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Durham County Social Services

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Proposed NC Medicaid Changes

PUBLIC NOTICE
Revised (SPA 22-0033)
PHARMACY COVERED OUTPATIENT DRUGS (COD) PROFESSIONAL DISPENSING FEE (PDF)
AND
PHYSICIAN ADMINISTERED DRUG PROGRAM (PADP) LONG- ACTING REMOVABLE CONTRACEPTIVE (LARC)

The Department of Health and Human Services, Division of Health Benefits hereby provides notice of its intent to amend the Medicaid State Plan Attachment 4.19-B, Section 12. This amendment revises the pharmacy reimbursement methodology for professional dispensing fees (PDF) to be set at a flat fee determined by the Cost of Dispensing Study conducted on behalf of the North Carolina Department of Health and Human Services, Division of Health Benefit every five (5) years and removes the rule allowing for only one PDF per drug, per member, per pharmacy, per month. This amendment also changes the reimbursement for long acting reversable contraceptives (LARCs) in the Physician Administered Drug Program (PADP) acquired and dispensed under the 340B program, to be reimbursed at the lesser of 340B ceiling price plus six percent (6%) or billed amount. These new reimbursements will be applicable to all active NC Medicaid providers.

The amendments will become effective December 1, 2022. The annual estimated state fiscal impacts of these changes are:

  1. SFY 2023($94,623)
  2. SFY 2024($200,342)

A copy of the proposed public notice may be viewed at the County Department of Social Services. Questions, comments, and requests for copies of the proposed State Plan amendment should be directed to the Division of Health Benefit at the address listed below:

Dave Richard Deputy Secretary
Durham County DSS
414. E. Main Street
Durham, NC 27701
Hours of operation: 7:30 a.m.- 5:30 p.m.

Posted on the Division of Health Benefits Website: October 28, 2022

Notice

TO PERSONS WHO HAVE HAD OR MAY IN THE FUTURE HAVE THEIR MEDICAID BENEFITS TERMINATED OR REDUCED IN NORTH CAROLINA:

PROPOSED SETTLEMENT OF FRANKLIN et al. v. KINSLEY.

United States District Court – Eastern District of North Carolina Case No.: 5:17-CV-581

Franklin et al. v. Kinsley, formerly known as Hawkins et al. v. Cohen, is a federal lawsuit filed in 2017. This case was certified by the Court as a class action lawsuit on behalf of

N.C. Medicaid beneficiaries.

In this lawsuit, the Plaintiffs allege that the N.C. Medicaid agency, along with county Departments of Social Services (DSS), was terminating and reducing Medicaid benefits without considering eligibility under all Medicaid categories and without first providing timely and adequate written notice, in violation of federal Medicaid statute and the U.S. Constitution. The Defendant denied those allegations.

The named Plaintiffs and the Defendant have reached a Settlement Agreement to resolve the lawsuit. In reaching the Settlement Agreement, the Defendant has not admitted any wrongdoing, but has agreed to modify the procedures, forms, and notices for redetermining Medicaid eligibility. The Court plans to approve the Settlement Agreement unless a good reason is given not to do so. The Settlement Agreement includes detailed descriptions of the steps that have been or will be taken to:

  • Assure that Medicaid does not stop without notice because the county DSS has not timely redetermined Medicaid eligibility;
  • Assure that all categories of Medicaid eligibility are considered before termination or reduction of Medicaid;
  • Assure that persons receiving Medicaid in other categories are given an opportunity to have their eligibility as a disabled person considered prior to termination or reduction of their Medicaid benefits;
  • Assure compliance with all federal regulations governing the Medicaid eligibility process;
  • Assure that the written notice provided before Medicaid is reduced or terminated clearly and specifically states what action will be taken and the reason for that action;
  • Assure that all county DSSs comply with the provisions of the agreement.

The members of the class who would be bound by the settlement include all current or future North Carolina Medicaid recipients for whom Defendant or county DSSs reduced or terminated Medicaid benefits without following the procedures set out above.

RIGHT TO OBJECT: Any class member has the right to object to this proposed Settlement Agreement; however, a class member does not have the ability to exclude himself or herself from being bound by the settlement if it is approved.

You may review the proposed Settlement Agreement by visiting the Civil Clerk's office at 413 Middle Street, New Bern, NC 28560. The Settlement Agreement is also available at the following websites: www.healthlaw.org/Franklinsettlement; www.charlottelegaladvocacy.org/Franklinsettlement.

You may file written objections to the dismissal by mailing your reasons for objection to the Clerk of Court at the above address no later than December 31, 2022. If you wish to file evidence to support your objections, you must file the evidence in writing by that date.

You also have the right to object to the Settlement Agreement in person at a hearing that will be held at 11:00 a.m. on January 13, 2023. The hearing will take place at the United States District Court, 413 Middle Street, New Bern, NC 28560.

To ask questions of Plaintiffs' attorneys about the case or the procedure for objecting to the dismissal, call toll free at 1-800-936-4971. You can also email Plaintiffs’ attorneys at hawkinsinfo@charlottelegaladvocacy.org.