Services covered by PHPs.--Capitated PHP contracts shall cover all Medicaid and NC
Health Choice services, including physical health services, prescription drugs, long-term
services and supports, and behavioral health services for NC Health Choice recipients,
except as otherwise provided in this subdivision. The capitated contracts required by this subdivision shall not cover:
a. Medicaid services covered by the local management entities/managed care organizations
(LME/MCOs) under the combined 1915(b) and (c) waivers shall not be covered under a
standard benefit plan, except that all capitated PHP contracts shall cover the following
services: inpatient behavioral health services, outpatient behavioral health emergency
room services, outpatient behavioral health services provided by direct-enrolled providers,
mobile crisis management services, facility-based crisis services for children and
adolescents, professional treatment services in a facility-based crisis program, outpatient
opioid treatment services, ambulatory detoxification services, nonhospital medical
detoxification services, partial hospitalization, medically supervised or alcohol
and drug abuse treatment center detoxification crisis stabilization, research-based
intensive behavioral health treatment, diagnostic assessment services, and Early and
Periodic Screening, Diagnosis, and Treatment services. In accordance with this sub-subdivision, 1915(b)(3) services shall not be covered
under a standard benefit plan.
b. Dental services.
c. Services provided through the Program of All-Inclusive Care for the Elderly (PACE).
d. Services documented in an individualized education program, as defined in G.S. 115C-106.3, or other document described in the Medicaid State Plan, and provided or billed by
a local education agency, as defined in G.S. 115C-106.3.
e. Services provided and billedby a Children's Developmental Services Agency (CDSA)
that are included on the child's Individualized Family Service Plan.
f. Services for Medicaid program applicants during the period of time prior to eligibility
g. The fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses,
and ophthalmic frames.
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