This bulletin provides guidance to nursing facilities serving NC Medicaid-only residents who will transition to NC Medicaid Managed Care on July 1, 2021.
Background
As most recently noted in Medicaid Bulletin published May 25, 2021:
North Carolina is transitioning to NC Medicaid Managed Care effective July 1, 2021. Standard Plans will be required to cover nursing facility admissions up to 90 days for those members whose only coverage is NC Medicaid. If the member remains in the nursing home 90 days, or otherwise is excluded from NC Medicaid Managed Care for reasons outlined below, the Member will disenroll from NC Medicaid Managed Care and return to NC Medicaid Direct [Medicaid’s fee-for service program].
Identifying the Resident’s Managed Care Status
As applicable, the resident’s NC Medicaid Managed Care status and Standard Plan information is available in the NCTracks Provider Portal. NC Medicaid Managed Care evidence will be reflected in the Provider Portal fields outlined below:
- Benefit Plan field: NC Medicaid Managed Care Standard Plan
- Managing Entity field: Displays the pre-paid health plan (PHP) in which the resident is enrolled.
If a resident remains in or returns to NC Medicaid Direct, the Benefit Plan field will display “Medicaid-FFS” and the Managing Entity field will be blank.
Engaging with a Resident’s Standard Plan
All providers serving NC Medicaid beneficiaries should currently be enrolled in the Standard Plans’ provider network or otherwise working to contract with the health plan. Information about Standard Plan contracting is available in the NC Medicaid Managed Care: Provider Playbook.
The resident’s Standard Plan will continue payments to a nursing facility not yet in its network on July 1, 2021, for minimum of 90 days or until the resident disenrolls, if occurs sooner. Nursing facilities should direct all Standard Plan contracting and rate questions to the resident’s Standard Plan.
Guidance on Retroactive Prior Authorizations Covering Dates of Service on or After July 1, 2021 for Impacted Beneficiaries
Prior authorizations (PAs) approved through NCTracks and in effect prior to July 1, 2021 will transfer to the resident’s Standard Plan and will remain in effect for 90 days or until the authorization expires, whichever occurs sooner.
The nursing facility should submit PAs for dates of service on or after July 1, 2021, directly to the resident’s Standard Plan. Plan-specific guidance is available through the Plan and summarized in the NC Medicaid Provider Playbook’s Managed Care Claims and Prior Authorizations Submission: Frequently Asked Questions – Part 2.
If a nursing facility submits a retroactive authorization to NCTracks, NCTracks will only adjudicate dates of service prior to July 1, 2021.
Starting July 1, 2021, NCTracks will include functionality for the nursing facility to indicate if the PA is retroactive. This check box will apply any time a retroactive authorization request is submitted. If the facility submits an authorization request after July 1, 2021 to NCTracks and the requested effective date is prior to July 1, 2021, the submitter should select the “Retro PA” checkbox available.
If a facility attempts to submit a PA request to NCTracks after July 1, 2021 for a resident now enrolled in NC Medicaid Managed Care and the PA request date span covers dates of service after July 1, 2021, NCTracks will only be able to authorize dates of service prior to July 1, 2021. The provider will receive a message directing it to submit authorizations for dates of service after July 1, 2021 to the resident’s Standard Plan.
When a Nursing Facility Resident Disenrolls from NC Medicaid Managed Care
Disenrollment from NC Medicaid Managed care for NC Medicaid-only nursing facility residents primarily occurs for the following reasons:
- The resident’s Medicare eligibility takes effect.
- The resident’s admission extends beyond 90 days.
- The resident’s discharges to the CAP/DA waiver (or other 1915 (c) waiver) or PACE program.
In each case, the resident’s disenrollment will occur the first of the following month. The resident’s Medicaid services will then be managed under NC Medicaid Direct, as they are today.
To assist in tracking the length of stay, the resident’s Plan is responsible for communicating the resident’s admission to the facility by submitting a Change in Circumstance Report to DSS.
Under the Standard Plan’s transition of care protocol, the Member’s Standard Plan is required to coordinate with the resident and the resident’s facility in supporting pending disenrollments.
Prior Approval for Nursing Facility Residents Moving from NC Medicaid Managed Care to NC Medicaid Direct
As noted in the Medicaid Bulletin posted on May 25, 2021,
[F]or a nursing home provider to receive payment for services delivered to a member who moves from NC Medicaid Managed Care to Medicaid Direct, the nursing home provider will be required to request Prior Approval for Nursing Home Services via NCTracks. The PHP is expected to follow established NC Medicaid transition of care protocol and transfer the information necessary to the nursing home when requested to ensure continuity of care to include the effective Managed Care disenrollment date.
The nursing home provider shall follow the prior approval requirements noted in section 5.3 of Clinical Policy 2B-1 and submit the Prior Approval request to NCTracks. A current PASRR authorization should be included with the request. In the event the PASRR authorization has expired or is close to expiring, the nursing home provider should submit a significant change PASRR authorization request via NCMUST.
As noted earlier, if the provider’s new authorization to Medicaid Direct is retroactive, the provider should indicate this by checking the “Retro PA” box in NCTracks.
Questions
- Questions about Standard Plan contracting, payment and PA requirements should be directed to the applicable Standard Plan. Information is also available through the NC Medicaid Provider Playbook.
- Questions about payments and authorizations for dates of service when a resident is enrolled in NC Medicaid Direct should be directed to NCTracks at 800-688-6696.
- Questions about NC Medicaid Clinical Coverage Policies or Transition of Care Policy may be directed to the NC Medicaid Contact Center at 888-245-0179.