Implementation of Short-Term Solution for Adult Care Home Providers Delivering Personal Care Services

To assist providers in navigating the managed care health plans' PCS referral and intake process, NC Medicaid has partnered with the health plans to implement a short-term solution for ACH providers who deliver PCS services.

Effective July 1, 2021, some Medicaid beneficiaries receiving Personal Care Services (PCS) transitioned from NC Medicaid Direct to receiving services through a NC Medicaid Managed Care health plan. After managed care launch, NC Medicaid has received reports of Adult Care Home (ACH) providers having  difficulty navigating the health plans’ PCS referral and intake process.

As a means of addressing these concerns, NC Medicaid, in partnership with the managed care health plans, has collaborated to implement a short-term solution for ACH providers who deliver PCS services.

The short-term solution will be in effect from Aug. 15, 2021 – Nov. 15, 2021, and is designed to support the ACH PCS providers’ transition to managed care. 

The short-term solution involves the following steps:

  • ACH provider submits a PCS authorization request within five days of the individual’s admission to the ACH.
    • **Note: The ACH provider has the option of submitting a copy of the individual’s initial assessment that is completed in accordance with GS 131D-2.15 along with the PCS authorization request. The submission of the initial assessment or the completion of an on-line service plan is not required.  
  • Upon receipt of the PCS authorization request by the ACH provider, the health plan issues a provisional authorization of 60 hours for the first 30 days of admission (retro to the date of admission) and coordinates the completion of the PCS assessment.
  • Pending the completion of the PCS assessment, the ACH provider should bill no more than eight units per day. If, after completion of the PCS assessment, it is determined the individual is eligible to receive the service, the health plan issues a new authorization approving PCS service hours based on the results of the PCS assessment.
    • **Note: The health plan ensures the assessment is completed and services authorized before the end of the first 30 days of admission. 
  • If the new authorization is less than the provisional authorization of 60 hours, the health plan must provide the individual with information about appeal rights and maintenance of service applies.

Each NC Medicaid Managed Care health plan has committed to ensuring the PCS provider community is adequately informed about its PCS intake and referral process.  The websites and provider support contact information for each health plan can be found on the NC Medicaid Health Plan Resources webpage. 

Contact

NCTracks Call Center: 800-688-6696

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