NOTE: This Medicaid Bulletin has been completely replaced by an updated version published on Oct. 11, 2024. Please see the updated Hurricane Helene Policy Flexibilities to Support Providers and Members - Oct. 11, 2024 bulletin, for the latest information.
This bulletin includes an update to the Sept. 26, 2024 bulletin regarding Hurricane Helene. New sections added from the previous bulletin are:
- Disaster Relief Applications Available for Health Care Providers Not Currently Enrolled as a NC Medicaid Provider
- Expanded Ability for Hospital Swing Beds
- Private Duty Nursing
- Reminder: Hospital at Home Program Remains Active
North Carolina Governor Roy Cooper issued Executive Order 315 on Sept. 25, 2024, which declared a state of emergency for North Carolina in anticipation of potential severe weather caused by the approach of Hurricane Helene.
NC Medicaid is committed to North Carolina's response to and recovery from Hurricane Helene. We are working with county and federal partners to make it faster and easier for beneficiaries to receive - and for health care professionals to provide - Medicaid care and services.
The flexibilities in this bulletin are effective from Sept. 26, 2024, through Oct. 15, 2024 (unless otherwise communicated by DHHS). This bulletin describes the extension of the flexibilities originally scheduled to end Oct. 2, 2024, for NC Medicaid Direct and NC Medicaid Managed Care, as indicated below. Additional updates will be provided as they become available.
As a reminder, providers should always check NC Medicaid eligibility in NCTracks to confirm beneficiary enrollment in NC Medicaid, especially when the beneficiary presents without a Medicaid ID or their health plan ID card, to determine which health benefit the beneficiary is enrolled in and whether their eligibility remains current.
Flexibilities for both NC Medicaid Direct and NC Medicaid Managed Care
Disaster Relief Applications Available for Health Care Providers Not Currently Enrolled as a NC Medicaid Provider
NC Medicaid wants to ensure access to care for NC Medicaid beneficiaries and reimbursement to qualified providers for services rendered during the period of impact due to Hurricane Helene.
The Centers for Medicare & Medicaid Services (CMS) granted approval effective Oct. 1, 2024, for NC Medicaid to implement a temporary, expedited enrollment process for health care providers to become a NC Medicaid provider due to a natural disaster. This process is available to enroll with a begin date of Sept. 25, 2024. The process will remain available through Oct. 15, 2024, and is not for providers who are already enrolled with NC Medicaid.
Health care providers who will render services to NC Medicaid beneficiaries due to Hurricane Helene can apply through the NCTracks Provider Portal. Instructions are available in the Disaster Relief Provider Enrollment Application Job Aid (PRV703) located under Quick Links on the NCTracks Provider Enrollment homepage. Be sure to review the job aid before applying as several preliminary steps are required.
Providers must indicate the application is for Disaster Relief by answering “Yes” to the Disaster Relief enrollment question on the Basic Information page of the application.
Note: This is not for providers who see NC Medicaid beneficiaries on a regular basis and are already enrolled with NC Medicaid.
Additional information is available in the North Carolina Medicaid Provider Enrollment Disaster Relief and Waiver or Modification of Requirements Under Section 1135 of the Social Security Act from the Secretary of Health and Human Services.
If you have questions, please contact:
- NCTracks Call Center: 800-688-6696
- Provider Ombudsman: 866-304-7062, Medicaid.ProviderOmbudsman@dhhs.nc.gov
Expanded Ability for Hospital Swing Beds
A swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare with CMS approval to provide post-hospital skilled nursing facility care.
Effective Sept. 26, 2024 through Oct. 15, 2024, for affected counties included in the NC Disaster Declaration, to support providers during Hurricane Helene, the eligibility requirements at 42 CFR 482.58(a)(1)-(4), “Special Requirements for hospital providers of long term care services (swing-beds)” have been waived. This allows hospitals to establish skilled nursing facility (SNF) swing beds payable under the SNF prospective payment system (PPS) to provide additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF.
The flexibility is for NC Medicaid Direct and NC Medicaid Managed Care. For information on billing for lower-level of care beds/swing beds, please review Clinical Coverage Policy 2A-1.
Reimbursement for medically necessary services during Hurricane Helene
NC Medicaid Direct and NC Medicaid Managed Care will reimburse providers for medically necessary drugs and services, equipment and supplies, provided during the Hurricane Helene emergency without prior authorization (PA) starting Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS).
Medical documentation must support medical necessity. In addition, beneficiaries who have been evacuated out-of-state, voluntarily or involuntarily, can receive medically necessary services and/or care if needed and NC Medicaid Direct and NC Medicaid Managed Care will reimburse the out-of-state provider without PA. Out-of-state providers must enroll as NC Medicaid providers. Please see the section of this bulletin “Disaster Relief Applications Available for Health Care Providers Not Currently Enrolled as an NC Medicaid Provider” for more details.
