10a ncac 43h .0111      MEDICAL SERVICES COVERED

The following medical services are covered under the N.C. Sickle Cell Syndrome Program if the North Carolina Division of Public Health Sickle Cell Program Supervisor determines that these services are related to sickle cell disease:

(1)           hospital outpatient care including emergency room visits.  The total number of emergency room visits per fiscal year shall not exceed three times the average number of emergency visits per patient over the previous two fiscal years, and it will be adjusted annually on July 1.

(2)           physicians' office visits;

(3)           drugs on a formulary established by the program based upon the following factors: the medical needs of sickle cell patients, the efficacy and cost effectiveness of the drugs, the availability of generic or other less costly alternatives, and the need to maximize the benefits to patients utilizing finite Program dollars.  A copy of this formulary may be obtained free of charge by writing to the N.C. Sickle Cell Syndrome Program, 1929 Mail Service Center, Raleigh, North Carolina, 27699-1929 or on the Purchase of Medical Care Services website at http://www.ncdhhs.gov/control/pomcs/guides/billing_sicklecell.pdf;

(4)           medical supplies and equipment;

(5)           preventive dentistry including education, examinations, cleaning, and X-rays; remedial dentistry including tooth removal, restoration, and endodontic treatment for pain prevention; and emergency dental care to control bleeding, relieve pain, and treat infection; dental care, including:

(a)           preventive dentistry including education, examinations, cleaning, and X-rays;

(b)           remedial dentistry including tooth removal, restoration, and endodontic treatment for pain prevention; and

(c)           emergency dental care to control bleeding, relieve pain, and treat infection;

(6)           eye care (when the Division of Services for the Blind will not provide coverage); and

(7)           the cost of inpatient care per client per year for a maximum of two admissions per fiscal year.

History Note:        Authority G.S. 130A-129;

Eff. February 1, 1976;

Amended Eff. April 22, 1977;

Readopted Eff. December 5, 1977;

Amended Eff. July 1, 1982; January 1, 1982;

Temporary Amendment Eff. November 7, 1983, for a period of 120 days to expire on March 4, 1984;

Amended Eff. October 1, 1984; March 1, 1984;

Temporary Amendment Eff. October 14, 1988, for a period of 180 days to expire on April 12, 1989;

Temporary Amendment Expired April 12, 1989;

Amended Eff. September 1, 1990;

Temporary Amendment Eff. June 19, 1996;

Temporary Amendment Expired March 11, 1997;

Amended Eff. August 1, 2000;

Temporary Amendment Eff. December 17, 2001; December 1, 2001;

Amended Eff. April 1, 2003;

Temporary Amendment Eff. January 27, 2004;

Amended Eff. January 1, 2014; October 1, 2006; July 1, 2004;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 6, 2016.