization review organization administrated by or under contract
with the Plan that an admission, availability of care, continued stay, or other
health care service has been reviewed and, based upon information provided,
does not meet the Plan's benefit offerings, or requirements for medical
necessity, appropriateness, health care setting, or level of care or care,
or effectiveness, and the requested service is therefore denied, reduced,
or terminated.
(c) Repealed by Session Laws 2011‑398, s. 49, effective January 1, 2012, and applicable to contested cases commenced on or after that date."
SECTION 3.(b) G.S. 135‑48.22(3) is repealed.
SECTION 3.(c) G.S. 150B‑1(e) reads as rewritten:
"(e) Exemptions From Contested Case Provisions. – The contested case provisions of this Chapter apply to all agencies and all proceedings not expressly exempted from the Chapter. The contested case provisions of this Chapter do not apply to the following:
…
(13) The State Health Plan for
Teachers and State Employees with respect to determinations (i)
decisions by the Executive Administrator and Board of Trustees, that
an internal appeal is not subject to external review under G.S. 135‑48.24,
or (ii) a determination by the Executive Administrator, the Plan's
designated utilization review organization, or a self‑funded health
maintenance organization under contract with the Plan that an admission,
availability of care, continued stay, or other health care service has been
reviewed and, based upon the information provided, does not meet the Plan's benefits
offering, or requirements for medical necessity, appropriateness, health
care setting, or level of care care, or effectiveness, and
the requested service is therefore denied, reduced, or terminated.
…."
SECTION 4. G.S. 135‑48.27 reads as rewritten:
"§ 135‑48.27. Reports to the General Assembly; General Assembly access to information.
In addition to the reports
required by G.S. 135‑48.23(d), the The
State Treasurer, the Executive
Administrator, and Board of Trustees shall report to the General Assembly at
such times and in such forms as shall be designated as requested, and in
the manner designated, by the President Pro Tempore of the Senate and the Speaker
of the House of Representatives. Employees of the
Legislative Services Commission designated by the Legislative Services Officer
(i) shall have access to all records related to the Plan of the State
Treasurer, the Board of Trustees, the Executive Administrator, the Claims
Processor, and the Plan and (ii) shall be entitled to attend all meetings,
including executive sessions, of the Board of Trustees."
SECTION 5. G.S. 135‑48.1(14) reads as rewritten:
"(14) Plan or State Health
Plan. – The North Carolina State Health Plan for Teachers and State Employees.
Depending on the context, the term may refer to the entity created in G.S. 153‑48.2
G.S. 135‑48.2 or to the health benefit plans offered by
the entity, in which case "Plan" includes all comprehensive health
benefit plans offered under the Plan."
SECTION 6. This act is effective when it becomes law.
In the General Assembly read three times and ratified this the 25th day of August, 2021.
s/ Phil Berger
President Pro Tempore of the Senate
s/ Tim Moore
Speaker of the House of Representatives
s/ Roy Cooper
Governor
Approved 11:49 a.m. this 30th day of August, 2021