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 PA overrides due to Hurricane Helene
Impacts from Hurricane Helene may present situations where NC Medicaid beneficiaries in impacted areas may have difficulty obtaining necessary PA for certain medications, including beneficiaries who may have traveled out of state to seek safety. Therefore, NC Medicaid enrolled pharmacy providers have been approved to override PA requirements starting Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS). This override of PA is being allowed to ensure that all Medicaid beneficiaries have access to necessary medications.
Out-of-state pharmacy providers, who may be serving beneficiaries who have been displaced, must enroll as NC Medicaid providers. Please see the section of this bulletin “Disaster Relief Applications Available for Health Care Providers Not Currently Enrolled as an NC Medicaid Provider” for more details.
As a reminder, per Clinical Coverage Policy 9, a provider cannot refuse to provide services if a beneficiary cannot pay a copay at the time of service.
For NC 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 1-800-688-6696.
For NC Medicaid Managed Care, providers should contact the pharmacy service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for PA overrides due to Hurricane Helene.
Standard Plans
- AmeriHealth: 1-866-885-1406
- Healthy Blue: 1-833-434-1212
- Carolina Complete: 1-833-992-2785
- United Healthcare: 1-855-258-1593
- Wellcare: 1-866-799-5318, option 3
Tailored Plans
- Alliance Health: 1-855-759-9300
- Partners: 1-866-453-7196
- Trillium: 1-866-245-4954
- Vaya Health: 1-800-540-6083
Early prescription refills during the Governor’s state of emergency declaration
Conditions following Hurricane Helene may present situations where NC Medicaid beneficiaries in impacted areas, including beneficiaries who may have traveled out of state to seek safety, 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 Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS) the early refill is being allowed to ensure that all Medicaid beneficiaries have access to necessary medications.
Out-of-state pharmacy providers, who may be serving beneficiaries who have been displaced, must enroll as NC Medicaid providers. Please see the section of this bulletin “Disaster Relief Applications Available for Health Care Providers Not Currently Enrolled as an NC Medicaid Provider” for more details.
As a reminder, per Clinical Coverage Policy 9, a provider cannot refuse to provide services if a beneficiary cannot pay a copay at the time of service.
For NC 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 1-800-688-6696.
For NC Medicaid Managed Care, providers should contact the 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.
Standard Plans
- AmeriHealth: 1-866-885-1406
- Healthy Blue: 1-833-434-1212
- Carolina Complete: 1-833-992-2785
- United Healthcare: 1-855-258-1593
- Wellcare: 1-866-799-5318, option 3
Tailored Plans
- Alliance Health: 1-855-759-9300
- Partners: 1-866-453-7196
- Trillium: 1-866-245-4954
- Vaya Health: 1-800-540-6083
Expediting Nursing Home Admissions for Individuals Displaced due to Hurricane Helene
NC Medicaid Direct and NC Medicaid Managed Care will allow expedited nursing home admissions for individuals displaced by Hurricane Helene effective Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS).
For NC Medicaid Direct, providers should upload the signed Physician Signature form with their portal submissions to NCTracks. NCTracks is designed to receive long-term care PA information in the FL2 format. Medicaid has temporarily suspended the requirement of a Pre-Admission Screening and Annual Resident Review (PASSR) number on the PA. Providers should note on their portal submissions the PASRR is unavailable due to Hurricane Helene emergency placement. In addition, providers should add all the pertinent information about the recipient’s levels of care needs in their portal submission on the long-term care FL2. For individuals displaced from an adult care home (ACH), on line 15 of the FL2, requested level of care should be “Nursing Facility” and on line 16 notate “Temporary Placement due to Hurricane Helene.” Additional questions can be directed to the NCTracks service line at 1-800-688-6696.
For NC Medicaid Managed Care, providers should contact the provider service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for expedited nursing home admissions for individuals displaced due to Hurricane Helene.
Standard Plans
- AmeriHealth Caritas: 1-888-738-0004 (TTY: 1-866-209-6421)
- Carolina Complete: 1-833-552-3876 - Option 3
- Healthy Blue: 1-844-594-5072
- United Healthcare: 1-800-638-3302
- WellCare: 1-866-799-5318
Tailored Plans
- Alliance Health: 1-855 759-9700
- Partners Health Management: 1-877-398-4145
- Trillium Health Resources: 1-855-250-1539
- Vaya Health: 1-866-990-9712
Temporary PASRR Procedures Due to Hurricane Helene
NC Medicaid Direct and NC Medicaid Managed Care will not require Level I and II Preadmission Screening and Resident Reviews (PASRRs) for new admissions effective Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS).
