This bulletin applies to NC Medicaid Direct.
NC Medicaid realigned how Personal Care Services (PCS) for individuals living in congregate settings are administered and reimbursed. The Center for Medicare & Medicaid Services (CMS) approved State Plan Amendment NC 23-0025 granting authority for the daily per diem reimbursement methodology. NC Medicaid held stakeholder engagement meetings to seek feedback on the realignment.
In accordance with SL 2019-240 Section 1(b), the realignment consists of a rate methodology change from 15-minute increments to a daily rate for individuals living in congregate settings.
Two clinical coverage policies (CCPs) were implemented that describe the payment reimbursement methodology in Attachment A- Claims-Related Information. The policies were posted for two 45-day public comment periods starting in December 2023 to June 2024.
The two CCPs are Personal Care Services in In-home settings (3L) and Personal Care Services in Congregate Settings (3L-1):
- 3L, Personal Care Services in In-home settings cover providers billing with current procedural terminology (CPT) 99509 HA and HB.
- 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, - Family Care Homes, 99509 HH - Supervised Living Facilities for adults with MI/SA, and 99209 HI - Supervised Living Facilities for adults with I/DD.
The two policies will be effective on Jan. 1, 2025.
- To allow additional time to providers, these policies will post to the NC Medicaid website on April 1, 2025.
- Providers will continue to follow the 3L CCP from Jan. 1, 2025, through March 31, 2025.
Technical support will be provided to providers to prepare them to submit claims for individuals living in congregate settings using a per diem billing methodology beginning in January. Please refer to the Updated Personal Care Services Rate Reimbursement Methodology for individuals living in congregate settings posted on Dec. 20, 2024.
The process for evaluating and scoring assessments did not change. The results from the independent assessment will continue to determine the number of qualifying PCS hours as outlined in sections 5.31 and 5.49 and in the Service Level Determination of both policies.
Contact
Personal Care Services Unit: PCS_Program_Questions@dhhs.nc.gov