GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1989

H	1 

HOUSE BILL 1165

Short Title:  Maternal/Newborn Health Services.	(Public)
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Sponsors: Representative Cromer.
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Referred to:  Human Resources.
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April 11, 1989

A BILL TO BE ENTITLED
AN ACT TO PROVIDE UNIVERSAL ACCESS TO MATERNAL AND NEWBORN HEALTH SERVICES.
The General Assembly of North Carolina enacts:
Section 1.  The General Statutes of North Carolina are amended by adding a new Chapter 130B to read as follows:
“Chapter 130B.
"Universal Access to Maternal and Newborn Services.
"§ 130B-1.  Short title.
This Chapter shall be known and may be cited as the Universal Access to Maternal and Newborn Health Services Law of North Carolina.
"§ 130B-2.  Declaration of policy and statement of purpose.
The legislature finds that many women in North Carolina are not receiving essential prenatal and newborn services.  Women who are not eligible for medical assistance, lack adequate private health insurance coverage, or the personal means to pay for health care services are most likely to lack such care.  Financial barriers are compounded by a lack of coordination of available benefits, as well as a lack of incentives among both health care facilities and private practitioners to provide services to low income women.
The absence of universally accessible prenatal and newborn care for women in North Carolina contributes to unacceptably high rates of infant mortality and low birth weight in our State.  Low birth weight infants are at great risk for physical, neurological and developmental disabilities and often require intensive neonatal medical care or special medical and educational services throughout their lives.  The provision of prenatal care can prevent infant deaths and thousands of infants from being born handicapped for life.
Therefore, the legislature declares a statewide system of universally accessible prenatal and newborn care services imperative to the alleviation of the enormous human suffering and social cost associated with infant mortality and low birth weight of infants.
"§ 130B-3. Definitions.
As used in this Chapter, unless the context requires otherwise:
(1)	‘Commission' means the Commission for Health Services.
(2)	‘Health insurance organization' or ‘organization' means an insurance company licensed or certified pursuant to Chapter 58 of the General Statutes.
(3)	‘Newborn' includes newborns and infants up to one month of age.
(4)	‘Providers of service' means a hospital as defined in Chapter 131E of the General Statutes, a health maintenance organization as defined in Chapter 57B of the General Statutes, a physician or surgeon licensed under Chapter 90 of the General Statues, and a nurse midwife as defined in Chapter 90 of the General Statutes.
(5)	‘Recipient' means a pregnant woman who does not have a health insurance plan that provides maternal and newborn coverage and pays for such services in sums equal to at least the usual and customary charges for such services.
(6)	‘Services' means prenatal care, delivery, and postpartum and newborn care services as set forth in G.S. 130B-6 of this Chapter.
(7)	‘Universal Access Program' means the program established pursuant to this Chapter providing eligible pregnant women access to prenatal care, delivery, postpartum care services, and newborn care services.
"§ 130B-4. Powers and duties of the Commission.
(a)	After consultation with and subject to the approval of the Commissioner of Insurance, and subject to the approval of the Director of the Budget, the Commission may enter into one or more contracts with a health insurance organization or organizations to administer the Universal Access Program pursuant to this Chapter.  Any such contract shall contain a description of services to be provided, and provisions for access to services, utilization review, quality assurance, recipient and provider of service  enrollment, payment, data collection and reporting.
(b)	The Commission shall set forth in the contract the number of recipients to be provided services by the health insurance organization.  The Commission shall ensure that payments to the organization to carry out its duties and responsibilities pursuant to the contract are made in such a way as to ensure that the Program is administered efficiently, that the organization contracts with a sufficient number of providers of service in a geographical area to provide recipients accessibility to providers, and that providers of service are reimbursed at a sufficient level to assure quality care.  If all services contracted for are not being provided to recipients, the Commission may withhold payment to the organization for the services not provided.
(c)	Pursuant to the contract, the Commission may impose a penalty up to the value of the unclaimed revenue on the organization if it fails to pursue payment for services provided to recipients who are eligible for participation in the medical assistance program established pursuant to the social services law or for services provided to recipients who are covered by health insurance.
(d)	The Commission shall establish a statewide public education campaign to publicize the Universal Access Program, to encourage enrollment in the Program, to emphasize the need for and importance of prenatal care for the health of mothers and newborns and to provide information about the effects of poor nutrition, tobacco, alcohol, and substance abuse on pregnant women.
(e)	The Commission may set standards for providers of service who may participate in the Universal Access Program including, but not limited to, licensure requirements, quality of care, and accessibility to providers of service.  The Commission may establish a program to assure the quality of services provided to recipients.
(f)	The Commission may promulgate such rules and regulations as may be necessary to implement the provisions of this title.
"§ 130B-5.  Program eligibility.
