North Carolina 2025-2026 Regular Session

North Carolina Senate Bill S600 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		GENERAL ASSEMBLY OF NORTH CAROLINA
2	2		SESSION 2025
3		-	S 2
	3	+	S 1
4	4		SENATE BILL 600
5		-	~~Health Care Committee Substitute Adopted 4/16/25~~
	5	+
6	6
7	7		Short Title: Medicaid Agency Omnibus. (Public)
8		-	Sponsors:
9		-	Referred to:
	8	+	Sponsors: Senators Burgin, Galey, and Sawrey (Primary Sponsors).
	9	+	Referred to: Rules and Operations of the Senate
10	10		March 26, 2025
11		-	S600 -v-2
	11	+	S600 -v-1
12	12		A BILL TO BE ENTITLED 1
13	13		AN ACT MAKING TECHNI CAL, CONFORMING, AND OTHER MODIFICATIONS TO 2
14	14		LAWS PERTAINING TO THE DEPARTMENT OF HEA LTH AND HUMAN SERVIC ES, 3
15	15		DIVISION OF HEALTH BENEFITS. 4
16	16		The General Assembly of North Carolina enacts: 5
17	17		6
18	18		TEMPORARILY EXTEND OPTION TO DECREASE MEDICAID ENROLLMENT 7
19	19		BURDEN ON COUNTY DEPARTMENTS OF SOCIAL SERVICES 8
20	20		SECTION 1. Section 1.8(a) of S.L. 2023-7, as amended by Section 9(a) of S.L. 9
21	21		2024-34, reads as rewritten: 10
22	22		"SECTION 1.8.(a) Notwithstanding G.S. 108A-54(d) and in accordance with 11
23	23		G.S. 143B-24(b), the Department of Health and Human Services (DHHS) is authorized, on a 12
24	24		temporary basis to conclude by June 30, 2025, 2028, to utilize the federally facilitated 13
25	25		marketplace (Marketplace), also known as the federal health benefit exchange, to make Medicaid 14
26	26		eligibility determinations. In accordance with G.S. 108A-54(b), G.S. 108A-54(f), these 15
27	27		eligibility determinations shall be in compliance with all eligibility categories, resource limits, 16
28	28		and income thresholds set by the General Assembly." 17
29	29		18
30	30		CLARIFY ENROLLMENT IN MEDICAID MANAGED CARE AFTER RELEASE 19
31	31		FROM INCARCERATION 20
32	32		SECTION 2.(a) G.S. 108D-40 reads as rewritten: 21
33	33		"§ 108D-40. Populations covered by PHPs. 22
34	34		(a) Capitated PHP contracts shall cover all Medicaid program aid categories except for 23
35	35		the following categories: 24
36	36		… 25
37	37		(9) Recipients who are inmates of prisons. Upon the recipient's release from 26
38	38		prison, the exception under this subdivision shall continue to apply for a 27
39	39		period that is the shorter of the following:until the first day of the month 28
40	40		following the twelfth month after the recipient's release. 29
41	41		a. The recipient's initial Medicaid eligibility certification period post 30
42	42		release. 31
43	43		b. Three hundred sixty-five days. 32
44	44		(9a) Recipients residing in carceral settings other than prisons and whose Medicaid 33
45	45		eligibility has been suspended. Upon the recipient's release from 34
46	46		incarceration, the exception under this subdivision shall continue to apply for 35 General Assembly Of North Carolina Session 2025
47		-	Page 2 Senate Bill 600-~~Second~~ Edition
	47	+	Page 2 Senate Bill 600-First Edition
48	48		a period that is the shorter of the following:until the first day of the month 1
49	49		following the twelfth month after the recipient's release. 2
50	50		a. The recipient's initial Medicaid eligibility certification period post 3
51	51		release. 4
52	52		b. Three hundred sixty-five days. 5
53	53		…." 6
54	54		SECTION 2.(b) This section is effective when it becomes law and applies to (i) 7
55	55		inmates released on or after that date and (ii) inmates released on or after January 1, 2025, who 8
56	56		are not enrolled with a PHP on the date this act becomes law. 9
57	57		10
58	58		CONFORM NORTH CAROLINA LAW TO FEDERAL REQUIREMENTS FOR 11
59	59		MEDICAID CATEGORICAL RISK LEVELS FOR PROVIDER SCREENINGS 12
60	60		SECTION 3.(a) G.S. 108C-3 reads as rewritten: 13
61	61		"§ 108C-3. Medicaid provider screening. 14
62		-	(a) Provider Screening. – The Department shall conduct provider screening of Medicaid 15
63		-	providers in accordance with applicable State or federal law or regulation. 16
64		-	(b) Enrollment Screening. – The Department must screen all initial provider applications 17
65		-	for enrollment in Medicaid, including applications for a new practice location, and all 18
66		-	revalidation requests based on Department the Department's assessment of risk and assignment 19
67		-	of the provider to a categorical risk level of "limited," "moderate," or "high." limited, moderate, 20
68		-	or high. If a provider could fit within more than one risk level described in this section, the highest 21
69		-	level of screening is applicable. 22
70		-	(c) Limited Categorical Risk Provider Types. – The All of the following provider types 23
71		-	are hereby designated as "limited" limited categorical risk: 24
	62	+	… 15
	63	+	(c) Limited Categorical Risk Provider Types. – The following provider types are hereby 16
	64	+	designated as "limited" categorical risk: 17
	65	+	… 18
	66	+	(10) Nursing facilities, including Intermediate Care Facilities for Individuals with 19
	67	+	Intellectual Disabilities.Disabilities, that are not skilled nursing facilities. 20
	68	+	… 21
