Extension of Out-of-Network Provisions Policy extended through Nov. 30, 2021

In an effort to ensure optimal access to care for Medicaid beneficiaries, to support providers during the recent COVID-19 surge, and to alleviate potential provider payment concerns, DHHS and the prepaid health plans (PHPs) have agreed to extend the policy for out-of-network flexibilities to providers who have not yet contracted with a PHP through Nov. 30, 2021. These flexibilities were originally expected to sunset on Aug. 30, 2021.  

Under this policy, the PHPs have agreed to:

• permit uncontracted, out-of-network providers enrolled in NC Medicaid to follow in-network provider prior authorization rules and may continue to get a prior authorization retroactively (This exception does not apply to concurrent reviews for inpatient hospitalizations which should still occur during this time period); 
• reimburse out-of-network providers at the in-network rate of 100% of the Medicaid fee schedule;
• delay implementation of the 90% rate reduction following good faith contracting provision; 
• allow beneficiaries to change their Primary Care Provider for any reason; and 
• extend flexibility for Non-Emergency Medical and Non-Emergency Ambulance Transportation providers through November 2021.  

During this period, the Department will allow for beneficiaries to change PHPs as needed. Additionally, PHPs will work to expedite hospital discharge to skilled nursing facilities and rehabilitation facilities to allow for increased bed capacity in the hospitals.

Medicaid has traditionally experienced high provider enrollment rates, which we want to continue. Health systems and providers are strongly encouraged to continue contract negotiations with PHPs and finalize contracts as soon as possible as the department expects this will be the final extension. 

For more information on contracting with a health plan, contact them directly. Contact information is available on the Medicaid Health Plan Contacts and Resources web page.

Questions and answers relating to provider contracting deadlines are available on the Provider Contracting with Health Plans webpage.

Contact

Provider Ombudsman or 866-304-7062