Public Policy Update: Insurance Coverage, Health Care Services and Managed Care

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The Autism Society of North Carolina advocates for ensuring that people on the autism spectrum have access to health care services under private and public health plans including private insurance, the state health plan, and Medicaid services.

Medicaid Expansion

This year, despite the efforts of many advocacy groups including ASNC, there will be no expansion of Medicaid funding that is available to states under the Affordable Care Act (ACA) (Senate Bill 4 No Medicaid Expansion/No State Health Exchange). This leaves limited options for lower income people whose income is not low enough to qualify for Medicaid, and who will not qualify for government subsidies to purchase insurance on the health care exchange under the ACA. ASNC will continue our education efforts during the interim on the importance of this expansion to our community, especially as North Carolina embarks on larger Medicaid changes.

Autism Insurance H 498

The NC House passed a bill requiring autism insurance coverage in private and the state employees’ health plans, but the Senate chose not to take up the bill this session. The House version of the bill was modified since its introduction: it places a cap of $36,000 on behavioral health treatment and limits coverage to individuals age 23 or younger who have been diagnosed by age 8. Funding for the cost to the state employees’ health plan for autism treatment was included in the budget, but the bill still must pass the Senate and any changes agreed on by the House to become law. The governor has expressed his support and said he would sign it upon passage.

Medicaid County of Residence H 867

This bill would allow Medicaid recipients to move and retain services. It particularly affects individuals with Cap/Innovations, allowing them portability of their slots, and would fix situations where families must choose between a needed move and retention of services. Problems arose because the way MCOs and services are funded could cause shifts in MCO capitated funding. The legislature has asked that the NC Department of Health and Human Services (DHHS) propose a solution to that problem and is holding the bill until the short session.

LEGISLATION THAT PASSED

Guardianship and Families as Providers H 543

Two bills, H 543 MHDDSAS Providers and Uncompensated Guardians and S 573 MHDDSA Providers/Guardianship Issues, were rolled into H 543, clarifying who can be paid for services and provide guardianship. Corporate guardians cannot be paid providers of services for the individual, but families, foster families, and – under limited circumstances – unrelated, appointed guardians can be paid to provide care and act as unpaid guardians.

LME/MCO Enrollee Grievance and Appeals S 553

The final version of the bill sets out a more standardized process for Medicaid beneficiaries filing a grievance, managed care appeals with the LME/MCO, and contested case appeals with the NC Office of Administrative Hearings (OAH). Grievances can be filed verbally but must be followed by a written request. There is no right to appeal a grievance. Appeals can be filed for managed care actions, and the bill allows 45 days to resolve the appeal. For cases in which 45 days would be too lengthy, an expedited appeal can be requested. In contested cases, the enrollee has the burden of proof on all issues submitted to OAH. For full details, please read Part 1 of the bill. ASNC will publish more information on appeals changes in consultation with other advocacy groups. Part 2 of the bill establishes the Transitions to Community Living Housing Program, recommended by the Blue Ribbon Commission and in response to the Department of Justice settlement regarding individuals with mental illness in adult care homes.

If you have questions about public policy issues, please contact Jennifer Mahan, Director of Advocacy and Public Policy, at 919-865-5068 or jmahan@autismsociety-nc.org.

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