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.

p. (For contingency, see editor's note) Behavioral health urgent care 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); 2021-180, s. 9F.11(c).)