	69	+	(e) Moderate Categorical Risk Provider Types. – The following provider types are hereby 22
	70	+	designated as "moderate" categorical risk: 23
	71	+	… 24
	72	+	(15) Revalidating skilled nursing facilities, unless they meet the description in 25
	73	+	subdivision (g)(13) of this section. 26
	74	+	… 27
	75	+	(g) High Categorical Risk Provider Types. – The following provider types are hereby 28
	76	+	designated as "high" categorical risk: 29
	77	+	… 30
	78	+	(13) Prospective (newly enrolling) skilled nursing facilities and those undergoing 31
	79	+	a change in ownership. 32
	80	+	…." 33
	81	+	SECTION 3.(b) G.S. 108C-3, as amended by Section 3(a) of this act, reads as 34
	82	+	rewritten: 35
	83	+	"§ 108C-3. Medicaid provider screening. 36
	84	+	… 37
	85	+	(c) Limited Categorical Risk Provider Types. – The following provider types are hereby 38
	86	+	designated as "limited" categorical risk: 39
	87	+	(1) Ambulatory surgical centers. 40
	88	+	(1a) Behavioral health and intellectual and developmental disability provider 41
	89	+	agencies that are nationally accredited by an entity approved by the 42
	90	+	Secretary.Secretary, unless they meet the description in subdivision (g)(15) of 43
	91	+	this section. 44
	92	+	… 45
	93	+	(16) Portable X-ray suppliers. 46
	94	+	… 47
	95	+	(e) Moderate Categorical Risk Provider Types. – The following provider types are hereby 48
	96	+	designated as "moderate" categorical risk: 49
	97	+	… 50 General Assembly Of North Carolina Session 2025
	98	+	Senate Bill 600-First Edition Page 3
	99	+	(5) Hospice organizations.Revalidating hospice organizations, unless they meet 1
	100	+	the description in subdivisions (g)(14) and (g)(15) of this section. 2
	101	+	… 3
	102	+	(10) Revalidating adult care homes delivering Medicaid-reimbursed 4
	103	+	services.services, unless they meet the description in subdivision (g)(15) of 5
	104	+	this section. 6
	105	+	(11) Revalidating agencies providing durable medical equipment, including, but 7
	106	+	not limited to, orthotics and prosthetics.prosthetics, unless they meet the 8
	107	+	description in subdivision (g)(15) of this section. 9
	108	+	(12) Revalidating agencies providing nonbehavioral health home- or 10
	109	+	community-based services pursuant to waivers authorized by the federal 11
	110	+	Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).42 12
	111	+	U.S.C. § 1396n(c), unless they meet the description in subdivision (g)(15) of 13
	112	+	this section. 14
	113	+	(13) Revalidating agencies providing private duty nursing, home health, personal 15
	114	+	care services or in-home care services, or home infusion.infusion, unless they 16
	115	+	meet the description in subdivision (g)(15) of this section. 17
	116	+	(14) Nonemergency medical transportation. 18
	117	+	(15) Revalidating skilled nursing facilities, unless they meet the description in 19
	118	+	subdivision subdivisions (g)(13) or (g)(15) of this section. 20
	119	+	(16) Portable X-ray suppliers. 21
	120	+	… 22
	121	+	(g) High Categorical Risk Provider Types. – The following provider types are hereby 23
	122	+	designated as "high" categorical risk: 24
72	123		… 25
73		-	(4) Health programs operated by an Indian Health Program (as Program, as 26
74		-	defined in section 4(12) of the Indian Health Care Improvement Act) Act, or 27
75		-	an urban Indian organization (as organization, as defined in section 4(29) of 28
76		-	the Indian Health Care Improvement Act) Act, that receives funding from the 29
77		-	Indian Health Service pursuant to Title V of the Indian Health Care 30
78		-	Improvement Act. 31
79		-	… 32
80		-	(10) Nursing facilities, including Intermediate Care Facilities for Individuals with 33
81		-	Intellectual Disabilities.Disabilities, that are not skilled nursing facilities. 34
82		-	(10a) Skilled nursing facilities that are limited categorical risk under subsection (k) 35
83		-	of this section. 36
84		-	… 37
85		-	(12) Physician or nonphysician practitioners (including practitioners, including 38
86		-	nurse practitioners, CRNAs, physician assistants, physician extenders, 39
87		-	occupational therapists, speech/language pathologists, chiropractors, and 40
88		-	audiologists), optometrists, audiologists; optometrists; dentists and 41
89		-	orthodontists, orthodontists; and medical groups or clinics. 42
90		-	… 43
91		-	(d) Limited Categorical Risk Screenings. – When the Department designates a provider 44
92		-	as a "limited" limited categorical level of risk, the Department shall conduct such the applicable 45
93		-	screening functions as required by federal law. 46
94		-	(e) Moderate Categorical Risk Provider Types. – The All of the following provider types 47
95		-	are hereby designated as "moderate" moderate categorical risk: 48
96		-	… 49
97		-	(8) Pharmacy Services. services. 50
98		-	… 51 General Assembly Of North Carolina Session 2025
99		-	Senate Bill 600-Second Edition Page 3
100		-	(11) Revalidating agencies providing durable medical equipment, including, but 1
101		-	not limited to, including orthotics and prosthetics. 2
102		-	… 3
