Article 3.
Managed Care Entity Provider Networks.
§ 108D-21. LME/MCO provider networks.
Until the date that BH IDD tailored plans begin operating, each LME/MCO operating the combined 1915(b) and (c) waivers or providing coverage of any services approved under the 1915(i) option shall develop and maintain a closed network of providers to provide mental health, intellectual or developmental disabilities, substance use disorder, and traumatic brain injury services to its enrollees. A closed network is the network of providers that have contracted with the local management entity/managed care organization operating the combined 1915(b) and (c) waivers. (2019-81, s. 1(a); 2022-74, s. 9D.13(d); 2023-134, s. 9E.16(b2).)
§ 108D-22. PHP provider networks.
(a) Provider Networks. - Except as provided in G.S. 108D-23(c) and G.S. 108D-24(b), each PHP shall develop and maintain an open network of providers that meets access to care requirements for its enrollees.
(b) Essential Providers. - A PHP must include all providers in its geographical coverage area that are designated essential providers by the Department, unless the Department approves an alternative arrangement for securing the types of services offered by the essential providers. The Department shall designate Medicaid providers as essential providers if, within a region defined by a reasonable access standard, the provider either (i) offers services that are not available from any other provider in the region or (ii) provides a substantial share of the total units of a particular service utilized by Medicaid beneficiaries within the region during the last three years and the combined capacity of other service providers in the region is insufficient to meet the total needs of the Medicaid enrollees. The Department shall not classify physicians and other practitioners as essential providers. At a minimum, providers in the following categories shall be designated essential providers:
(1) Federally qualified health centers.
(2) Rural health centers.
(3) Free clinics.
(4) Local health departments.
(5) State Veterans Homes.
(c) Exceptions for Individual Providers. - Individual providers, except for designated essential providers, may be excluded from the PHP open network for any of the following reasons:
(1) A provider fails to meet objective quality standards.
(2) A provider refuses to accept the network rates.
(3) In accordance with G.S. 108C-7(e3).
(d) Closed Networks for Designated Service Categories. - If an open network for a designated service category would jeopardize quality of care, program integrity, or cost-effective use of Medicaid funds, then, notwithstanding subsection (a) of this section, a PHP may develop a closed network for that designated service category and exclude providers that are not designated essential providers from that closed network. Prior to creating a closed network for a designated service category, the PHP must receive approval from the Department of the PHP's written request to close its provider network for that service category. This written request must include a demonstration of ongoing network adequacy. If the Department does not respond to a written request from a PHP for approval to close its provider network for a designated service category within 180 days after the request was submitted, the request is deemed approved. (2019-81, s. 1(a); 2022-74, s. 9D.15(z); 2023-134, s. 9E.22(e); 2026-1, s. 3C.12(a).)
§ 108D-23. BH IDD tailored plan provider networks.
(a) Each LME/MCO shall operate provider networks with respect to its BH IDD tailored plan contract in accordance with this section and G.S. 108D-22.
(b) Repealed by Session Laws 2026-1, s. 3C.12(b), effective April 30, 2026.
(c) With regard to services and supports that are excluded from PHP coverage except under BH IDD tailored plans, each LME/MCO shall develop a closed network and may exclude providers from that closed network in accordance with all of the following:
(1) A closed network must include all essential providers designated in accordance with G.S. 108D-22(b) that (i) are located or provide services within the region for which the LME/MCO holds a BH IDD tailored plan contract and (ii) provide any covered behavioral health, intellectual and developmental disability, or traumatic brain injury service in that region.
(2) With regard to services identified by the Department as necessary to improve access for behavioral health, intellectual and developmental disability, and traumatic brain injury services, an LME/MCO shall accept all providers of those services that (i) meet objective quality standards and (ii) accept network rates, notwithstanding the requirement to operate a closed network, except that a provider may be excluded in accordance with G.S. 108C-7(e3). (2019-81, s. 1(a); 2021-62, s. 4.7(b); 2022-74, s. 9D.13(e); 2023-134, s. 9E.16(b3); 2026-1, s. 3C.12(b).)
§ 108D-24. Children and families specialty plan networks.
(a) The entity operating the children and families specialty plan shall operate provider networks in accordance with this section and G.S. 108D-22.
(b) The entity operating the children and families specialty plan shall develop a closed network, and may exclude providers from that closed network, for the provision of the following services:
(1) Intensive in-home services.
(2) Multisystemic therapy.
(3) Residential treatment services.
(4) Services provided in psychiatric residential treatment facilities.
(c) Repealed by Session Laws 2026-1, s. 3C.12(c), effective April 30, 2026.
(d) In addition to the requirement to cover essential providers under G.S. 108D-22, the entity operating the CAF specialty plan shall not exclude federally recognized tribal providers or Indian Health Service providers from any provider network. (2023-134, s. 9E.22(f); 2026-1, s. 3C.12(c).)
§ 108D-25. Reserved for future codification purposes.
§ 108D-26. Other provider networks.
(a) Beginning on the date that BH IDD tailored plans begin operating, each LME/MCO under contract with the Department (i) to provide coverage of services as a PIHP or (ii) to provide coverage of any services approved under the 1915(i) option shall operate a closed network in accordance with this section.
(b) A closed network is the network of providers that have contracted with the LME/MCO to provide to enrollees the services and supports covered by the LME/MCO either as a PIHP or under the 1915(i) option.
(c) With regard to services identified by the Department as necessary to improve access for behavioral health, intellectual and developmental disability, and traumatic brain injury services, an LME/MCO shall accept all providers of those services that (i) meet objective quality standards and (ii) accept network rates, notwithstanding the requirement in this section to operate a closed network. (2023-134, s. 9E.16(b4).)
§ 108D-27. Reserved for future codification purposes.
§ 108D-28. Reserved for future codification purposes.