Personal Care Services (PCS) provide essential support to individuals who need assistance with daily living activities. This article outlines key information and updates regarding PCS in North Carolina, focusing on recent policy changes, reimbursement methodologies, and provider requirements.
North Carolina Medicaid’s PCS Program Updates and Resources
NC Medicaid has implemented several changes to the PCS program to improve efficiency and ensure quality care. These updates impact providers and beneficiaries, particularly those in congregate settings.
Reimbursement Methodology Changes for Congregate Settings
Effective January 1, 2025, NC Medicaid transitioned from a 15-minute increment reimbursement model to a daily per diem rate for PCS provided in congregate settings. This shift aims to simplify billing and provide a more predictable payment structure. The daily rate is calculated based on the total approved units for a beneficiary divided by the authorized period. Two new Clinical Coverage Policies (CCPs), 3L for in-home settings and 3L-1 for congregate settings, detail this new methodology. Providers billing under CPT codes 99509 HC (Adult Care Homes), 99509 TT (Combination Homes), and 99509 SC (Special Care Units) fall under CCP 3L-1. NC Medicaid hosted informational webinars and published bulletins to clarify these changes.
Prior Authorization (PA) Extension Process
To ensure continuous care for beneficiaries awaiting annual assessments, NC Medicaid automatically extends eligible PAs. The system identifies beneficiaries with expiring PAs and generates extensions transmitted to NC Tracks on the last day of each month. Providers should verify PA status in NC Tracks two business days after the month’s end.
Provider Requirements and Attestations
PCS providers must annually attest to their compliance with Clinical Coverage Policy 3L, specifically Section 7.7 regarding Internal Quality Improvement Programs. This attestation, using form NC Medicaid 3136, is due by December 31st each year and must be uploaded to the QiRePort portal. Additionally, providers serving beneficiaries requiring additional hours under Session Law 2013-306 must submit a one-time attestation, form NC Medicaid 3085, confirming completion of required aide training. Detailed instructions for uploading these forms to QiRePort are available.
Transition to New Comprehensive Independent Assessment Entity (CIAE)
NC Medicaid transitioned to a new CIAE, Kepro (Acentra Health), impacting the assessment process for PCS. To facilitate a smooth transition, existing PAs were extended while annual assessments were scheduled by the new vendor. A customer support center webinar was held to assist providers and beneficiaries in accessing the new NCLIFTSS system.
Electronic Visit Verification (EVV) Implementation
In compliance with the 21st Century Cures Act, NC Medicaid implemented Electronic Visit Verification (EVV) for PCS and other home-based services effective January 1, 2021. Sandata Technologies, LLC was awarded the contract to be the state’s EVV vendor.
Conclusion
Understanding the evolving landscape of personal care services in North Carolina is crucial for both providers and beneficiaries. Staying informed about reimbursement changes, compliance requirements, and system updates ensures the continued delivery of essential care. Refer to the provided resources and links for detailed information and guidance.
