SPECIAL BULLETIN COVID-19 #171: COVID-19 Rate Increases Under NC Medicaid Managed Care

This Special Bulletin is being released to inform NC Medicaid providers of COVID-19 rate reimbursement that providers will receive from Prepaid Health Plans (PHPs) under NC Medicaid Managed Care.

This Special Bulletin is being released to inform NC Medicaid providers of COVID-19 rate reimbursement that providers will receive from Prepaid Health Plans (PHPs) under NC Medicaid Managed Care.

As previously communicated in the recently released Special Bulletin COVID-19 #169, NC Medicaid has extended COVID-19 temporary provider rate increases for all providers (excluding hospitals) through July 31, 2021. This continuance of the rate increases is contingent on the official extension of the federal public health emergency (PHE). Continuation of rate increases beyond July 31, 2021 depends on availability of funding.

Effective July 1, 2021, COVID-19 temporary provider rate increases applicable in NC Medicaid Direct (formerly known as fee-for-service) will also apply in managed care (Standard Plan PHPs and LME-MCOs) as follows:
 

  • For Standard Plan PHP in-network providers with rate floors (as outlined in the next section), fee schedules inclusive of COVID-19 rate increases will apply.
  • For Standard Plan PHP in-network providers without an applicable rate floor, providers will receive a COVID-19 rate differential added to their negotiated provider reimbursement rates. For each of these providers, the COVID-19 rate differential will be no less than the difference between the pre-COVID-19 NC Medicaid Direct fee schedule rate and the NC Medicaid Direct fee schedule rate (that includes COVID-19 increases) in effect on July 1, 2021.
  • For Standard Plan PHP out-of-network providers, reimbursement will be calculated based on the applicable percentage of the NC Medicaid Direct fee schedule, inclusive of any COVID-19 rate increases. For the first 60 days following the July 1, 2021, launch of managed care, all out-of-network providers will be reimbursed at 100% of the applicable NC Medicaid Direct rate.
  • For LME-MCO contracted providers, LME-MCO reimbursement to providers will include a COVID-19 rate increase consistent with the percentage increase applicable in NC Medicaid Direct (15% increase for residential treatment services and 5% increase for other services). The percentage increase is applicable to the negotiated reimbursement rate excluding any COVID-19 rate increase.

Providers should be aware that PHPs and LME-MCOs are required to reprocess claims reimbursed at rates that do not include the appropriate COVID-19 rate increase amounts.

Rate Floor Program Reimbursement

Rate floors are the established NC Medicaid Direct rates that PHPs are required to reimburse Medicaid providers (at no less than 100% of the applicable NC Medicaid Direct rate), unless the PHP and provider mutually agree to an alternative reimbursement arrangement. PHP reimbursement of rate floor program services will include any applicable COVID-19 increase. The following programs have been designated as Rate Floor programs under managed care for which COVID-19 increases will apply until they are discontinued in NC Medicaid Direct:

  • In-network primary and specialty care physicians, as well as physician extenders (e.g., nurse practitioners and physician assistants)
  • Skilled nursing facilities
  • Federally qualified health centers (FQHCs) and rural health centers (RHCs)
  • Pharmacy dispensing fees
  • Local Health Departments (LHDs)
  • Hospice services
  • Durable Medical Equipment (DME)
  • Medical home per member per month (PMPM) payments
  • Facility Based Crisis
  • Mobile Crisis

While rate floors also apply to inpatient and outpatient hospital services (excluding behavioral health claims), COVID-19 rate increases are not applicable to the revised NC Medicaid Direct hospital reimbursement amounts effective July 1, 2021.

Additionally, rate floors for public ambulance providers are based on managed-care specific enhanced reimbursement amounts effective July 1, 2021. As such, COVID-19 rate increases in NC Medicaid Direct are not applicable to public ambulance providers.

COVID-19 Outbreak Status Reimbursement

Reimbursement of program services based on the NC Department of Public Health COVID-19 outbreak status determinations will continue under managed care. Skilled nursing facilities (rate floor program) will not receive a rate differential but will be reimbursed at 100% of their applicable NC Medicaid Direct outbreak rate. Personal Care Service (non-rate floor program) providers will receive a rate differential based on the difference between their pre-COVID-19 base rate and their base rate that includes the COVID-19 increase. If the provider is in outbreak status, the differential will be based on the difference between their enhanced outbreak rate and the pre-COVID-19 base rate.

Personal Care Service Hours Related to COVID-19 Outbreak Status Rates

Reimbursement based on NC Department of Public Health COVID-19 outbreak status also includes an increase of service hours for Personal Care Service providers. The increase of service hours for every resident in a facility in outbreak status will continue under managed care. Additional hours are applicable to residents as indicated below:

  1. An Adult Care Home (ACH) COVID-19 outbreak site may bill up to 100 additional service hours per month for each beneficiary with current prior approval up to 80 hours per month. 
  2. An ACH COVID-19 outbreak site may bill up to 40 additional service hours per month for each beneficiary with current prior approval greater than 80 hours per month. 

Federal Public Health Emergency Declaration

Although the current expiration date for the federal PHE is July 19, 2021, the federal government has informed states in writing that it plans to extend the PHE through at least the end of the calendar year. Please refer to the federal Public Health Emergency website for more information and updates.

NC Medicaid will continue to provide updates in July on the status of the COVID-19 rate increases and may end the legislated or other rate increases at the end of July if these rate increases are not funded by the NC General Assembly.

Please refer to relevant COVID-19 Medicaid Bulletins and Medicaid fee schedules for details and further communication.

Contact

NCTracks Contact Center: 800-688-6696

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