This bulletin applies to NC Medicaid Direct.
NC Medicaid Personal Care Services (PCS) providers were notified of the realignment of PCS for individuals living in congregate settings beginning on April 1, 2025. Please refer to the Medicaid provider bulletins:
- Updated Policy Guidance for Personal Care Services in Congregate and Home Settings (January 6, 2025)
- UPDATED: Policy Guidance for Personal Care Services in Congregate and Home Settings (December 20, 2024)
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 with a new PCS policy, outlined below.
New Processes Effective April 1, 2025
1. Utilization of the Appropriate PCS Policy: PCS providers must follow the policy that applies to the services they are rendering. Two clinical coverage policies (CCPs) available for oversight and guidance on the NC Medicaid website are:
- Personal Care Services in In-home settings (3L). This policy covers providers billing with current procedural terminology (CPT) 99509 HA and 99509 HB.
- Personal Care Services in Congregate Settings (3L-1). This policy covers providers billing under the following CPT codes:
- 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 Mental Illness/Substance Abuse (MI/SA)
- 99209 HI - Supervised Living Facilities for adults with Intellectual/Development Disabilities(I/DD).
2. Transition to a Daily Rate for Congregate Settings:
- The submission of a daily unit for claim processing for Medicaid beneficiaries living in congregate settings is described above.
- 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.
Provider Support and Training
Providers can refer to the PCS training tool and the NCTracks billing guide for ongoing technical support.
On April 1, 2025, NC Medicaid implemented the following strategies to reduce provider billing issues:
- Post-Transition Virtual Office Hours: NC Medicaid will host virtual post-transition office hours to answer questions, troubleshoot billing issues, and assist providers in establishing billing practices that align with the new PCS congregate setting billing methodology.
The virtual office hours and contact links are listed below:
April 10, 2025, at 9:30 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,155861068#
April 17, 2025, at 10:00 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,629259565#
May 8, 2025, at 9:30 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,461484784#
May 22, 2025, at 9:30 a.m.
Click on this link to join, Join the meeting now or dial +1 984-204-1487,,459237251#
- As a preventive step, NC Medicaid will watch claim processing through June 2025 to ensure claims are adjudicated as intended. For those identified as error claims, NC Medicaid will intervene directly to assist the provider in correcting the claim to promote adjudication.
- Providers experiencing hardship due to delays in adapting the new billing methodology to a daily unit may request a Provider Hardship. NC Medicaid will assist with providing billing evidence to support the hardship request.
What will not change:
- The referral process to request PCS.
- The process for evaluating and scoring assessments.
- The PCS base unit rate.
- The PCS prior approval units.