(a)	Persons eligible for participation in the Universal Access Program shall include pregnant women and their newborns who (i) are eligible for medical assistance under Universal Access Program regulations, or (ii) do not have private health insurance, or (iii) have private health insurance that does not provide full coverage for services defined in G.S. 130B-6, and (iv) who file an application for enrollment in the Universal Access Program with the health insurance organization.
(b)	When a pregnant woman files an application for enrollment in the Universal Access Program she must advise the health insurance organization of any individual, group, or blanket accident and health insurance policy under which she is covered.  If a pregnant woman is covered by an individual, group, or blanket accident and health insurance policy which provides benefits directly to her, upon enrollment in the Universal Access Program, she shall assign any maternity care and newborn infant benefits under such policy to the health insurance organization.
(c)	A woman residing in this State for at least six months shall be presumed to be eligible for participation in the Universal Access Program from the date that an eligible provider of service as defined in G.S. 130B-3 of this Chapter determines (i) that the woman intends to become pregnant and is in need of preconceptional or genetic counseling, or (ii) that the woman is pregnant.  If a recipient is subsequently determined to be ineligible for services, the organization shall pay for the cost of services provided to the recipient by an eligible provider of service during the period of presumed eligibility prior to the determination of ineligibility.  Appropriate reimbursement to the organization for the cost of such services shall be included in the contract.
"§ 130B-6.  Provision of maternal and newborn services.
(a)	The health insurance organization shall pay for prenatal care, delivery, postpartum and newborn care services provided to eligible recipients and their newborns by eligible service providers.  Prenatal care, delivery, postpartum and newborn care services shall include (i) preconceptional and genetic counseling, (ii) prenatal care as defined by the Commission, (iii) referral for special tests, consultations and hospitalization, (iv) referral for nutrition services, such as programs that provide food, screening to identify nutritional risks and problems, and education about proper diet, (v) delivery services and associated care provided by eligible providers, (vi) postpartum services, as defined by the Commission, for a 60-day period beginning on the last day of the pregnancy, and (vii) medical services for newborns up to six months after birth, and the cost of referral to other programs such as those provided by the Department of Social Services.  Referral services shall be covered for an eligible recipient's alcohol, substance abuse, or mental health program only when such are determined to be a factor related to the health of the mother or child.  Covered services do not include abortion or abortion referrals unless the mother's life is endangered.
(b)	Notwithstanding any inconsistent provision of this Chapter or any other law to the contrary, every pregnant woman eligible for or receiving medical assistance in the State shall be provided services as defined in this section only by eligible providers pursuant to the Universal Access Program established by this Chapter, except for good cause as defined by the State Health Director.  Participation in the Universal Access Program shall not affect a pregnant  recipient's medical assistance eligibility or the scope of available medical services to which she is otherwise entitled, other than for the services defined in G.S. 130B-6.
"§ 130B-7.  Program administration.
The responsibilities of the health insurance organization shall be:
(1)	To ensure that all Program services as defined in this Chapter are provided to all eligible recipients enrolled in the Universal Access Program.
(2)	To enroll providers of service or a network of providers of service who are eligible and who meet standards established by the Commission pertaining to accessibility of services and quality of care.  The organization shall provide the Commission, upon request, any information, including patient records, pertaining to the quality of service that is provided in the Program.
(3)	To enroll recipients in the Program as early in the pregnancy as possible and to encourage early and continuous prenatal care.  The health insurance organization shall be responsible for determining if recipients are eligible to participate in the Program pursuant to the provisions of this Chapter.  The organization shall establish procedures regarding an enrolled recipient's right to register complaints about the services provided to her and the process to be followed if such recipient wishes to seek Program services from another eligible provider enrolled in the Universal Access Program.  A copy of such procedures shall be given to each recipient upon her enrollment in the Universal Access Program.
(4)	To ensure that arrangements exist between eligible providers of prenatal care services and eligible providers of delivery services so that there is a continuity of care provided to the eligible recipient.
(5)	To coordinate benefits with those insurance companies providing maternity care coverage to pregnant women who are enrolled in the Universal Access Program, and to provide for recoupment of any duplicate reimbursement paid by the organization on behalf of an eligible recipient.
(6)	To provide periodic reports and data, including financial data, as required by the Commission.  The organization shall provide information, including patient records, to the Department of Social Services concerning services provided under the Program to recipients who are eligible for medical assistance. Except as otherwise provided in this Chapter, the organization shall be responsible for assuring confidentiality of all information concerning recipients.  All information concerning applicants for or recipients of medical assistance shall be kept confidential in accordance with G.S. 108A-80.
"§ 130B-8.  Eligible providers of service.