For NC Medicaid Direct:
- If the individual is expected to remain in the nursing facility beyond Oct. 15, 2024, a notice of the need for a PASRR review should be submitted via NCMUST.
- In addition, individuals transferred from one nursing facility to another nursing facility because of Hurricane Helene will not be considered a new admission and will not need a PASRR.
- The transferring nursing facility must ensure that all copies of the resident’s PASRR paperwork (including any Level II information) is transferred with the individual.
- From Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS) NCTracks is authorized to suspend the requirements of a PASSR number on the PA. Providers should note on their portal submission that the PASRR is unavailable due to Hurricane Helene emergency placement. A Level I and II PASRR for new admissions will not be required during this period.
- Additional questions can be directed to the NCTracks service line at 800-688-6696.
For NC Medicaid Managed Care:
- Providers should contact the provider service line to confirm if additional documentation or processes need to be completed for individuals expected to remain in the nursing facility beyond Oct. 15, 2024.
- Standard Plans
- AmeriHealth Caritas: 1-888-738-0004 (TTY: 1-866-209-6421)
- Carolina Complete: 1-833-552-3876 - Option 3
- Healthy Blue: 1-844-594-5072
- United Healthcare: 1-800-638-3302
- WellCare: 1-866-799-5318
- Tailored Plans
- Alliance Health: 1-855 759-9700
- Partners Health Management: 1-877-398-4145
- Trillium Health Resources: 1-855-250-1539
- Vaya Health: 1-866-990-9712
For those individuals receiving specialized services, the nursing facility should focus on promoting the basic health and safety of individuals who had been receiving specialized services in the nursing facility before the crisis or who were receiving specialized services in another nursing facility before the transfer.
The admitting nursing facility is responsible for submitting a claim for payment. Those nursing facilities serving as an emergency shelter due to Hurricane Helene cannot submit a claim for payment.
The safety of your staff and the NC Medicaid members served by your agency are of prime importance. If your area was impacted by Hurricane Helene, please follow the instructions of the local emergency operations in your area located at ncdps.gov/our-organization/emergency-management/county-emergency-management-agencies and implement your emergency plan.
State Plan Personal Care Services
Conditions from the impact of Hurricane Helene may present situations where NC Medicaid Direct and NC Medicaid Care beneficiaries in impacted areas cannot receive their scheduled in-person personal care assessment. In those situations, a telephonic assessment, if attainable, may be conducted from Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS). To ensure the health and well-being of impacted individuals needing PCS and expedited or abbreviated assessment may be conducted from Sept. 26, 2024, through Oct. 15, 2024. During the hurricane recovery period, providers and beneficiaries are asked to call NCLIFTSS at 1-833-522-5429 to provide new contact information, if applicable to maintaining consistent communication. NC Medicaid Direct and NC Medicaid Care beneficiaries who are displaced from their homes or facilities may continue to receive their PCS in their relocated settings.
For NC Medicaid Direct, NCLIFTSS will work with individuals in impacted areas to reschedule in-person assessments as telephonic assessments.
For NC Medicaid Managed Care, providers can contact the provider service line to confirm if additional steps need to be completed for individuals impacted and are scheduled for in-person assessments.
Standard Plans
- AmeriHealth Caritas: 1-888-738-0004 (TTY: 1-866-209-6421)
- Carolina Complete: 1-833-552-3876 - Option 3
- Healthy Blue: 1-844-594-5072
- United Healthcare: 1-800-638-3302
- WellCare: 1-866-799-5318
Tailored Plans
- Alliance Health: 1-855 759-9700
- Partners Health Management: 1-877-398-4145
- Trillium Health Resources: 1-855-250-1539
- Vaya Health: 1-866-990-9712
Private Duty Nursing
Private Duty Nursing (for pediatric and adult beneficiaries) may be provided without prior authorization (PA) for NC Medicaid Direct and NC Medicaid Managed Care beneficiaries, effective Sept. 26, 2024, through Oct. 15, 2024 (unless otherwise communicated by DHHS).
For NC Medicaid Direct, NCTracks is authorized to suspend the standard PA requirements per PDN Clinical Coverage Policy, 3G-1 and 3G-2. Medical documentation must support medical necessity, and providers are encouraged to obtain PA if possible (as required under normal policy). All claims are subject to audit. Additional questions can be directed to the NC Tracks service line at 1-800-688-6696.
For NC Medicaid Managed Care, Providers can contact the provider service line to confirm if additional steps are needed for individuals needing PDN.