103		-	(15) Skilled nursing facilities that are moderate categorical risk under subsection 4
104		-	(k) of this section. 5
105		-	(f) Moderate Categorical Risk Screenings. – When the Department designates a provider 6
106		-	as a "moderate"' moderate categorical level of risk, the Department shall conduct such the 7
107		-	applicable screening functions as required by federal law and regulation. 8
108		-	(g) High Categorical Risk Provider Types. – The All of the following provider types are 9
109		-	hereby designated as "high" high categorical risk: 10
110		-	(1) Prospective (newly enrolling) Prospective, or newly enrolling, adult care 11
111		-	homes delivering Medicaid-reimbursed services. 12
112		-	… 13
113		-	(4) Prospective (newly enrolling) Prospective, or newly enrolling, agencies 14
114		-	providing durable medical equipment, including, but not limited to, orthotics 15
115		-	and prosthetics. 16
116		-	… 17
117		-	(6) Prospective (newly enrolling) Prospective, or newly enrolling, agencies 18
118		-	providing nonbehavioral health home- or community-based services pursuant 19
119		-	to waivers authorized by the federal Centers for Medicare and Medicaid 20
120		-	Services under 42 U.S.C. § 1396n(c). 21
121		-	(7) Prospective (newly enrolling) Prospective, or newly enrolling, agencies 22
122		-	providing personal care services or in-home care services. 23
123		-	(8) Prospective (newly enrolling) Prospective, or newly enrolling, agencies 24
124		-	providing private duty nursing, home health, or home infusion. 25
125		-	(9) Providers against whom which the Department has imposed a payment 26
126		-	suspension based upon a credible allegation of fraud in accordance with 42 27
127		-	C.F.R. § 455.23 within the previous 12-month period. The Department shall 28
128		-	return the provider to its original risk category not later than 12 months after 29
129		-	the cessation of the payment suspension. 30
130		-	… 31
131		-	(11) Providers who that have incurred a Medicaid final overpayment, assessment, 32
132		-	or fine to the Department in excess of twenty percent (20%) of the provider's 33
133		-	payments received from Medicaid in the previous 12-month period. The 34
134		-	Department shall return the provider to its original risk category not later than 35
135		-	12 months after the completion of the provider's repayment of the final 36
136		-	overpayment, assessment, or fine. 37
137		-	… 38
138		-	(13) Skilled nursing facilities that are high categorical risk under subsection (k) of 39
139		-	this section. 40
140		-	(h) High Categorical Risk Screenings. – When the Department designates a provider as 41
141		-	a "high" high categorical level of risk, the Department shall conduct such the applicable screening 42
142		-	functions as required by federal law and regulation. 43
143		-	(i) Dually-Enrolled Providers. – For providers dually enrolled in the federal Medicare 44
144		-	program and Medicaid, the Department may rely on the results of the provider screening 45
145		-	performed by Medicare contractors. 46
146		-	(j) Out-of-State Providers. – For out-of-state providers, the Department may rely on the 47
147		-	results of the provider screening performed by the Medicaid agencies or Children's Health 48
148		-	Insurance Program agencies of other states. 49
149		-	(k) Skilled Nursing Facilities. – The categorical risk level for provider screening of 50
150		-	skilled nursing facilities is the categorical risk level required by federal law or regulation. If 51 General Assembly Of North Carolina Session 2025
151		-	Page 4 Senate Bill 600-Second Edition
152		-	federal law or regulation does not require a particular categorical risk level, skilled nursing 1
153		-	facilities are limited categorical risk." 2
154		-	SECTION 3.(b) G.S. 108C-3, as amended by Section 3(a) of this act, reads as 3
155		-	rewritten: 4
156		-	"§ 108C-3. Medicaid provider screening. 5
157		-	… 6
158		-	(c) Limited Categorical Risk Provider Types. – All of the following provider types are 7
159		-	designated as limited categorical risk: 8
160		-	(1) Ambulatory surgical centers. 9
161		-	(1a) Behavioral health and intellectual and developmental disability provider 10
162		-	agencies that are nationally accredited by an entity approved by the 11
163		-	Secretary.Secretary, unless they meet the description in subdivision (g)(15) of 12
164		-	this section. 13
165		-	… 14
166		-	(16) Portable X-ray suppliers. 15
167		-	… 16
168		-	(e) Moderate Categorical Risk Provider Types. – All of the following provider types are 17
169		-	designated as moderate categorical risk: 18
170		-	… 19
171		-	(5) Hospice organizations.Revalidating hospice organizations, unless they meet 20
172		-	the description in subdivisions (g)(14) and (g)(15) of this section. 21
173		-	… 22
174		-	(10) Revalidating adult care homes delivering Medicaid-reimbursed 23
175		-	services.services, unless they meet the description in subdivision (g)(15) of 24
176		-	this section. 25
177		-	(11) Revalidating agencies providing durable medical equipment, including 26
