This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care. The policy update expands the adult visit limit for outpatient specialized therapy (OST) services as required by the Centers for Medicare & Medicaid Services (CMS) and federal regulations per the Alternative Benefit Plan (ABP) process for Medicaid expansion. The ABP process requires state Medicaid agencies to benchmark Essential Health Benefits (EHB) against a commercial Affordable Care Act (ACA) plan. Rehabilitative and Habilitative services are EHB items.
Utilization management of visits described in this policy update applies to NC Medicaid Direct. NC Managed Care Plans cover the same amount, scope and duration. Providers should refer to NC Managed Care Plans for their utilization management requirements of available visits.
Prior authorization (PA) continues to be required for all treatment visits. PA requirements and coverage limits on OST treatment visits for beneficiaries aged 21 and older are updated in Clinical Coverage Policy 10A, subsection 5.4:
PA can be obtained for up to 12 therapy treatment visits and six months in a single PA request. Each reauthorization request must document the efficacy of treatment. Annual treatment visits must be medically necessary and are available to beneficiaries 21 years and older as follows:
- A total maximum of 30 treatment visits per calendar year combined across occupational and physical therapy habilitative services.
- A total maximum of 30 treatment visits per calendar year combined across occupational and physical therapy rehabilitative services.
- A total maximum of 30 treatment visits per calendar year for speech therapy habilitative services.
- A total maximum of 30 treatment visits per calendar year for speech therapy rehabilitative services.
Habilitative and Rehabilitative Services are defined by CMS through the Glossary of Health Coverage and Medical Terms and 45 CFR § 156.115.
In addition, subsection 3.2.1 was amended to update the ordering practitioners for home health services to align with Clinical Coverage Policy 3A, Home Health Services per 42 CFR 440.70.
Providers are reminded to discuss available visits with beneficiaries when the treatment plan is established. NC Medicaid Direct, NC Medicaid Utilization Review Contractor(s), and Medicaid Managed Care Plans perform reviews for monitoring utilization, quality and appropriateness of all services rendered as well as compliance with clinical coverage policies.
- Additional Resources: NC Medicaid Program Specific Clinical Coverage Policies
- For beneficiaries enrolled in a Prepaid Health Plan (PHP), refer to the health plan for information on utilization management.
- For Medicaid Direct Utilization Review, refer to Constellation Quality Health (CCME Services) ChoicePA website.
Contact
NC Medicaid Contact Center, 888-245-0179
NC Medicaid Managed Care health plans