Standard Plans
- AmeriHealth Caritas: 1-888-738-0004 (TTY: 1-866-209-6421)
- Carolina Complete: 1-833-552-3876 - Option 3
- Healthy Blue: 1-844-594-5072
- United Healthcare: 1-800-638-3302
- WellCare: 1-866-799-5318
Tailored Plans
- Alliance Health: 1-855 759-9700
- Partners Health Management: 1-877-398-4145
- Trillium Health Resources: 1-855-250-1539
- Vaya Health: 1-866-990-9712
Innovations and Traumatic Brain Injury (TBI) waiver flexibility due to Hurricane Helene
These flexibilities below are intended for NC Innovations and TBI Waiver beneficiaries, in NC Medicaid Direct and NC Medicaid Managed Care, impacted by the hurricane either directly or due to staff impacted and unable to provide services and effective Sept. 26, 2024, through Oct. 15, 2024, (unless otherwise communicated by DHHS). They are not intended to be utilized by every waiver beneficiary. Tailored Plans and Local Management Entities/Managed Care Organizations (LME/MCOs) should assess the continued need for these flexibilities case-by-case.
NC Medicaid will seek approval for Appendix K authority, more information will be provided on the flexibilities of service utilization and the effective period of Appendix K when available.
The flexibilities below are specific to beneficiaries impacted by Hurricane Helene.
NC Medicaid will 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.
- Relatives of adult waiver beneficiaries and minor waiver beneficiaries may provide Community Living and Supports, Supported Employment and Supported Living. This should only be used for cases when direct support staff is impacted by Hurricane Helene and not able to provide services.
- Additional services hours may be provided without PA due to issues related to Hurricane Helene. This should only be in cases where additional hours are 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 a PA.
- Allow replacement or repair of home and vehicle modifications damaged by Hurricane Helene when cost of repair or replacement will exceed the Innovations Waiver limit.
- Innovations waiver services may be provided out of state without PA by the Tailored Plan and LME/MCO when the Innovation Waiver member is displaced and requires out of state shelter. Respite may also be provided out-of-state for individuals who have been displaced due to Hurricane Helene.
Tailored Plans and LME/MCOs must provide an assessment of the health and well-being status of each impacted Innovations and TBI waiver beneficiary to NC Medicaid at the conclusion of the state of emergency.
Reminder: Hospital at Home Program Remains Active
As a reminder, NC Medicaid continues to allow coverage of the Acute Hospital at Home (HaH) program. This program is designed to provide relief to hospitals with limited bed capacity and can be leveraged by hospitals during Hurricane Helene. NC Medicaid continues to cover Acute HaH under the existing DRG methodology through Dec. 31, 2024, when CMS Medicare Waiver flexibility is scheduled to end. To bill for Acute HAH, providers should bill DRG claims using revenue code 0161 for room and board and occurrence span code 82.
More information on the Acute HaH program can be found in the Hospital at Home Program Re-Launching for NC Medicaid bulletin.
Flexibilities for NC 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 Helene.
When helping CAP beneficiaries activate their plans, it is imperative to emphasize checking and updating disaster kits. ReadyNC.gov is a valuable resource to use for additional information and assistance to prepare for a hurricane. Providers should 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 Helene, and to coordinate resources, NC 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. NC Medicaid will seek approval for Appendix K authority, more information will be provided on the flexibilities of service utilization and the effective period of Appendix K when available. 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 because of Hurricane Helene
- If it does not, specify what additional or replacement services are needed through a plan revision.
In-home aide, pediatric nurse aide, attendant nurse care, personal assistance services, and coordinated caregiving can be authorized to be administered in a different residence or alternative setting in the event the waiver participant is displaced from their home.
CAP/C and CAP/DA waiver beneficiaries in impacted areas who cannot receive their in-person scheduled assessment or a required in-person monitoring visit, a telephonic assessment or monitoring visit may be conducted. Annual assessments and new and annual service plans during the hurricane recovery period, can be postpone until safe contact can be arranged to complete these assessments and service plans.
CAP/C and CAP/DA home and community-based services that are identified from the CAP emergency and disaster plan assessment may be implemented and a retroactive approval may be granted. The assessed need for the home and community-based service must be documented in the emergency and disaster plan or evidence of the need if access to e-CAP is not available.
CAP/C and CAP/DA waiver beneficiaries in impacted areas who lost access to their direct care worker due to the impact of the weather may become the direct care worker temporarily during this emergency as a qualifying extraordinary condition as described in the CAP waiver applications.
To seek technical assistance in managing a waiver beneficiary’s recovery from Hurricane Helene, contact the CAP unit at medicaid.capc@dhhs.nc.gov or medicaid.capda@dhhs.nc.gov. CAP/C and CAP/DA case management entities should contact NC Medicaid at 1-919-855-4340 to provide updated contact information, if current contact information is temporarily inaccessible.