NC Medicaid is committed to ensuring our providers and beneficiaries are supported at the launch of Medicaid expansion on Dec. 1, 2023. A key priority at transition is to ensure Medicaid expansion beneficiaries receive the care they need with no interruption.
The Department has policy flexibilities for expansion members and providers treating those expansion members to ensure beneficiaries receive the care they need, while easing provider administrative burden. Unless otherwise noted, the below flexibilities apply to only expansion members.
- Providers can identify expansion members by checking the member’s eligibility in the NCTracks Recipient Eligibility Verification feature in the Category of Eligibility section.
- Expansion members, for whom these flexibilities apply, will have eligibility categories MXPNN or MXPGN listed.
The Provider Factsheet on Medicaid Expansion has more information for providers related to Medicaid expansion.
Please see the below flexibilities for expansion beneficiaries and providers for the launch of Medicaid expansion.
- Medical Prior Authorizations (PA): For medical PAs, between Dec. 1, 2023 and May 31, 2024, health plans will honor existing NC Medicaid medical PAs. Medical PAs are any PA for physical and behavioral health services. This flexibility applies to both in-network and out-of-network providers who are active enrolled NC Medicaid providers.
- Pharmacy PAs: For pharmacy PAs, between Dec. 1, 2023, and May 31, 2024, Standard Plans and NC Medicaid Direct will honor existing pharmacy PAs (from NC Medicaid, as well as other health plans). Previous PAs available as of Dec. 1, 2023, will be honored through May 31, 2024, or for the life of the PA, whichever is longer. Plans may consider previous PAs and current drug therapy when making coverage determinations through May 31, 2024. This flexibility applies to both in-network and out-of-network providers who are active enrolled NC Medicaid providers.
- Expedited PA Requests/Reviews for Expansion Beneficiaries: Health plans are required to implement strategies to minimize disruption of benefits at launch of expansion, specifically related to PAs. Health plans are required to implement processes to allow providers to submit expedited PAs for expansion beneficiaries so that services are not disrupted at transition. This flexibility applies to both in-network and out-of-network providers who are active enrolled NC Medicaid providers.
- Out of Network Provider Rates: In addition to out of network requirements found in the Department’s Transition of Care policy, between Dec. 1, 2023, and May 31, 2024, health plans must reimburse Medicaid-eligible nonparticipating/out of network providers equal to those of in network providers. This means that medically necessary services will be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in- and out- of network providers.
Starting on June 1, 2024, out-of-network providers with whom the health plans have made a good faith effort to contract with, will be reimbursed at no more than 90% of the Medicaid fee-for-service rate. Note: Out of network providers must be enrolled in NC Medicaid to be reimbursed by the health plans.
- Out of Network Providers Follow In-Network PA Rules: Between June 1, 2024, and Aug. 31, 2024, health plans will permit uncontracted, out-of-network providers enrolled in NC Medicaid to follow in-network provider PA rules. Starting on Sept. 1, 2024, out-of-network providers must seek authorization for all services.
- Primary Care Provider (PCP) Changes for All Beneficiaries: Between Dec. 1, 2023, and Aug. 31, 2024, all beneficiaries may change their PCP for any reason.
NC Medicaid remains committed to working with provider and health plan partners to verify services are paid for without undue burden to beneficiaries and providers during the launch of Medicaid expansion. Providers who experience issues during this transition period should reach out to the contacts below.