Providers of service are eligible to participate in the Universal Access Program if they (i)	satisfy the standards for providing service established by the Commission pursuant to G.S. 130B-3, (ii) have not been disqualified from participation in the medical assistance program, and (iii) agree to provide services to recipients in the Universal Access Program and participate in a quality assurance program.
"§ 130B-9.  Payment for services.
(a)	The health insurance organization shall be responsible for negotiating the amount of reimbursement to be paid to eligible providers of service for services delivered to recipients enrolled in the Universal Access Program.  Notwithstanding any provision of law to the contrary and subject to the provisions of this Chapter, the organization and eligible providers of service may negotiate varying or uniform prices or rates of payment of services provided to eligible recipients in accordance with this Chapter.  Subject to the approval of the Commission, the organization may arrange for subcontracts among providers for the provision of appropriate services.  The organization shall ensure that reimbursement is not made to providers of service unless the services are delivered to recipients.
(b)	After consultation with and approval of the Secretary of Human Resources, the Commission shall determine the amount to be paid, subject to the approval of the Director of the Budget, to the health insurance organization for the provision of services to eligible recipients.  In determining such amount, the Commission may consider regional differences and incentives to the organization for effectively implementing this Chapter.  Upon execution of a contract between the Commission and the health insurance organization, the organization shall be liable for any costs incurred in excess of the contractual provisions.
"§ 130B-10.  Universal Access Program Fund created; funding.
The Commission may create a Universal Access Program Fund to pay the health insurance organization pursuant to the terms of a contract for the services provided under this Chapter.  The Universal Access Program Fund shall include the following:
(1)	Funds appropriated annually to the prenatal care and nutrition program.  All funds which have been allocated to the Program shall be transferred to the Universal Access Program Fund.
(2)	Funds from the federal maternal and child health services block grant, as enacted by the federal omnibus reconciliation act of 1981. Upon approval of the Director of the Budget, funds shall be transferred to the Universal Access Program Fund from such grant in an amount set forth in an expenditure plan prepared by the Commission for the current federal fiscal year for services defined in this Chapter.  The amount to be transferred to the Universal Access Program Fund shall not be less than the proportionate amount reflected in the expenditure plan prepared by the Commission for the current federal fiscal year for services defined in G.S. 130B-6.  The amount to be transferred to the Universal Access Program Fund shall not be less than the proportionate amount reflected in the expenditure plan prepared by the Commission for the immediately preceding federal fiscal year.
(3)	Private health insurance covering an eligible recipient shall be used before any funds are expended from the Universal Access Program Fund.
(4)	To the extent expenditures are provided to recipients pursuant to the Universal Access Program, the Commission shall be subrogated to any rights such recipient may have to medical support or third party reimbursement.  For purposes of this section, the term ‘medical support' means the right to support for medical care as determined by a court or administrative order. The right of subrogation does not attach to insurance benefits paid or provided under any health insurance policy prior to the receipt of written notice of the exercise of such subrogation rights by the carrier.  No right of subrogation to insurance benefits available under any health insurance policy shall be enforceable unless written notice of the exercise of such subrogation right is received by the carrier within two years from the date services for which benefits are provided under the policy or contract are rendered.  The Commission shall also notify the carrier when the exercise of subrogation rights has terminated because a person is no longer receiving Program services under this Chapter.  Such carrier shall establish mechanisms to maintain the confidentiality of all individually identifiable information or records to the specific purpose for which such disclosure is made, and shall not further disclose such information or records.
(5)	Notwithstanding any inconsistent provisions of this Chapter or any other law to the contrary, no employer or organization who has a plan providing care and other medical benefits for persons, whether by insurance or otherwise, shall exclude a person from eligibility, coverage or entitlement to benefits under such plan by reason of the eligibility of such person for services under this Chapter, or by reason of the fact that such person would, except for such plan, be eligible for services under this Chapter.  Where an eligible recipient has health insurance in force covering care and other medical benefits provided under this Chapter, payment or part-payment of the premium for such insurance may also be made by the Commission when deemed appropriate pursuant to the regulations.
(6)	Each employer of four or more persons shall pay to the State, in addition to taxes required by law elsewhere, the sum of              dollars ($   ) per month per employee, to be allocated to the Universal Access Program.  Payment shall be made on a quarterly basis for all employees of the employer during the quarter; provided, that each employer shall be entitled to a credit against any payment required by this subsection equal to one dollar and twenty-five cents ($1.25) for each one dollar ($1.00) paid by the employer for health insurance premiums paid by the employer if the health insurance provided by the employer provides coverage essentially equal to those services set forth in G.S. 130B-6.
(7) 	No county shall reduce its aggregate expenditures for family health and other public health services below the aggregate level expended by such county during the fiscal year immediately preceding the effective date of this title.
"§ 130B-11.  Fund administration.
