subchapter 27I – AREA AUTHORITY OR COUNTY PROGRAM REQUIREMENTS

 

SECTION .0100 – (RESERVED)

 

10A NCAC 27I .0101         RESERVED FOR FUTURE CODIFICATION

SECTION .0200 – (RESERVED)

 

10A NCAC 271 .0201 – RESERVED FOR FUTURE CODIFICATION

 

SECTION .0300 – (RESERVED)

 

10A NCAC 271 .0301 – RESERVED FOR FUTURE CODIFICATION

 

SECTION .0400 - SECRETARY APPROVAL OF LME SERVICE DELIVERY

 

10A NCAC 27I .0401         SCOPE

(a)  This Section governs the procedures for Local Management Entities (LME) to seek approval from the Secretary to directly deliver mental health, developmental disabilities and substance abuse services.

(b)  These Rules are applicable to all LMEs seeking approval to directly deliver any of the services set forth in the Division of Medical Assistance (DMA) Clinical Policy Numbers 8A, 8C, 8D1 and 8D2 including subsequent amendments and editions, services under the CAP-MR/DD waiver as approved by the Centers for Medicare and Medicaid Services, and state funded only services. Copies of Clinical Policy Numbers 8A, 8C, 8D1 and 8D2 are available at no cost from the DMA website at http://www.ncdhhs.gov/dma/. Copies of the CAP-MR/DD waiver and the service definitions for state funded only services are available at no cost from the Division of Mental Health, Developmental Disabilities and Substance Abuse Services website at http://www.ncdhhs.gov/dmhddsas/.

 

History Note:        Authority G.S. 122C-112.1(a)(26);

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0402         DEFINITIONS

As used in the rules of this Section, the following terms have the meanings specified:

(1)           "Local Management Entity (LME)" means the same as defined in G.S. 122C-3(20b).

(2)           "Request for Application (RFA)" means a procurement strategy through which a LME solicits applications from public and private providers of mental health, developmental disabilities, and substance abuse services to provide one or more specific service(s) to clients in the LME's catchment area.

(3)           "Request for Information (RFI)" means a procurement strategy through which a LME solicits information from public and private providers of mental health, developmental disabilities and substance abuse services regarding the providers' interest in providing one or more specific services to clients in the LME's catchment area.

(4)           "Request for Proposal (RFP)" means a procurement strategy through which a LME solicits proposals from public and private providers of mental health, developmental disabilities and substance abuse services interested in providing one or more specific services to clients in the LME's catchment area.

 

History Note:        Authority G.S. 122C-112.1(a)(26);

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0403         INFORMATION INCLUDED IN REQUEST

A LME seeking approval from the Secretary to directly deliver services in accordance with the rules of this section shall submit the following information:

(1)           the name(s) of the service(s) for which approval is sought;

(2)           the period of time for which approval is sought;

(3)           the number of existing providers in the catchment area, by service, and the number of clients existing providers have the capacity to serve, for any service for which approval is sought;

(4)           the estimated number of clients in the catchment area or relevant geographic territory, if the LME is requesting to deliver services in only a portion of the catchment area, in need of the service for which approval is sought and the estimated number of clients to be served directly by the LME and the estimated number of clients to be served by the providers;

(5)           information on the actions the LME has taken to seek to attract sufficient numbers of providers for the service for which approval is sought to the catchment area such that it is not necessary for the LME to directly deliver services, including copies of Request for Application (RFA), Request for Information (RFI) and Request for Proposals (RFP), copies of all applications, information and proposals received in response to such activities, and the number of providers attracted through such efforts;

(6)           a description of the LME's organizational structure detailing how service delivery staff and staff performing LME functions are separately managed;

(7)           a description of how clients will be given a choice of service provider for the service(s) for which approval is sought;

(8)           documentation that the LME Board has approved the LME's request to deliver services; and

(9)           documentation that the local Consumer and Family Advisory Committee (CFAC) has approved the LME's request to deliver services.

