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.

(c)        No person shall be eligible for coverage as a dependent if eligible as an employee or retired employee, except when a spouse is eligible on a fully contributory basis. basis or when the person is a disabled dependent child. In addition, no person shall be eligible for coverage as a dependent of more than one employee or retired employee at the same time.

….

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:

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(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