178		-	orthotics and prosthetics. prosthetics, unless they meet the description in 27
179		-	subdivision (g)(15) of this section. 28
180		-	(12) Revalidating agencies providing nonbehavioral health home- or 29
181		-	community-based services pursuant to waivers authorized by the federal 30
182		-	Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).42 31
183		-	U.S.C. § 1396n(c), unless they meet the description in subdivision (g)(15) of 32
184		-	this section. 33
185		-	(13) Revalidating agencies providing private duty nursing, home health, personal 34
186		-	care services or in-home care services, or home infusion.infusion, unless they 35
187		-	meet the description in subdivision (g)(15) of this section. 36
188		-	… 37
189		-	(16) Portable X-ray suppliers. 38
190		-	… 39
191		-	(g) High Categorical Risk Provider Types. – All of the following provider types are 40
192		-	designated as high categorical risk: 41
193		-	… 42
194		-	(14) Prospective, or newly enrolling, hospice organizations and revalidating 43
195		-	hospice organizations undergoing a change in ownership. 44
196		-	(15) The following revalidating providers (i) that are revalidating for the first time 45
197		-	since newly enrolling and (ii) for which fingerprinting requirements, as a 46
198		-	newly enrolling provider, were waived due to a national, state, or local 47
199		-	emergency: 48
200		-	a. Opioid treatment programs that have not been fully and continuously 49
201		-	certified by the Substance Abuse and Mental Health Services 50
202		-	Administration since October 23, 2018. 51 General Assembly Of North Carolina Session 2025
203		-	Senate Bill 600-Second Edition Page 5
204		-	b. Agencies providing durable medical equipment, including orthotics 1
205		-	and prosthetics. 2
206		-	c. Adult care homes delivering Medicaid-reimbursed services. 3
207		-	d. Agencies providing private duty nursing, home health, personal care 4
208		-	services, or in-home care services, or home infusion. 5
209		-	e. Hospice organizations. 6
210		-	…." 7
211		-	SECTION 3.(c) Subsection (a) of this section is retroactively effective January 1, 8
212		-	2023. The remainder of this section is retroactively effective January 1, 2024. 9
213		-	10
214		-	CLARIFY MEDICAID SUBROGATION RIGHTS IN MANAGED CARE 11
215		-	ENVIRONMENT 12
216		-	SECTION 4.(a) G.S. 108A-57 reads as rewritten: 13
217		-	"§ 108A-57. Subrogation rights; withholding of information a misdemeanor. 14
218		-	(a) As used in this section, the term "beneficiary" means (i) the beneficiary of medical 15
219		-	assistance, including a minor beneficiary, (ii) the medical assistance beneficiary's parent, legal 16
220		-	guardian, or personal representative, (iii) the medical assistance beneficiary's heirs, and (iv) the 17
221		-	administrator or executor of the medical assistance beneficiary's estate. 18
222		-	Notwithstanding any other provisions of the law, to the extent of payments under this Part, 19
223		-	the State shall be subrogated to all rights of recovery, contractual or otherwise, of a beneficiary 20
224		-	against any person. Any claim brought by a medical assistance beneficiary against a third party 21
225		-	shall include a claim for all medical assistance payments for health care items or services 22
226		-	furnished to the medical assistance beneficiary as a result of the injury or action, hereinafter 23
227		-	referred to as the "Medicaid claim." Any claim brought by a medical assistance beneficiary 24
228		-	against a third party that does not state the Medicaid claim shall be deemed to include the 25
229		-	Medicaid claim. If the beneficiary has claims against more than one third party related to the 26
230		-	same injury, then any amount received in payment of the Medicaid claim related to that injury 27
231		-	shall reduce the total balance of the Medicaid claim applicable to subsequent recoveries related 28
232		-	to that injury. 29
233		-	The Department may designate one or more PHPs to receive all or a portion of payments due 30
234		-	under this section to the Department for the Medicaid claim by sending a notice of designation 31
235		-	to (i) the beneficiary who has the claim against the third party and (ii) any PHP designated in the 32
236		-	notice. As used in this section, the term "designated PHP" refers to a PHP designated in the notice 33
237		-	of designation under this subsection. 34
238		-	(a1) If the amount of the Medicaid claim does not exceed one-third of the medical 35
239		-	assistance beneficiary's gross recovery, it is presumed that the gross recovery includes 36
240		-	compensation for the full amount of the Medicaid claim. If the amount of the Medicaid claim 37
241		-	exceeds one-third of the medical assistance beneficiary's gross recovery, it is presumed that 38
242		-	one-third of the gross recovery represents compensation for the Medicaid claim. 39
243		-	(a2) A medical assistance beneficiary may dispute the presumptions established in 40
244		-	subsection (a1) of this section by applying to the court in which the medical assistance 41