 

History Note:        Authority G.S. 122C-112.1(a)(26);

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0404         PROCESS

(a)  A LME seeking approval to directly deliver services shall submit a request in writing containing all required information at least 60 days in advance of the date on which the LME wishes to begin service delivery or the expiration date of a previous approval if the LME wishes to continue service delivery.

(b)  The request shall be submitted to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS), 3001 Mail Service Center, Raleigh, NC 27699-3001.

(c)  The Director of DMH/DD/SAS or designee shall review the submitted documentation and request additional information, if necessary. If the service the LME wishes to deliver is a Medicaid payable service, DMH/DD/SAS shall also consult with the Division of Medical Assistance.

(d)  The Secretary shall make a decision regarding the request within 15 business days of receipt of the recommendation from the Director of DMH/DD/SAS or designee.

(e)  The Secretary's decision shall be based upon the following:

(1)           access;

(2)           availability of qualified public or private providers;

(3)           client choice; and

(4)           fair competition.

(f)  The Director of DMH/DD/SAS or his designee shall communicate the Secretary's decision to the LME in writing within 15 business days of the decision.

(g)  In the event that a LME requests to deliver services on a temporary basis as a result of an unanticipated closure of a private or public provider in the LME catchment area, the LME may request an expedited review of its service delivery request.

 

History Note:        Authority G.S. 122C-112.1(a)(26);

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

SECTION .0500 – CONTENT, FORMAT, SUBMISSION, REVIEW AND APPROVAL OF LOCAL MANAGEMENT ENTITY BUSINESS PLAN

 

10A NCAC 27I .0501         SCOPE

(a)  The requirements of this Section shall govern the content, format, submission, review and approval of an LME business plan as set forth in G.S. 122C-115.2.

(b)  The LME business plan shall be in effect for at least three State fiscal years.

 

History Note:        Authority G.S. 122C-112.1(a)(4)(5); 122C-115.2;

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0502         LME BUSINESS PLAN CONTENT AND FORMAT REQUIREMENTS

(a)  The plan shall be divided into chapters that correspond to the administrative functions carried out by the LME. The chapters shall address administrative functions including:

(1)           governance or administration;

(2)           provider relations;

(3)           service management;

(4)           quality management;

(5)           consumer affairs; and

(6)           business and information management.

(b)  A LME that has organized itself using different administrative function titles may use substitute title names and may expand or reduce the number of chapters. Each LME shall address all of the administrative functions as set forth in G.S. 122C-115.2(b) and 122C-115.4(b) unless a function has been removed pursuant to G.S. 122C-115.4(d).

(c)  The LME business plan shall be submitted in a template provided by the Secretary.

(d)  Each chapter shall address the following elements:

(1)           Mission Statement. The LME shall develop a mission statement to identify what the LME plans to accomplish for the administrative function addressed in each chapter.

(2)           Current Operations. The LME shall address the organizational structure used to fulfill all activities associated with the administrative function addressed in each chapter. The current operations element shall include an organizational chart for the administrative function addressed in each chapter of the LME business plan.

(3)           Strategic Objective. The LME shall provide a narrative identifying the planned improvements in operations for the administrative function addressed in each chapter for each of the next three State fiscal years.

(4)           Resource Allocation. The LME shall compare the current operational costs associated with the administrative function addressed in each chapter to the administrative allocation and provide an explanation for deviation from that norm.

(5)           Business Rules. The LME shall list the business rules for each administrative function that enhances or inhibits the efficiency and effectiveness of the organization.

 

History Note:        Authority G.S. 122C-112.1(a)(4)(5); 122C-115.2;

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0503         LME BUSINESS PLAN SIGNATURE REQUIREMENTS

(a)  Each LME business plan shall include the signatures of the individuals named as follows:

(1)           director of the area authority or county program;

(2)           board chairman indicating approval by the area authority or county program board of directors;

(3)           chairperson(s) of each board of county commissioners in the catchment area of the area authority or county programs; and

(4)           chairperson of the area authority or county program consumer and family advisory committee (CFAC).

(b)  The signatures required in Paragraph (a) of this Rule may be either on the cover letter accompanying the LME business plan or via separate correspondence.

