To support providers and members, NC Medicaid is increasing the nursing facility rate for managed care members during nursing facility stays. Starting Jan. 1, 2023, NC Medicaid is requiring health plans to pay nursing facilities no less than 95% of the facilities’ adjusted Medicare rate for the first 20 days of the nursing facility stay, and then pay no less than 80% of the facilities’ adjusted Medicare rate for the remainder of the nursing facility stay covered under managed care.
If the nursing facility stay exceeds 90 days and the member is discharged back to NC Medicaid Direct, the 80% rate should remain in place until the member is discharged to NC Medicaid Direct. Note, the facility’s Medicare rate has been adjusted downward to account for the Drugs/Lab/Radiology expenses that NC Medicaid covers outside of the per-diem. The fee schedule rates reflect an application of the above percentages to the published Medicare facility rate after these adjustments. These rates are based on average Medicare facility payment and not individual member acuity.
NC Medicaid is implementing these rates to promote timely hospital discharges and admissions to nursing facilities across the NC system. Therefore, NC Medicaid will be monitoring hospital discharges and nursing facility admissions to evaluate if these increased rates have a positive impact as intended. If there is no positive impact on timely hospital discharges and nursing facility admissions, the rate may be reduced.
Standard Plans have until March 6, 2023, to implement these rate changes for nursing facility stays and until April 5, 2023, to reprocess claims for dates of service on or after Jan. 1, 2023, with the adjusted facility rates. Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans will have these updated rates reflected in their systems prior to Tailored Plan Launch on April 1, 2023.
Please contact the health plans for questions or more information. Providers will be able to find the updated rates on the NC Medicaid Fee Schedules page under the “Nursing Facility Rates” program with a fee schedule name of “SNF Short Stay Managed Care.” These rates will be loaded by Feb. 10, 2023.