245		-	beneficiary's claim against the third party is pending, or if there is none, then to a court of 42
246		-	competent jurisdiction in this State, for a determination of the portion of the beneficiary's gross 43
247		-	recovery that represents compensation for the Medicaid claim. An application under this 44
248		-	subsection shall be filed with the court and served on the Department pursuant to the Rules of 45
249		-	Civil Procedure no later than 30 days after the date that the settlement agreement is executed by 46
250		-	all parties and, if required, approved by the court, or in cases in which judgment has been entered, 47
251		-	no later than 30 days after the date of entry of judgment. If a PHP made payments on behalf of a 48
252		-	Medicaid beneficiary that are included in the Medicaid claim, then the application shall also be 49
253		-	served on that PHP within the same time frame in which service is required on the Department. 50 General Assembly Of North Carolina Session 2025
254		-	Page 6 Senate Bill 600-Second Edition
255		-	The court shall hold an evidentiary hearing no sooner than 60 days after the date the action was 1
256		-	filed. All of the following shall apply to the court's determination under this subsection: 2
257		-	(1) The medical assistance beneficiary has the burden of proving by clear and 3
258		-	convincing evidence that the portion of the beneficiary's gross recovery that 4
259		-	represents compensation for the Medicaid claim is less than the portion 5
260		-	presumed under subsection (a1) of this section. 6
261		-	(2) The presumption arising under subsection (a1) of this section is not rebutted 7
262		-	solely by the fact that the medical assistance beneficiary was not able to 8
263		-	recover the full amount of all claims. 9
264		-	(3) If the beneficiary meets its burden of rebutting the presumption arising under 10
265		-	subsection (a1) of this section, then the court shall determine the portion of 11
266		-	the recovery that represents compensation for the Medicaid claim and shall 12
267		-	order the beneficiary to pay the amount so determined to the Department 13
268		-	Department, or designated PHP, in accordance with subsection (a5) of this 14
269		-	section. In making this determination, the court may consider any factors that 15
270		-	it deems just and reasonable. 16
271		-	(4) If the beneficiary fails to rebut the presumption arising under subsection (a1) 17
272		-	of this section, then the court shall order the beneficiary to pay the amount 18
273		-	presumed pursuant to subsection (a1) of this section to the Department 19
274		-	Department, or designated PHP, in accordance with subsection (a5) of this 20
275		-	section. 21
276		-	(a3) Notwithstanding the presumption arising pursuant to subsection (a1) of this section, 22
277		-	the medical assistance beneficiary and the Department may reach an agreement on the portion of 23
278		-	the recovery that represents compensation for the Medicaid claim. If such an agreement is 24
279		-	reached after an application has been filed pursuant to subsection (a2) of this section, a stipulation 25
280		-	of dismissal of the application signed by both parties shall be filed with the court. 26
281		-	(a4) Within 30 days of receipt of the proceeds of a settlement or judgment related to a 27
282		-	claim described in subsection (a) of this section, the medical assistance beneficiary or any 28
283		-	attorney retained by the beneficiary shall notify the Department Department, and any designated 29
284		-	PHP, of the receipt of the proceeds. 30
285		-	(a5) The medical assistance beneficiary or any attorney retained by the beneficiary shall, 31
286		-	out of the proceeds obtained by or on behalf of the beneficiary by settlement with, judgment 32
287		-	against, or otherwise from a third party by reason of injury or death, distribute to the Department 33
288		-	Department, or designated PHP, the amount due pursuant to this section as follows: 34
289		-	(1) If, upon the expiration of the time for filing an application pursuant subsection 35
290		-	(a2) of this section, no application has been filed, then the amount presumed 36
291		-	pursuant to subsection (a1) of this section, as prorated with the claims of all 37
292		-	others having medical subrogation rights or medical liens against the amount 38
	124	+	(14) Prospective (newly enrolling) hospice organizations and those undergoing a 26
	125	+	change in ownership. 27
	126	+	(15) The following revalidating providers (i) that are revalidating for the first time 28
	127	+	since newly enrolling and (ii) for which fingerprinting requirements as a 29
	128	+	newly enrolling provider were waived due to a national, State, or local 30
	129	+	emergency: 31
	130	+	a. Opioid treatment programs that have not been fully and continuously 32
	131	+	certified by the Substance Abuse and Mental Health Services 33
	132	+	Administration since October 23, 2018. 34
	133	+	b. Agencies providing durable medical equipment, including, but not 35
	134	+	limited to, orthotics and prosthetics. 36