 

History Note:        Authority G.S. 122C-112.1(a)(4)(5); 122C-115.2;

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10A NCAC 27I .0504         PLAN OF CORRECTION

(a)  When a LME fails to meet the requirements as set forth in this Section, the LME shall submit a plan of correction to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. The Department of Health and Human Services may withhold administrative funding from an LME that does not submit a plan of correction.

(b)  The Division of Mental Health, Developmental Disabilities and Substance Abuse Services shall conduct the following activities:

(1)           review the plan of correction;

(2)           evaluate the information submitted; and

(3)           conduct follow-up onsite reviews when required to verify information submitted by a LME.

(c)  The Division of Mental Health, Developmental Disabilities and Substance Abuse Services shall respond in writing to the LME's plan of correction within 30 calendar days of the receipt of the plan of correction with approval or denial of the plan of correction.

(d)  The LME shall submit a revised plan of correction within 30 calendar days if the original plan of correction is denied. Upon receipt of the second plan of correction the Division of Mental Health, Developmental Disabilities and Substance Abuse Services shall conduct the following activities:

(1)           review the second plan of correction;

(2)           evaluate information; and

(3)           provide assistance needed to resolve outstanding issues so that the LME business plan may be certified as set forth in G.S. 122C-115.2(c).

(e)  The Division of Mental Health, Developmental Disabilities and Substance Abuse Services shall share Plans of correction with the LME Board of Directors and the Consumer and Family Advocacy Committee.

 

History Note:        Authority G.S. 122C-112.1(a)(4)(5); 122C-115.2;

Eff. July 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

SECTION .0600 - nON-mEDICAID aPPEAL PROCESS

 

10a ncac 27I .0601         SCOPE

(a)  The rules of this Section shall govern appeals made to the Division of decisions made by an area authority or county program affecting a non-Medicaid eligible client.

(b)  A non-Medicaid eligible client may appeal to the Director the review decision of an area authority or county program to deny, reduce, suspend, or terminate a non-Medicaid state funded service.

(c)  An appeal shall be filed with the Division only after a client has received a review decision from the area authority or county program.

(d)  Nothing in these Rules shall be interpreted as granting a non-Medicaid eligible client the right to appeal decisions of third party payers to the Division.

(e)  As set forth in G.S. 143B-147(a)(9), nothing in these Rules shall be interpreted as granting a non-Medicaid eligible client the right to appeal the findings of the Division by requesting a contested case hearing pursuant to G.S. 150B.

(f)  There shall be no reprisal or retaliation to anyone who is a party to an appeal.

(g)  The area authority or county program may authorize interim services until the final written decision as set forth in Rule .0609 of this Section is reached.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0602         definitions

As used in the rules in this Section, the following terms shall have the meanings specified:

(1)           "Director" means the Director of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

(2)           "Division" means the Division of Mental Health, Developmental Disabilities and Substance Abuse Services.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0603         Filing Requirements

(a)  An appeal shall be filed with the Division no later than 11 calendar days from the date of the area authority or county program written review decision.

(b)  The appeal shall include a copy of the area authority or county program review decision and a request for appeal on a form provided by the Division.

(c)  A verbal appeal shall not be accepted.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0604         Change in Client Condition

If the client's medical condition changes relative to the service under appeal, the appeal shall be returned to the area authority or county program for review.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0605         Initial response to a DMH/DD/SAS APPeal

(a)  The Director shall screen the request for appeal to the Division to determine:

(1)           if the appeal was reviewed by the area authority or county program according to the area authority or county program policy and procedures; and

(2)           if the appeal includes the denial, reduction, suspension or termination of a non-Medicaid state funded service.

(b)  The Director shall send an acknowledgement letter to the client and the area authority or county program within 5 business days of receipt of the request for appeal to the Division.

(c)  The acknowledgement letter shall specify whether the appeal has been accepted or not. The Division shall accept an appeal if it meets the standards as set forth in Paragraph (a) of this Rule.

(d)  The Director shall notify the area authority or county program and the client whose appeal is accepted for review to forward all documentation considered during the area authority or county program review to the Division no later than 10 calendar days from the date of the acknowledgement letter. The acknowledgment letter shall advise the parties that a panel will be convened to conduct a hearing.

