State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_135 > GS_135-44_4

§ 135‑44.4.  Powers andduties of the Executive Administrator and Board of Trustees.

The Executive Administratorand Board of Trustees of the Teachers' and State Employees' Comprehensive MajorMedical Plan shall have the following powers and duties:

(1)        Supervising andmonitoring of the Claims Processor.

(2)        Providing forenrollment of employees in the Plan.

(3)        Communicating withemployees enrolled under the Plan.

(4)        Communicating withhealth care providers providing services under the Plan.

(5)        Making payments atappropriate intervals to the Claims Processor for benefit costs andadministrative costs.

(6)        Conductingadministrative reviews under G.S. 135‑44.7.

(7)        Annually assessingthe performance of the Claims Processor.

(8)        Preparing andsubmitting to the Governor and the General Assembly cost estimates for thePlan, including those required by Article 15 of Chapter 120 of the GeneralStatutes.

(9)        Recommending to theGovernor and the General Assembly changes or additions to the health benefitsprograms and health care cost containment programs offered under the Plan,together with statements of financial and actuarial effects as required byArticle 15 of Chapter 120 of the General Statutes.

(10)      Working with Stateemployee groups to improve health benefit programs.

(11)      Determining basis ofpayments to health care providers, including payments in accordance with G.S.58‑50‑56.

(12)      Requiring bonding ofthe Claims Processor in the handling of State funds.

(13)      In case oftermination of the contract under  subdivision (27) of this section, to selecta new Claims Processor, after bidding procedures approved by the Department ofAdministration.

(13a)    The Plan and itspharmacy benefit manager may implement and administer pharmacy and medicalutilization management programs and programs to detect and address utilizationabuse of benefits.

(14)      Notwithstanding theprovisions of Part 3 of this Article, to formulate and implement cost‑containmentmeasures which are not in direct conflict with that Part.

(15)      Implementing pilotprograms necessary to evaluate proposed cost containment measures which are notin direct conflict with  Part 3 of this Article, and expending funds necessaryfor the implementation of the pilot programs.

(16)      Authorizing coveragefor alternative forms of care not otherwise provided by the Plan in individualcases when medically necessary, medically equivalent to services covered by thePlan, and when such alternatives would be less costly than would have beenotherwise.

(17)      Establishing and operatinga hospital and other provider bill audit program and a fraud detection program.

(18)      Determiningadministrative and medical policies that are not in direct conflict with Part 3of this Article after consultation with the Claims Processor and the Plan'sconsulting actuary when Plan costs are involved.

(19)      Supervising thepayment of claims and all other disbursements under this Article, including therecovery of any disbursements that are not made in accordance with theprovisions of this Article.

(20)      Implementing andadministering a program of long‑term care benefits pursuant to Part 4 ofthis Article.

(21)      Repealed by SessionLaws 2008‑107, s. 10.13(a), effective July 1, 2008.

(22)      Implementing andadministering a case management and disease management program and a wellnessprogram.

(23)      Implementing andadministering a pharmacy benefit management program through a third‑partycontract awarded after receiving competitive quotes.

(24)      Repealed by SessionLaws 2008‑168, s. 2(j), effective July 1, 2008.

(25)      The ExecutiveAdministrator may establish pilot programs to measure potential cost savingsand improvements in patient care available through local, provider‑drivenmedical management.

(26)      It is the intent ofthe General Assembly that active employees and retired employees covered underthe Plan and its successor Plan shall have several opportunities in each fiscalyear to attend presentations conducted by Plan management staff providingdetailed information about benefits, limitations, premiums, co‑payments,and other pertinent Plan matters. To this end, beginning in 2007 and annuallythereafter, the Plan's management staff shall conduct multiple presentationseach year to Plan members and association groups representing active andretired employees across all geographic regions of the State. Regional meetingsshall be held in locations that afford reasonably convenient access to Planmembers. The presentations shall be designed not only to present informationabout the Plan but also to hear and respond to Plan members' questions andconcerns.

(27)      The ExecutiveAdministrator and Board of Trustees may terminate the contract with the ClaimsProcessor in accordance with the terms of the contract.

(28)      The prompt payrequirements of G.S. 58‑3‑225 apply to the Plan.

(29)      For transplant andbariatric medical procedures, the Plan may restrict coverage to certain in‑networkproviders that are designated by the Plan's Claims Processing Contractor.

(30)      The ExecutiveAdministrator shall ensure provisions in contracts between the Plan and thePlan's Claims Processing Contractor that call for the Plan to contract with anindependent auditor, selected by the Plan, to review the Claims ProcessingContractor's administrative costs and services to the Plan by the Claim'sProcessing Contractor.

(31)      The Plan shallconduct a monthly review of Plan costs as compared to the same month in theimmediately preceding year and a comparison of projected costs and savings toactual costs and savings. The Plan shall report the results of the review tothe Committee on Employee Hospital and Medical Benefits and the State HealthPlan Blue Ribbon Task Force at least semiannually.  (1981 (Reg. Sess., 1982), c.1398, s. 6; 1983, c. 922, s. 2; 1985, c. 732, ss. 7, 9, 23, 24, 50, 51; 1985(Reg. Sess., 1986), c. 1020, ss. 3, 20; 1987, c. 857, ss. 6, 7; 1987 (Reg.Sess., 1988), c. 1091, s. 5; 1989, c. 752, s. 22(a); 1991, c. 427, s. 3; 1993(Reg. Sess., 1994), c. 679, s. 10.3; 1997‑468, s. 2; 1997‑519, s.3.15; 1998‑1, s. 4(c); 2000‑141, s. 3; 2001‑253, ss. 1(a),1(q); 2001‑487, s. 85.5; 2006‑249, s. 4(b); 2007‑323, s.28.22(i); 2008‑107, s. 10.13(a); 2008‑168, ss. 1(a), 2(a), (k),(j); 2009‑16, s. 5(b).)