This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.
Section 1(b) of Session Law 2019-240 directed NC Medicaid to realign how Personal Care Services (PCS) for individuals living in congregate settings are administered and reimbursed. Effective Jan. 1, 2025, the unit of reimbursement will change from a 15-minute increment to a daily per diem.
Reimbursement Methodology Changes
NC Medicaid is modifying NCTracks to be able to implement the per diem methodology to accompany Medicaid clinical coverage policy (CCP) 3L-1 (see the Policy Guidance for Personal Care Services Beneficiaries in Congregate and In-Home Settings bulletin for more information on this topic. The new policy and reimbursement methodology will become effective Jan. 1, 2025, and will be characterized by the following elements:
- Only procedure code 99509 and modifiers SC, HC, or TT will be impacted.
- Reimbursement will no longer be based on the actual time spent delivering the service on a specific day. Instead, reimbursement will be based on a calculated per diem (daily) rate.
- Per diem rates will be based on the number of total units prior-approved by NC Medicaid for PCS services to each specific beneficiary for an authorized period.
- The PCS authorization period will contain the PA effective and end date.
- The APPROVED DAILY UNITS will be calculated using the available PA information at the time of adjudication, according to the following formula: PA Approved Daily Units/Approved PA days, with the latter defined as “PA End date – PA Beg Date +1 Day.” For example, if a beneficiary’s PA allows 320 total units for a period that spans 30 days, the approved daily units would be 320/30 = 10.666.
- Providers will submit one line per date of service.
Providers are not required to take any action at this time. Details regarding this change can be found on the NC Medicaid Health Plan Billing Guidance web page.
Information Sessions and Virtual Office Hours
NC Medicaid will facilitate virtual information sessions on the daily rate reimbursement process for PCS providers rendering PCS in congregate settings (Adult Care Homes, Combination Homes, and Special Care units). Both presentations will be the same. Click on one of the links below to register to attend.
NC Medicaid will offer virtual office hours during the months of December 2024, January and February 2025 to address any questions about the daily rate reimbursement process.
- Dec. 18, 2024, at 12 p.m.
Click on the following link to join: Join the meeting now or dial +1 984-204-1487,,669163860# - Jan. 8, 2025, at 9 a.m.
Click on the following link to join: Join the meeting now or dial +1 984-204-1487,,655478979# - Jan. 22, 2025, at 12 p.m.
Click on the following link to join: Join the meeting now or dial +1 984-204-1487,,144469253# - Feb. 5, 2025, at 9 a.m.
Click on the following link to join: Join the meeting now or dial +1 984-204-1487,,849288036#