	135	+	c. Adult care homes delivering Medicaid-reimbursed services. 37
	136	+	d. Agencies providing private duty nursing, home health, personal care 38
	137	+	services, or in-home care services, or home infusion. 39
	138	+	e. Skilled nursing facilities. 40
	139	+	f. Hospice organizations. 41
	140	+	…." 42
	141	+	SECTION 3.(c) Subsection (a) of this section is retroactively effective January 1, 43
	142	+	2023. The remainder of this section is retroactively effective January 1, 2024. 44
	143	+	45
	144	+	CLARIFY MEDICAID SUBROGATION RIGHTS IN MANAGED CARE 46
	145	+	ENVIRONMENT 47
	146	+	SECTION 4.(a) G.S. 108A-57 reads as rewritten: 48
	147	+	"§ 108A-57. Subrogation rights; withholding of information a misdemeanor. 49
	148	+	(a) As used in this section, the term "beneficiary" means (i) the beneficiary of medical 50
	149	+	assistance, including a minor beneficiary, (ii) the medical assistance beneficiary's parent, legal 51 General Assembly Of North Carolina Session 2025
	150	+	Page 4 Senate Bill 600-First Edition
	151	+	guardian, or personal representative, (iii) the medical assistance beneficiary's heirs, and (iv) the 1
	152	+	administrator or executor of the medical assistance beneficiary's estate. 2
	153	+	Notwithstanding any other provisions of the law, to the extent of payments under this Part, 3
	154	+	the State shall be subrogated to all rights of recovery, contractual or otherwise, of a beneficiary 4
	155	+	against any person. Any claim brought by a medical assistance beneficiary against a third party 5
	156	+	shall include a claim for all medical assistance payments for health care items or services 6
	157	+	furnished to the medical assistance beneficiary as a result of the injury or action, hereinafter 7
	158	+	referred to as the "Medicaid claim." Any claim brought by a medical assistance beneficiary 8
	159	+	against a third party that does not state the Medicaid claim shall be deemed to include the 9
	160	+	Medicaid claim. If the beneficiary has claims against more than one third party related to the 10
	161	+	same injury, then any amount received in payment of the Medicaid claim related to that injury 11
	162	+	shall reduce the total balance of the Medicaid claim applicable to subsequent recoveries related 12
	163	+	to that injury. 13
	164	+	The Department may designate one or more PHPs to receive all or a portion of payments due 14
	165	+	under this section to the Department for the Medicaid claim by sending a notice of designation 15
	166	+	to (i) the beneficiary who has the claim against the third party and (ii) any PHP designated in the 16
	167	+	notice. As used in this section, the term "designated PHP" refers to a PHP designated in the notice 17
	168	+	of designation under this subsection. 18
	169	+	(a1) If the amount of the Medicaid claim does not exceed one-third of the medical 19
	170	+	assistance beneficiary's gross recovery, it is presumed that the gross recovery includes 20
	171	+	compensation for the full amount of the Medicaid claim. If the amount of the Medicaid claim 21
	172	+	exceeds one-third of the medical assistance beneficiary's gross recovery, it is presumed that 22
	173	+	one-third of the gross recovery represents compensation for the Medicaid claim. 23
	174	+	(a2) A medical assistance beneficiary may dispute the presumptions established in 24
	175	+	subsection (a1) of this section by applying to the court in which the medical assistance 25
	176	+	beneficiary's claim against the third party is pending, or if there is none, then to a court of 26
	177	+	competent jurisdiction in this State, for a determination of the portion of the beneficiary's gross 27
	178	+	recovery that represents compensation for the Medicaid claim. An application under this 28
	179	+	subsection shall be filed with the court and served on the Department pursuant to the Rules of 29
	180	+	Civil Procedure no later than 30 days after the date that the settlement agreement is executed by 30
	181	+	all parties and, if required, approved by the court, or in cases in which judgment has been entered, 31
	182	+	no later than 30 days after the date of entry of judgment. If a PHP made payments on behalf of a 32
	183	+	Medicaid beneficiary that are included in the Medicaid claim, then the application shall also be 33
	184	+	served on that PHP within the same time frame in which service is required on the Department. 34
	185	+	The court shall hold an evidentiary hearing no sooner than 60 days after the date the action was 35
	186	+	filed. All of the following shall apply to the court's determination under this subsection: 36
	187	+	(1) The medical assistance beneficiary has the burden of proving by clear and 37
	188	+	convincing evidence that the portion of the beneficiary's gross recovery that 38
	189	+	represents compensation for the Medicaid claim is less than the portion 39
	190	+	presumed under subsection (a1) of this section. 40
	191	+	(2) The presumption arising under subsection (a1) of this section is not rebutted 41
	192	+	solely by the fact that the medical assistance beneficiary was not able to 42
