Guidance for Nursing Facilities Admitting Beneficiaries Assigned to a Prepaid Health Plan

Medicaid applicants and beneficiaries who meet financial and medical necessity based on the nursing facility (NF) level of care criteria are eligible for Medicaid NF services. Under NC Medicaid Managed Care, the level of care is approved by the Medicaid beneficiary’s assigned Prepaid Health Plan (PHP). 

The local Department of Social Services (DSS) in the county where the applicant’s eligibility is maintained is responsible for determining financial eligibility. Prior to determining a Medicaid member’s financial eligibility and share of cost, the local DSS must have evidence the individual meets NF level of care. The FL-2, the level of care approval form for NC Medicaid Direct beneficiaries, is available to counties through NCTracks. For Medicaid beneficiaries enrolled with a Standard Plan when admitted to a NF, the Standard plan sends the approval to the NF and cannot be accessed through NCTracks. 

Effective the date of this bulletin, the admitting NF is responsible for submitting the level of care approval documentation received from the PHP to the local DSS in the county where the applicant’s eligibility is maintained. To ensure payments to NFs by the PHPs are accurate, the PHPs are directed by NC Medicaid not to reimburse the NFs until the member’s financial eligibility and patient monthly liability (PML) is established. 

NC Medicaid is aware of cases outstanding since NC Medicaid Managed Care launch (July 1, 2021) where the level of care approval was not received and financial eligibility was not determined. To correct this issue, PHPs will be sending the level of care approval documentation for these cases to the NF. As applicable, the local DSSs will be reaching out to the NFs to request a copy of the level of care approval documentation so that financial eligibility can be determined for these cases.  

Contact

NC Medicaid Contact Center, 888-245-0179