Note: This bulletin is replaced by Updated: NC Medicaid Temporary Flexibilities Due to Hurricane Idalia published on Aug. 30, 2023 to correct the end date which is Sept. 13, 2023.
North Carolina Governor Roy Cooper issued Executive Order 284 on Aug. 28, 2023, which declared a state of emergency for North Carolina in anticipation of potential severe weather caused by the approach of Hurricane Idalia.
NC Medicaid is committed to North Carolina's response to and recovery from Hurricane Idalia. We are working with county and federal partners, utilizing many existing federal authorities in place due to the COVID-19 Public Health Emergency, to make it faster and easier for beneficiaries to receive— and for health care professionals to provide—Medicaid care and services.
This bulletin describes flexibilities effective Aug. 28, 2023, to the NC Medicaid program including NC Medicaid Direct and NC Medicaid Managed Care, as indicated below. Updates will be provided as they become available.
Flexibilities for both Medicaid Direct and NC Medicaid Managed Care
Reimbursement for medically necessary services during Hurricane Idalia
Medicaid Direct and NC Medicaid Managed Care will reimburse providers for medically necessary drugs and services, and equipment and supplies, provided during the Hurricane Idalia emergency without prior approval (PA) starting Aug. 28. 2023 through the end of the state of emergency.
Medical documentation must support medical necessity. In addition, beneficiaries who have been evacuated out-of-state (OOS), voluntarily or involuntarily, can receive medical care if needed and Medicaid Direct and NC Medicaid Managed Care will reimburse the OOS provider without PA. OOS providers must enroll as NC Medicaid providers in an abbreviated, expedited process on the NCTracks Provider Enrollment webpage.
Providers are encouraged to obtain a PA if it is possible to do so (and normally required for the service). All claims are subject to audit.
Medication prior approval overrides due to Hurricane Idalia
The potential for severe weather conditions may present situations where NC Medicaid beneficiaries in impacted areas may have difficulty obtaining necessary PA for certain medications. Therefore, NC Medicaid enrolled pharmacy providers have been approved to override PA requirements during the state of emergency. This override of PA is being allowed while the governor’s state of emergency order remains in place to ensure that all Medicaid beneficiaries have access to necessary medications.
For Medicaid Direct, NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field to override a denial for PA required. Do not place any values in the Submission Clarification Code field. Additional questions can be directed to the NCTracks service line at 800-688-6696.
For NC Medicaid Managed Care, providers should contact the Standard Plan pharmacy service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for prior authorization overrides due to Hurricane Idalia.
Pharmacy service line contact information:
- AmeriHealth Caritas: 866-885-1406
- Carolina Complete Health: 833-992-2785
- Healthy Blue: 833-434-1212
- United Healthcare: 855-258-1593
- WellCare: 866-799-5318, option 3
Early prescription refills during the Governor’s state of emergency declaration
The potential for severe weather conditions may present situations where NC Medicaid beneficiaries in impacted areas may require an early refill of their medications. NC Medicaid enrolled pharmacy providers have been approved to early fill these prescriptions and will follow applicable co-pay requirements. Effective Aug. 28, 2023, the early refill is being allowed while the governor’s state of emergency order remains in place to ensure that all Medicaid beneficiaries have access to necessary medications.
For Medicaid Direct, NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and a valid value for an E.R. override in the Reason for Service, Professional Service and Result of Service fields to override a denial for an early refill. Do not place any values in the Submission Clarification Code field. This allows the beneficiaries to receive their medication during an emergency without using either of their limited-use Submission Clarification Code overrides. Additional questions can be directed to the NCTracks service line at 800-688-6696.
For NC Medicaid Managed Care, providers should contact the Standard Plan pharmacy service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for emergency prescription refills during the state of emergency.
Pharmacy service line contact information:
- AmeriHealth Caritas: 866-885-1406
- Carolina Complete Health: 833-992-2785
- Healthy Blue: 833-434-1212
- United Healthcare: 855-258-1593
- WellCare: 866-799-5318, option 3
Flexibilities for Medicaid Direct Only
Community Alternatives Program for Children (CAP/C) and Community Alternatives Program for Disabled Adults (CAP/DA)
A critical role for case management entities serving CAP/C and CAP/DA beneficiaries is to provide support to ensure the health, safety and well-being of all CAP beneficiaries in the preparation for, during and immediately after, a natural disaster. To fulfill this requirement, NC CAP case management entities are directed to assist their assigned CAP beneficiaries in activating their emergency and disaster plans in preparation for the unknown impact of Hurricane Idalia.
When helping CAP beneficiaries activate their plans, it is imperative to emphasize checking and updating disaster kits. Ready NC is a valuable resource to use for additional information and assistance to prepare for a hurricane. Encourage beneficiaries to register with their special needs’ registry in their county.
It is our utmost concern that not only are our beneficiaries safe and accounted for during times of disaster, but that case management entities are equipped to communicate with staff and beneficiaries effectively as well as take the appropriate steps to remain safe. Please coordinate with local county emergency management departments if assistance is needed.