	193	+	recover the full amount of all claims. 43
	194	+	(3) If the beneficiary meets its burden of rebutting the presumption arising under 44
	195	+	subsection (a1) of this section, then the court shall determine the portion of 45
	196	+	the recovery that represents compensation for the Medicaid claim and shall 46
	197	+	order the beneficiary to pay the amount so determined to the Department 47
	198	+	Department, or designated PHP, in accordance with subsection (a5) of this 48
	199	+	section. In making this determination, the court may consider any factors that 49
	200	+	it deems just and reasonable. 50 General Assembly Of North Carolina Session 2025
	201	+	Senate Bill 600-First Edition Page 5
	202	+	(4) If the beneficiary fails to rebut the presumption arising under subsection (a1) 1
	203	+	of this section, then the court shall order the beneficiary to pay the amount 2
	204	+	presumed pursuant to subsection (a1) of this section to the Department 3
	205	+	Department, or designated PHP, in accordance with subsection (a5) of this 4
	206	+	section. 5
	207	+	(a3) Notwithstanding the presumption arising pursuant to subsection (a1) of this section, 6
	208	+	the medical assistance beneficiary and the Department may reach an agreement on the portion of 7
	209	+	the recovery that represents compensation for the Medicaid claim. If such an agreement is 8
	210	+	reached after an application has been filed pursuant to subsection (a2) of this section, a stipulation 9
	211	+	of dismissal of the application signed by both parties shall be filed with the court. 10
	212	+	(a4) Within 30 days of receipt of the proceeds of a settlement or judgment related to a 11
	213	+	claim described in subsection (a) of this section, the medical assistance beneficiary or any 12
	214	+	attorney retained by the beneficiary shall notify the Department Department, and any designated 13
	215	+	PHP, of the receipt of the proceeds. 14
	216	+	(a5) The medical assistance beneficiary or any attorney retained by the beneficiary shall, 15
	217	+	out of the proceeds obtained by or on behalf of the beneficiary by settlement with, judgment 16
	218	+	against, or otherwise from a third party by reason of injury or death, distribute to the Department 17
	219	+	Department, or designated PHP, the amount due pursuant to this section as follows: 18
	220	+	(1) If, upon the expiration of the time for filing an application pursuant subsection 19
	221	+	(a2) of this section, no application has been filed, then the amount presumed 20
	222	+	pursuant to subsection (a1) of this section, as prorated with the claims of all 21
	223	+	others having medical subrogation rights or medical liens against the amount 22
	224	+	received or recovered, shall be paid to the Department Department, or 23
	225	+	designated PHP, within 30 days of the beneficiary's receipt of the proceeds, in 24
	226	+	the absence of an agreement pursuant to subsection (a3) of this section. 25
	227	+	(2) If an application has been filed pursuant to subsection (a2) of this section and 26
	228	+	no agreement has been reached pursuant to subsection (a3) of this section, 27
	229	+	then the Department Department, or designated PHP, shall be paid as follows: 28
	230	+	a. If the beneficiary rebuts the presumption arising under subsection (a1) 29
	231	+	of this section, then the amount determined by the court pursuant to 30
	232	+	subsection (a2) of this section, as prorated with the claims of all others 31
	233	+	having medical subrogation rights or medical liens against the amount 32
	234	+	received or recovered, shall be paid to the Department Department, or 33
	235	+	designated PHP, within 30 days of the entry of the court's order. 34
	236	+	b. If the beneficiary fails to rebut the presumption arising under 35
	237	+	subsection (a1) of this section, then the amount presumed pursuant to 36
	238	+	subsection (a1) of this section, as prorated with the claims of all others 37
	239	+	having medical subrogation rights or medical liens against the amount 38
293	240		received or recovered, shall be paid to the Department Department, or 39
294		-	designated PHP, within 30 days of the beneficiary's receipt of the proceeds, in 40
295		-	the absence of an agreement pursuant to subsection (a3) of this section. 41
296		-	(2) If an application has been filed pursuant to subsection (a2) of this section and 42
297		-	no agreement has been reached pursuant to subsection (a3) of this section, 43
298		-	then the Department Department, or designated PHP, shall be paid as follows: 44
299		-	a. If the beneficiary rebuts the presumption arising under subsection (a1) 45
300		-	of this section, then the amount determined by the court pursuant to 46
301		-	subsection (a2) of this section, as prorated with the claims of all others 47
302		-	having medical subrogation rights or medical liens against the amount 48
303		-	received or recovered, shall be paid to the Department Department, or 49
304		-	designated PHP, within 30 days of the entry of the court's order. 50 General Assembly Of North Carolina Session 2025