(e)  An appeal that does not meet the criteria as set forth in Paragraph (a) of this Rule shall be returned to the client as disqualified with an explanation of the basis for disqualification.

(f)  The area authority or county program shall review the appeal, if the appeal made to the Division is disqualified on the basis of not having been reviewed according to the area authority or county program's policy and procedures.

(g)  The client shall have 11 calendar days from the date of the area authority or county program review decision to resubmit the appeal to the Division.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0606         hearing SCHEDULE and Composition of the Panel

(a)  The Director shall convene a five member panel to conduct a hearing for an appeal that is accepted in accordance with the requirements of Rule .0605 of this Section.

(b)  The panel members shall consist of the following:

(1)           a provider agency representative who meets the following requirements:

(A)          the representative shall be from a provider agency that is not be a party to the appeal; and

(B)          the representative shall have clinical expertise in the disability area pertinent to the appeal;

(2)           an employee of an area authority or county program who meets the following requirements:

(A)          the employee shall be from an area authority or county program that is not a party to the appeal; and

(B)          the employee shall have clinical expertise in the disability area pertinent to the appeal;

(3)           two individuals who are members of a consumer and family advisory committee who is not a party to the appeal; and

(4)           an employee of the Division.

(c)  The employee of the Division shall serve as the chairperson of the panel and shall be a voting member in the case of a tie.

(d)  The Director shall forward the record on appeal and all supplemental documentation to the chairperson of the panel within five days of receipt thereof.

(e)  The Director shall provide a copy of applicable law and rules to the chairperson of the panel.

(f)  The chairperson shall schedule a panel hearing including designation of a time and place.

(g)  The chairperson shall notify the client, other panel members and the area authority or county program of the time and place no less than 15 calendar days prior to the date of the hearing.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0607         Panel hearing procedureS

(a)  The chairperson of the panel:

(1)           shall convene the hearing at the prearranged time and place;

(2)           may afford the opportunity for rebuttal and summary comments to either of the presenting parties; and

(3)           shall conduct proceedings in an orderly manner.

(b)  The panel:

(1)           may limit the total number of persons presenting for the client and area authority or county program; and

(2)           may impose time limits for presentations.

(c)  Either party may be represented by a person or attorney of their choice.

(d)  Prior to the hearing, the client and the area authority or county program shall:

(1)           specify by name and position all individuals who will be present for the hearing;

(2)           provide the panel with requested information; and

(3)           when applicable, ensure that representatives of the parties shall be present at the hearing.

(e)  Any member of the panel may address questions to either party.

(f)  The panel may obtain any form of technical assistance or consultation relevant to the appeal.

(g)  No transcript shall be made and no party shall be allowed to record the proceeding. The panel may choose to record the proceeding for its own use. A tape so made shall be destroyed after the panel issues its decision.

(h)  Witnesses shall not be sworn before testifying.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0608         Panel Decision findings

(a)  The panel findings and decisions are based on the record and any new evidence that would be material to the issues on appeal.

(b)  The standard of review for the panel is whether the decision of the area authority or county program is supported by evidence presented.

(c)  The panel shall vote on each specific item being appealed.

(d)  Findings and decisions of the panel shall be by majority vote.

(e)  Any decision may be rescheduled for a subsequent meeting if the panel determines that it lacks sufficient information to render a decision at the initial hearing.

(f)  All panel findings and decisions shall be reached and sent in writing within 60 days of the written request for appeal to the client, the area authority or county program and the Director.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.

 

10a ncac 27I .0609         Final written Decision

(a)  Upon receipt of the panel's findings and decisions, the area authority or county program shall issue a final decision based on those findings. The area authority or county program shall issue the decision in writing within 10 days of receipt of the panel's findings and decisions.

(b)  Neither the panel findings and decisions nor the area authority or county program final decision shall be interpreted as an agency decision granting a non-Medicaid eligible client the right to appeal by requesting a contested case hearing pursuant to G.S. 150B.

 

History Note:        Authority G.S. 143B-147;

Eff. October 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 24, 2017.