This bulletin updates Revised Reimbursement Methodology for Individuals Living in Congregate Settings Administered by Personal Care Service Providers published Nov. 26, 2024.
This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.
Reimbursement Methodology Changes
The rate methodology for NC Medicaid Direct providers rendering Personal Care Services (PCS) in congregate setting was originally planned to change effective Jan. 1, 2025. However, to provide additional support to providers and mitigate potential provider abrasion, the rate methodology changes will be delayed.
Beginning on April 1, 2025, NCTracks will adjudicate claim using a per diem methodology to accompany Medicaid clinical coverage policy (CCP) 3L-1 (see the Policy Guidance for Personal Care Services Beneficiaries and In-Home Settings) bulletin for more information on this topic. Providers have until March 31, 2025, to make the necessary changes to their systems related to this change.
Key elements of the new reimbursement methodology include:
- Impacted Procedure Codes: Only procedure code 99509 and modifiers SC, HC, TT, HH, HI, HQ will be impacted by the change.
- 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 still contain the prior authorization (PA) effective and end date. This is not a change.
- 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 minus PA Beg Date plus 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.
- 3L-1, Personal Care Services in Congregate Settings covers providers billing with CPT 99509 HC- Adult Care Homes, 99509 TT - Combination Homes, 99509 SC - Special Care Units, 99509 HQ - Family Care Homes, 99509 HH - Supervised Living Facilities for adults with MI/SA, and 99209 HI - Supervised Living Facilities for adults with I/DD.
Providers are not required to take any action to comply until April 1, 2025.
Details regarding this change can be found on the NC Medicaid Health Plan Billing Guidance web page.
Technical Assistance to Support Medicaid Direct
Providers
Technical assistance is available to support Medicaid Direct providers from Dec. 3, 2024 – March 27, 2025, to ensure a smooth transition to the new rate methodology and billing guidelines that will launch on April 1, 2025.
NC Medicaid recently facilitated 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). The presentation from these sessions is available at Daily Rate Reimbursement PowerPoint.
NC Medicaid will invite providers to virtual office hours during the months of December 2024, January and February 2025 to address any questions about the daily rate reimbursement process at the following dates and times:
Jan. 8, 2025, at 9 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,655478979#
Jan. 22, 2025, at noon
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,144469253#
Feb. 5, 2025, at 9 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,849288036#
Feb. 13, 2025, at noon.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,738839464#
Feb. 27, 2025, at 9 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,858372041#
March 13, 2025, at noon.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,456981953#
March 20, 2025, at 9 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,440615693#
March 27, 2025, at noon.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,581296387#
NC Medicaid will meet with providers during office hours and review with them previously paid claims and walk them through how to submit claims that align with the daily per diem methodology.
Providers experiencing a hardship after April 1, 2025, due to pended or denied claims that are not able to adjudicate because of the claim don’t align with the new billing guideline, may qualify for a hardship advancement.