This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care health plans unless noted otherwise.
NC Medicaid changes related to the coverage, cost sharing and reimbursement for COVID-19 related products and treatment will take effect Oct. 1, 2024.
COVID-19 Vaccines Administration Reimbursement
The rates for COVID-19 vaccine administration will revert to the vaccine administration rates in effect for all other vaccines listed on the appropriate fee schedules. As of Oct. 1, 2024, COVID-19 vaccine administration claims with revenue code 0771 will no longer reimburse at the $65 vaccine administration rate. For more information, review the COVID-19 Vaccines Reimbursement section of the Medicaid Bulletin, SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency.
The hospital COVID-19 Vaccine MAB Admin and COVID-19 Vaccine MAB Admin fee schedules will be end-dated effective Sept. 30, 2024.
Updates to the NC Medicaid Fee Schedules will be posted to the NC Medicaid Fee Schedules by Oct. 1, 2024.
COVID-19 Vaccine Counseling Coverage
Additional changes beginning Oct. 1, 2024, include the end of coverage for CPT 99401 for COVID-19 vaccine counseling and the addition of coverage of “stand-alone” vaccine counseling codes G0310, G0312 and G0315.Providers should use codes G0310, G0312, and G0315 for vaccine counseling when the vaccine is not administered on the same date of service.
NC Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) CPT code 90460 for face-to-face counseling with the patient and family by the physician or qualified health care professional during the administration of a vaccine must be billed with the EP modifier. One unit is billed for each vaccine for which counseling is provided. CPT code 90460 is an immunization administration code, which includes counseling. It is not an add-on “counseling” code.
For more information on vaccine guidance for children, review the Health Check Program Guide, available on the NCTracks Provider Policies, Manuals, Guidelines and Forms page under Provider Policies, Manuals and Guidelines.
COVID-19 vaccines should continue to be provided to children in alignment with the Advisory Committee on Immunization Practices (ACIP) Child and Adolescent Immunization Schedule.
For more information is available in the COVID-19 Vaccine Counseling Coverage section of the Medicaid Bulletin, SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency.
Over-the-Counter Tests for Home Use Coverage for COVID-19
Coverage for point-of-sale (POS) billing for FDA-authorized over the counter (OTC) COVID-19 tests dispensed for use by NC Medicaid beneficiaries, with full coverage, in a home setting ends Sept. 30, 2024.
The Department of Health and Human Services (NCDHHS) partnered with more than 270 local organizations statewide, called Community Access Points, to distribute free COVID-19 at-home tests in their communities. Individuals can use this website to find COVID-19 home tests for pickup near them. Individuals should call a community access point before going to pick up a test to make sure tests are available. Locations may choose to limit the number of tests available per person, per day. Individuals must be 14 years or older to pick up free at-home tests. An ID is not required.
NC Medicaid continues to cover Nucleic Acid Amplification Test (NAAT) panels (testing 3-5 targets) after Oct. 1, 2024. Providers can leverage CPT 0240U (SARS-CoV-2, influenza A, influenza B) and CPT 0241U (SARS-CoV-2, influenza A, influenza B, RSV).
Guidance on pharmacy POS coverage is available on the Outpatient Pharmacy Services page under OTC COVID 19 Tests for Home Use. The end date for this coverage (Sept. 30, 2024) was previously communicated in the Medicaid Bulletin, SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency.
Copays and Mandatory Coverage for COVID-19 Related Treatment
NC Medicaid will reinstate cost-sharing (i.e., copays) for COVID-19 related treatments (including treatment of conditions that may seriously complicate the treatment of COVID-19) on Oct. 1, 2024. When applicable, beneficiaries will be responsible for copays for medications and outpatient specialized therapies (i.e., audiology, occupational therapy, physical therapy, respiratory therapy and speech therapy).
The limits listed in the Clinical Coverage Policy 10A will be enforced for individuals ages 21 and older who are seeking treatment due to COVID-19 beginning Oct. 1, 2024.
See the Medicaid Bulletin, SPECIAL BULLETIN COVID-19 #259: Mandatory Coverage of COVID-19-Related Treatment Under the American Rescue Plan Act of 2021 (UPDATE) for additional information.
COVID-19 Testing Coverage for Beneficiaries with Family Planning Medicaid
NC Medicaid will no longer cover COVID-19 testing for Family Planning (MAFDN) beneficiaries through the NC Medicaid Optional COVID-19 Testing Program after Sept. 30, 2024.
Additional information is available in the Medicaid Bulletin, SPECIAL BULLETIN COVID-19 #156: Clinical Policy 1E-7, Family Planning Services, COVID-19 Lab Testing for MAFDN Beneficiaries.
Contact
For questions related to NC Medicaid Managed Care, contact the health plans for more information. For questions related to NC Medicaid Managed Care, contact the health plans for more information. Contact information is available on the Health Plan Contacts and Resources webpage.
For questions related to NC Medicaid Direct, contact the NCTracks Call Center at 800-688-6696.