H97 - 2015 Appropriations Act, Sec. 12H.3: Standardized LME/MCO Out-of-Network Agreements (SL 2015-241)

Overview: Sec. 12H.3 of S.L. 2015-241 requires the Department of Health and Human Services (DHHS) to ensure that LME/MCOs utilize an out-of-network agreement that contains standardized elements developed in consultation with LME/MCOs. The out-of-network agreement is to be a streamlined agreement between a single provider of behavioral health or intellectual/developmental disability (IDD) services and an LME/MCO to ensure access to care in accordance with State and federal laws and regulations and reduce administrative burden on the provider.

Beginning November 1, 2015, LME/MCOs are required to use the out-of-network agreement in lieu of a comprehensive provider contract when all of the following conditions are met:

• The services requested are medically necessary and cannot be provided by an in-network provider.
• The behavioral health or IDD provider's site of service delivery is located outside of the geographical catchment area of the LME/MCO, and the LME/MCO is not accepting applications or the provider does not wish to apply for membership in the LME/MCO closed network.
• The behavioral health or IDD provider is not excluded from participation in the Medicaid program, the NC Health Choice program, or other State or federal health care program.
• The behavioral health or IDD provider is serving no more than two enrollees of the LME/MCO, unless the agreement is for inpatient hospitalization, in which case the LME/MCO may, but is not required to enter into more than five such out-of-network agreements with a single hospital or health system in any 12-month period.

This section became effective July 1, 2015.