305		-	Senate Bill 600-Second Edition Page 7
306		-	b. If the beneficiary fails to rebut the presumption arising under 1
307		-	subsection (a1) of this section, then the amount presumed pursuant to 2
308		-	subsection (a1) of this section, as prorated with the claims of all others 3
309		-	having medical subrogation rights or medical liens against the amount 4
310		-	received or recovered, shall be paid to the Department Department, or 5
311		-	designated PHP, within 30 days of the entry of the court's order. 6
312		-	(3) If an agreement has been reached pursuant to subsection (a3) of this section, 7
313		-	then the agreed amount, as prorated with the claims of all others having 8
314		-	medical subrogation rights or medical liens against the amount received or 9
315		-	recovered, shall be paid to the Department Department, or designated PHP, 10
316		-	within 30 days of the execution of the agreement by the medical assistance 11
317		-	beneficiary and the Department. 12
318		-	(a6) The United States and the State of North Carolina shall be entitled to shares in each 13
319		-	net recovery by the Department under this section. Their shares shall be promptly paid under this 14
320		-	section and their proportionate parts of such sum shall be determined in accordance with the 15
321		-	matching formulas in use during the period for which assistance was paid to the recipient. 16
322		-	(b) It is a Class 1 misdemeanor for any person seeking or having obtained assistance 17
323		-	under this Part for himself or another to willfully fail to disclose to the county department of 18
324		-	social services or its attorney and to the Department the identity of any person or organization 19
325		-	against whom the recipient of assistance has a right of recovery, contractual or otherwise. 20
326		-	(c) (For contingent repeal, see note) This section applies to the administration of and 21
327		-	claims payments under the NC Health Choice Program established under Part 8 of this Article. 22
328		-	(d) As required to ensure compliance with this section, the Department may apply to the 23
329		-	court in which the medical assistance beneficiary's claim against the third party is pending, or if 24
330		-	there is none, then to a court of competent jurisdiction in this State for enforcement of this 25
331		-	section." 26
332		-	SECTION 4.(b) This section is effective when it becomes law and applies to 27
333		-	Medicaid claims brought by medical assistance beneficiaries against third parties on or after that 28
334		-	date. 29
335		-	30
336		-	EFFECTIVE DATE 31
337		-	SECTION 5. Except as otherwise provided, this act is effective when it becomes 32
338		-	law. 33
	241	+	designated PHP, within 30 days of the entry of the court's order. 40
	242	+	(3) If an agreement has been reached pursuant to subsection (a3) of this section, 41
	243	+	then the agreed amount, as prorated with the claims of all others having 42
	244	+	medical subrogation rights or medical liens against the amount received or 43
	245	+	recovered, shall be paid to the Department Department, or designated PHP, 44
	246	+	within 30 days of the execution of the agreement by the medical assistance 45
	247	+	beneficiary and the Department. 46
	248	+	(a6) The United States and the State of North Carolina shall be entitled to shares in each 47
	249	+	net recovery by the Department under this section. Their shares shall be promptly paid under this 48
	250	+	section and their proportionate parts of such sum shall be determined in accordance with the 49
	251	+	matching formulas in use during the period for which assistance was paid to the recipient. 50 General Assembly Of North Carolina Session 2025
	252	+	Page 6 Senate Bill 600-First Edition
	253	+	(b) It is a Class 1 misdemeanor for any person seeking or having obtained assistance 1
	254	+	under this Part for himself or another to willfully fail to disclose to the county department of 2
	255	+	social services or its attorney and to the Department the identity of any person or organization 3
	256	+	against whom the recipient of assistance has a right of recovery, contractual or otherwise. 4
	257	+	(c) (For contingent repeal, see note) This section applies to the administration of and 5
	258	+	claims payments under the NC Health Choice Program established under Part 8 of this Article. 6
	259	+	(d) As required to ensure compliance with this section, the Department may apply to the 7
	260	+	court in which the medical assistance beneficiary's claim against the third party is pending, or if 8
	261	+	there is none, then to a court of competent jurisdiction in this State for enforcement of this 9
	262	+	section." 10
	263	+	SECTION 4.(b) This section is effective when it becomes law and applies to 11
	264	+	Medicaid claims brought by medical assistance beneficiaries against third parties on or after that 12
	265	+	date. 13
	266	+	14
	267	+	EFFECTIVE DATE 15
	268	+	SECTION 5. Except as otherwise provided, this act is effective when it becomes 16
	269	+	law. 17