NC Medicaid gave notification to CAP case management entities that if the state is impacted by Hurricane Idalia, and to coordinate resources, Medicaid will request from case management entities an assessment of the health and well-being status of each CAP beneficiary. Case management entities will be required to complete in the eCAP systems the Disaster Wellness Check Documentation related to the health and well-being status of the CAP beneficiaries they serve. Below is the information that must be included in the Disaster Wellness report.
- Name of contact person for questions regarding the report
- Status of beneficiary (safe, sustained impact, unknown)
- Beneficiary current location (home, shelter, facility, relative – in/out of county/state)
- Beneficiary contact information, if displaced from home
- Documentation if the current service plan meets the needs of the beneficiary as a result of Hurricane Idalia
- If it does not, specify what additional or replacement services are needed through a plan revision.
To seek technical assistance in managing a waiver beneficiary’s recovery from Hurricane Idalia, contact the CAP unit at medicaid.capc@dhhs.nc.gov or medicaid.capda@dhhs.nc.gov.
Innovations and Traumatic Brain Injury (TBI) waiver flexibility due to Hurricane Idalia
The COVID-19 public health emergency (PHE) Appendix K flexibilities for the Innovations and TBI waiver may be used to support members impacted by Hurricane Idalia. These flexibilities below are intended for NC Innovations and TBI Waiver beneficiaries impacted by the hurricane either directly or due to their staff being impacted and unable to provide services. They are not intended to be utilized by every waiver beneficiary. They are intended to be utilized only as long as needed until further notice. LME/MCOs should be assessing the continued need for these flexibilities case-by-case. Please note that COVID-19 related Appendix K flexibilities will continue until six months after the end of the Federal PHE per SPECIAL BULLETIN COVID-19 #265: Ending Clinical Policy Flexibilities Associated with the Federal Public Health Emergency.
The flexibilities below are specific to beneficiaries impacted by Hurricane Idalia.
NC Medicaid continues to allow the following approved flexibilities:
- Relatives of adult waiver beneficiaries and minor waiver beneficiaries who reside in the home and out of the home may provide services prior to background check and training for 90 days.
- It is understood that the background check will be completed by the agency as soon as possible after the service begins and training will occur as soon as possible without leaving the beneficiary without necessary care.
- Once conducted, if the background check demonstrates the individual should not continue working with the participant long-term, that individual will be immediately determined unqualified to render services.
- Relatives of adult waiver beneficiaries may provide community living and supports, day supports, supported employment, community networking and supported living. This should only be used for cases where the family is unable to be reached by provider staff or when staff is unavailable due to being displaced by the hurricane.
- Services may be provided without PA due to issues related to Hurricane Idalia. This should only be in cases where additional services were needed by the beneficiary because of the hurricane and either the beneficiary could not reach the provider to notify them of this need or the provider did not have the time/ability to submit PA.
- More than the maximum number of hours allowed for a relative who resides with an adult beneficiary may be provided by that relative for up to 90 days. The relative may also provide community networking, day supports and supported employment for 90 days. This can only be used for cases where the family is unable to be reached by provider staff or when staff is unavailable due to being displaced by the hurricane.
- Direct care may be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker when the waiver participant is displaced from the home because of the hurricane, or the provider facility is inaccessible/damaged.
- The $135,000 waiver limit may be exceeded due to additional services, equipment, or modifications during Hurricane Idalia.
- Beneficiaries who receive fewer than one service per month for a period of 90 days will not be subject to discharge.
- Annual reassessments of level of care initiated between Aug. 28, 2023, and the end of the state of emergency may be postponed by 90 calendar days to allow sufficient time to complete the annual reassessment and accompanying paperwork.
- Payment for direct care services for purposes of supporting 1915(c) enrollees in acute care hospital or short-term institutional stay, and waiving time limits on institutional respite, which is currently limited to a 30-day stay.
- Waive the monthly face-to-face care coordinator and beneficiary meeting for individuals receiving residential supports, new to waiver, or relative as provider. Waive the quarterly face-to-face care coordinator and beneficiary meeting case-by-case.
- Innovations waiver services may be provided out of state without PA by the MCO. Respite may also be provided out of state for individuals who have been displaced.
LME/MCOs must provide an assessment of the health and well-being status of each Innovations and TBI waiver beneficiary to NC Medicaid at the conclusion of the state of emergency
1915(i) Option Services
For individuals whose (b)(3) service authorization are ending and who are unable to have an independent assessment for 1915(i) services may continue their (b)(3) services during this emergency period without PA starting Aug. 30, 2023, and may continue for up to 90 days after the end of the state of emergency. An independent assessment needs to be completed within 30 days of the end of the state of emergency to ensure services are in place prior to the end of the 90-day period.
Quarterly monitoring is waived during the state of emergency.
Providers should contact the LME/MCO providers service line for any additional information:
- Alliance Health: 855-759-9700
- Eastpointe: 888-977-2160
- Partners: 877-398-4145
- Sandhills: 855-777-4652
- Trillium: 855-250-1539
- Vaya Health: 866-990-9712