HB 390: Medicaid Prepaid Health Plan Practices. - North Carolina

Edition 1 → Edition 2 · 6 edits

MODERATE

HB 390 was completely rewritten via a Senate Health Care Committee Substitute, changing its subject from surgical smoke evacuation standards in hospitals and ambulatory surgical facilities to allowing Medicaid Prepaid Health Plans (PHPs) certain claims management practices. The new bill permits PHPs to require itemized bills for high-cost outlier claims, align claims operations with national coding standards, and direct inpatient services to outpatient settings. This is a fundamental change in policy area, moving from occupational health/safety regulation to Medicaid program administration.

Scope change

Complete subject matter change from hospital and ambulatory surgical facility safety standards (surgical smoke evacuation) to Medicaid program administration (PHP claims management practices). The bill now applies to Medicaid Prepaid Health Plans rather than hospitals and surgical facilities.

SCOPE

Entire surgical smoke evacuation requirement removed. Previously required hospitals and ambulatory surgical facilities to adopt policies mandating use of smoke evacuation/filtering systems during procedures likely to generate surgical smoke.

New bill allows Medicaid PHPs to require itemized bills for inpatient hospital outlier claims exceeding $250,000 or more than two standard deviations from the median mean claim amount of the applicable billing code.

REQUIREMENT

Allows PHPs to align claims operations with national standards for coding, edits, and claims adjudication.

Allows PHPs to direct inpatient hospital and inpatient hospital laboratory services to outpatient settings where appropriate, with the Department authorized to adopt rules establishing when such direction is appropriate.

TIMELINE

Effective date changed from January 1, 2026 to 'when it becomes law,' applying only to contracts entered into or amended on or after that date.

TECHNICAL

Bill includes a conditional structure: if HB 696 becomes law, it amends G.S. 108D-65(b) as rewritten by that act; if HB 696 does not become law by June 1, 2026, it rewrites G.S. 108D-65 in its entirety.

Edition 2 → Edition 3 · 3 edits

MINOR

This bill was updated to reflect a change in the referenced legislation from House Bill 696 (2025) to S.L. 2026-1, adjusting the effective date of the law to June 1, 2026. Additionally, the bill added a new requirement for the Department to set parameters ensuring consistent claims coding among Medicaid Prepaid Health Plans, while retaining the authority to direct inpatient services to outpatient settings.

Scope change

The bill's applicability timeline was extended to June 1, 2026, and the scope of PHP authority was narrowed regarding claims coding to require consistency across plans.

TIMELINE

The conditional trigger for the law changed from House Bill 696 becoming law by June 1, 2026, to S.L. 2026-1, updating the legislative reference and effective date context.

REQUIREMENT

The Department is now required to set parameters to ensure consistent claims coding among all Medicaid Prepaid Health Plans, adding a layer of standardization to the existing authority.

The threshold for requiring itemized bills for outlier claims was updated to include 'median' mean claim amount, providing a more specific statistical benchmark for identifying high-cost claims.

A1: ATR-22-V-3 → Edition 1 · 6 edits

MODERATE

The document was completely replaced with a new version of House Bill 390. The old text, which was an amendment to a different bill regarding claims operations, was removed. The new text establishes new legal requirements for hospitals and ambulatory surgical facilities to use smoke evacuation systems during surgeries that generate smoke, effective January 1, 2026.

Scope change

The bill's scope changed from an amendment to a claims operations bill to a standalone act establishing new safety standards for surgical smoke evacuation in healthcare facilities.

SCOPE

Removed all text related to amending a previous bill about claims coding and adjudication standards.

REQUIREMENT

Added new requirements for hospitals to adopt policies mandating smoke evacuation systems during procedures likely to generate surgical smoke.

Added new requirements for ambulatory surgical facilities to adopt policies mandating smoke evacuation systems during procedures likely to generate surgical smoke.

ENFORCEMENT

Added provisions allowing the Department of Health and Human Services to take adverse action against facilities that violate the new smoke evacuation standards.

TIMELINE

Added an effective date of January 1, 2026, for the new requirements.

DEFINITION

Added new legal definitions for 'smoke evacuation/filtering system' and 'surgical smoke' to clarify the standards.

Filed → A1: ATR-22-V-3 · 4 edits

MODERATE

The bill was amended to remove its original focus on surgical smoke evacuation standards for hospitals and ambulatory surgical facilities. Instead, the amendment redirects the legislation to update existing statutes regarding healthcare claims operations, specifically aligning them with national coding and adjudication standards.

Scope change

The bill's scope shifted entirely from occupational safety and health regulations to healthcare financial administration and claims processing.

REQUIREMENT

All requirements mandating the use of smoke evacuation systems in hospitals and ambulatory surgical facilities were deleted.

New language was added to align claims operations with national standards for coding, edits, and claims adjudication, while allowing the Department to set parameters for consistent coding among PHPs.

DEFINITION

Definitions for 'Smoke evacuation/filtering system' and 'Surgical smoke' were removed.

TIMELINE

The effective date was changed from January 1, 2026, to February 2026.

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