The Commission may contract with such Fund administrators as the Commission designates to receive funds for the Universal Access Program Fund and to distribute such funds in accordance with this Chapter.  In the event a contract with a Fund administrator is effectuated, the Commission shall conduct annual audits of the receipt and distribution of the funds.
"§ 130B-12.  Evaluation.
The Commission shall evaluate the effect of the Universal Access Program in reducing the incidence of infant mortality and low birthweight babies born to recipients.  The Commission shall also determine the cost effectiveness of the Program and shall consider the impact of prenatal care services on the need for neonatal intensive care services and services provided to developmentally disabled children.  In determining cost effectiveness of the Program, the Commission shall include recommendations relating to findings concerning Program cost growth and propose feasible alternatives for addressing such issues.  After consultation with the Secretary of Human Resources, the Commission shall submit to the General Assembly and to the Governor an interim report on the evaluation. The interim report shall be submitted one year after this Chapter takes effect. A final report to the General Assembly and the Governor shall be submitted three years after this Chapter takes effect."
Sec. 2.  Chapter 108A of the General Statutes is amended by adding new sections to read:
"§ 108A-67.  Universal Access Program.
(a)	Notwithstanding any inconsistent provision of this Chapter or any other law to the contrary, the Department is authorized to participate in the Universal Access Program established pursuant to Chapter 130B of the General Statutes.  Subject to the approval of the Director of the Budget, the Department may apply for the appropriate waivers under federal law and regulation.
(b)	For the purposes of determining eligibility for medical assistance under this Chapter for pregnant women enrolled in the Universal Access Program, the estimated cost of prenatal care, delivery, postpartum and newborn care services shall be deducted from household income.
(c)	Every pregnant woman receiving medical assistance pursuant to this Chapter, or eligible for medical assistance under this section, shall be provided services as defined in G.S. 130B-6 only by eligible providers of service participating in the Universal Access Program established pursuant to Chapter 130B of the General Statutes except for good cause as defined by the Department.  Participation in the Universal Access Program shall not affect a pregnant woman's medical assistance eligibility or the scope of available medical services to which she is otherwise entitled pursuant to this Chapter except as provided in this section.
(d)	After consultation with Commission, the Department may pay for the cost of services, as determined pursuant to G.S. 130B-6, provided to recipients eligible for medical assistance enrolled in the Universal Access Program pursuant to Chapter 130B.  The Commission may reduce such payments for the cost of services provided to a recipient eligible for medical assistance in the amount that maternity care benefits are available from health insurance or other third party reimbursement under which such recipient is covered.  If all services paid for are not being provided to recipients enrolled in the Universal Access Program, the Department may, after consultation with the Commission of Health Services withhold payment to the organization for the services not provided.
"§ 108A-68.  Special medical assistance.
(a)	Special medical assistance shall be provided to pregnant women and infants younger than one year old who are not otherwise eligible for medical assistance pursuant to this section.
(b)	The General Assembly shall establish a special income eligibility standard for pregnant women and infants younger than one year old.  This income eligibility standard may equal, but may not exceed, the comparable nonfarm federal poverty level for a family of the same size.  Pregnant women and infants younger than one year old may receive medical assistance care and services if their family income does not exceed this income eligibility standard.  Family income shall be determined for purposes of this subsection by use of the same methodology used to determine eligibility for aid to dependent children benefits.  Pregnant women and infants younger than one year old whose family income exceeds the income eligibility standard authorized by this subsection may not become eligible for medical assistance pursuant to this subsection by incurring medical expenses sufficient to reduce their income to this eligibility standard.  In determining eligibility pursuant to this subsection, resources available to pregnant women or infants younger than one year old shall not be considered nor required to be applied toward the payment or part payment of the cost of medical assistance care and services available under this paragraph.
(c)	Pregnant women and infants younger than one year old who are eligible for medical assistance pursuant to subsection (b) of this section may receive medical assistance care and services as follows:
(1)	Eligible pregnant women may receive only pregnancy-related services during their pregnancies and for 60 days after their pregnancies end.  Pregnancy-related services include prenatal, delivery, and postpartum services as well as services related to conditions that complicate pregnancy.
(2)	Eligible infants younger than one year old may receive all medical assistance care and services authorized pursuant to this Chapter."
Sec. 3.  G.S. 58-251.2 of the General Statutes is amended by adding a new subsection to read:
"( h)	No terms of any policy or contract which directly or indirectly prevent or prohibit the assignment of rights under any policy or contract shall prevent the Commission from claiming benefits to which it shall be subrogated under Chapter 130B of the General Statutes.  The right of subrogation attaches to any benefits paid or provided under any policy, plan or contract upon receipt of written notice of the exercise of such subrogation rights."
Sec. 4.  This act shall become effective July 1, 1989.