UPDATED:
The rate methodology for NC Medicaid Direct providers rendering Personal Care Services (PCS) in a congregated setting will be delayed until April 1, 2025. The original implementation date was January 1, 2025. See DHHS bulletin here.
The NC Medicaid Personal Care Services (PCS) program will change from a per unit or per hour billing structure to a per diem or per day billing structure. The NC Department of Health and Human Services (DHHS) issued the following bulletin:
Revised Reimbursement Methodology for Individuals Living in Congregated Settings Administered by Personal Care Providers. Effective [April ] 1, 2025, the unit of reimbursement will change from a 15-minute increment to a per daily per diem.
Reimbursement Methodology Changes
NC Medicaid is modifying NCTracks to be able to implement the per diem methodology to accompany Medicaid clinical coverage policy (CCP) 3L-1 (see the Policy Guidance for Personal Care Services Beneficiaries in Congregate and In-Home Settings bulletin for more information on this topic. The new policy and reimbursement methodology will become effective [April] 1, 2025, and will be characterized by the following elements:
Only procedure code 99509 and modifiers SC, HC, or TT will be impacted.
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 contain the PA effective and end date.
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 – PA Beg Date +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.
Providers are not required to take any action at this time. Details regarding this change can be found on the NC Medicaid Health Plan Billing Guidance web page.
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