Through the Bipartisan Safer Communities Act and guidance from The Centers for Medicare & Medicaid Services (CMS), NC Medicaid has implemented clinical and reimbursement changes for School-Based Services (SBS). These updates are intended to increase access to physical and mental health services through the school environment, with increased compliance and inter-agency coordination between NC Medicaid and NC Department of Public Instruction (NCDPI) to meet the following goal:
Improve schools’ capacity to provide more health services by adding provider types and additional services while improving federal reimbursement potential, improving integrity monitoring, and reducing administrative burden.
Key Clinical Policy Updates
To accomplish this goal, NC Medicaid Clinical Coverage Policy 10C (CCP 10C) updates include the following key clinical changes effective July 1, 2026:
- Expand types of eligible behavioral health providers by including these new practitioners [Subsection 3.8]:
- School Psychologist Intern
- Licensed Marriage and Family Therapist (LMFT)
- Licensed Marriage and Family Therapist Associate (LMFTA)
- Licensed Clinical Addiction Specialist (LCAS)
- Licensed Clinical Addiction Specialist Associate (LCASA)
- Licensed Physician Assistant (PA)
- Nurse Practitioner (NP), including Psychiatric Mental Health Nurse Practitioner (PMHNP)
- Licensed Behavioral Analyst
- Licensed Assistant Behavioral Analyst
- Behavior Technician
- Medical Doctor (MD)
- Doctor of Osteopathic Medicine (DO)
- Expand service plans from services pursuant only to an Individualized Education Program (IEP), Individualized Family Service Plan (IFSP), Behavioral Intervention Plan (BIP), Individual Health Plan (IHP) or 504 Plan, to include a new, “other written plan within a provider’s scope of practice”; remove IFSP [Subsection 3.2.1].
- Expand eligible services to include [Subsections 3.10.1-2 and Attachment A, C.]:
- Behavioral health-related services
- Nursing assessments
- Crisis services
- Align the CPT codes eligible for telehealth and telephonic visits with other NC Medicaid Clinical Coverage Policies [Attachment A, C.]
- Expand ordering practitioners beyond MD only; update NC Medicaid enrollment requirements for ordering and rendering providers [Subsection 3.1.3].
- Clarify nursing services to indicate Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) are the only direct nursing service providers; remove CPT code S5125 [Subsection 3.7 and Attachment A, C.].
Key Reimbursement Updates
The following key reimbursement updates are effective July 1, 2026:
- Expand the time study methodology from three quarters to four.
- Reduce the time study window to two days for notice and two days for response.
- Allow substitutions and vacancies to be included within a Cost Pool.
- Exempt contractors with 100% direct Medicaid-reimbursable services from time studies and record all costs on the cost report.
Contact
- NC Medicaid Contact Center: 888-245-0179
- NC Medicaid School-Based Services Team: Medicaid.SchoolBasedServices@dhhs.nc.gov
- Provider Ombudsman: Medicaid.ProviderOmbudsman@dhhs.nc.gov