S681 - Agency Policy Directives/2019-2020. (SL 2020-78)

Overview: Section 4D.4 of S.L. 2020-78 requires local management entities/managed care organizations (LME/MCOs) to utilize out-of-network agreements between a single provider of behavioral health or intellectual and developmental disability (IDD) services and the LME/MCO to ensure access to care. LME/MCOs must use an out-of-network agreement instead of a comprehensive provider contract to allow their enrollees to receive services outside of the LME/MCO’s catchment area when certain conditions are met.

LME/MCOs may not restrict the number of out-of-network agreements to provide inpatient hospitalization services except in limited circumstances or restrict the number of out-of-network agreements for other behavioral health and IDD services to foster children or independent foster care adolescents who are already receiving services from the provider.

Any provider enrolled in the North Carolina Medicaid program that provides services pursuant to an out-of-network agreement must be considered a network provider for purposes of Chapter 108D of the General Statutes only as it relates to enrollee grievances and appeals for those services.

This section became effective July 1, 2020.