Stay Updated on the North Carolina Medicaid Personal Care Services Program: Key Policy and Procedure Changes

Navigating the complexities of healthcare administration is crucial for providers, especially within programs like North Carolina Medicaid’s Personal Care Services (PCS). This article serves as your comprehensive guide to the latest updates, ensuring you remain compliant and informed about the Personal Care Services Program. We’ve compiled essential announcements and policy revisions to keep you ahead of the curve in delivering quality care.

Important Updates for PCS Providers: Reimbursement and Operational Changes

North Carolina Medicaid consistently refines its personal care services program to enhance efficiency and quality. Here’s a breakdown of recent critical updates you need to be aware of:

Transition to Daily Reimbursement Rates for Congregate Settings (Effective January 1, 2025)

Significant changes are coming to how PCS reimbursement is structured for individuals in congregate living environments. Starting January 1, 2025, NC Medicaid is shifting from a 15-minute increment billing system to a daily per diem rate. This realignment affects reimbursement for services provided in settings like Adult Care Homes, Combination Homes, and Special Care Units.

Key Changes to Reimbursement:

Daily Per Diem Rate: Reimbursement will no longer be based on the exact time spent with a beneficiary each day. Instead, a predetermined daily rate will apply.
Calculation of Daily Units: The daily rate is calculated based on the total units prior-approved by NC Medicaid for each beneficiary over an authorized period. The formula is: PA Approved Daily Units / Approved PA days, where “Approved PA days” is defined as PA End date – PA Beg Date + 1 Day.
- Example: If a beneficiary’s Prior Authorization (PA) is for 320 units over 30 days, the approved daily units will be 320 / 30 = 10.666.
Billing Procedure: Providers will submit one line item per date of service under this new system.
Governing Policies: Two new Clinical Coverage Policies (CCPs) detail this reimbursement methodology:
- 3L: Personal Care Services in In-home settings
- 3L-1: Personal Care Services in Congregate Settings (specifically for CPT code 99509 HC, 99509 TT, and 99509 SC)

These CCPs, effective January 1, 2025, will be available on the NC Medicaid website, offering detailed claims-related information in Attachment A. Providers are encouraged to review these policies thoroughly to ensure accurate billing and compliance within the personal care services program.

Important Notice Regarding DHB Form 3051 (Effective April 1, 2025)

Starting April 1, 2025, be sure to use the most current version of the DHB 3051 form, “Request for Services and Instructions (DHB 3051),” when submitting PCS requests. Using outdated forms will lead to processing delays as providers will be required to correct their submissions with the updated version. Ensure your team is using the latest forms to avoid administrative hurdles and maintain timely processing of requests within the personal care services program.

Compliance and Quality Assurance in Personal Care Services

Maintaining compliance with NC Medicaid’s regulations is paramount for all PCS providers. Here are critical compliance requirements and updates:

Annual Compliance Attestation for Quality Improvement Program

Each year, providers enrolled in the personal care services program must attest to their adherence to Clinical Coverage Policy 3L, Section 7.7, which pertains to the Internal Quality Improvement Program. This annual requirement involves submitting the Quality Improvement Attestation Form, NC Medicaid 3136, by December 31st each year.

Key Steps for Compliance:

Access and Review Form NC Medicaid 3136 and Instructions NC-Medicaid 3136 I: Familiarize yourself with the form and guidelines.
Complete and Sign Form NC Medicaid 3136: Ensure accurate completion and authorized signature.
Upload to QiRePort Portal: Submit the signed form electronically via the QiRePort portal.

NC Medicaid utilizes the QiRePort portal to audit provider compliance with Section 7.7. All providers must use this portal for attestation submissions.

Training Attestation for Additional Service Hours (Session Law 2013-306)

For providers supporting beneficiaries approved for additional service hours under Session Law 2013-306, a one-time submission of the Session Law 2013-306 PCS Training Attestation Form, NC Medicaid 3085, is required. This form confirms that the provider’s aide training curriculum is complete and they are qualified to support beneficiaries needing these additional hours.

Requirement Details:

One-time Submission: This attestation is only needed once per agency, not annually or per beneficiary.
Trigger: Required when additional hours are requested for beneficiaries under Session Law 2013-306.
Form NC Medicaid 3085 and Instructions NC Medicaid-3085 I: Use these resources for guidance and form completion.
Upload via QiRePort Portal: Submit the completed form through the QiRePort portal.

QiRePort Portal: Document Upload Instructions

To streamline form submissions, NC Medicaid requires electronic uploads via the QiRePort portal for both Form 3136 and Form 3085. Administrative rights within the portal are necessary to perform these uploads.

Step-by-Step Upload Guide:

PI Setup Menu Access: Navigate to the PI Setup Menu in QiRePort. (Administrative rights required).
Documents Section: Click “Documents” and locate your Provider Name/NPI#.
Add Document: Select your Provider Name hyperlink, then click “Add Document” to open the “Upload Record” screen.
Document Details: Choose Document Type, Document Year, and upload the saved Form 3136 or 3085 file from your computer.
Complete Upload: Click “Done” and then “Save” to finalize the upload to the Provider Documents table.

Important Points for QiRePort Usage:

Administrative Rights: Only authorized personnel with administrative rights can upload forms.
Provider-Specific Uploads: Forms are uploaded per provider, not per beneficiary.
Centralized Storage: QiRePort serves as the central repository for these forms.

For QiRePort support or administrative right inquiries, contact VieBridge Support at 888-705-0970. For PCS program-specific questions, reach out to NC Medicaid at [email protected] or 919-855-4360.

System Updates and Transitions within NC Medicaid PCS

The personal care services program is continually evolving, with system updates designed to improve service delivery and administration. Stay informed about these key system-related changes:

NCLIFTSS and Comprehensive Independent Assessment Entity (CIAE) Transition

NC Medicaid is transitioning to a new Comprehensive Independent Assessment Entity (CIAE), KEPRO (also known as Acentra Health), and the new NC Linking Individuals and Families for Long Term Services and Supports (NCLIFTSS) system. This transition aims to streamline assessments and service authorizations.

Key Transition Points:

New CIAE Vendor: KEPRO/Acentra Health was awarded the contract as the new CIAE vendor in June 2023.
NCLIFTSS Implementation: NCLIFTSS is the new system for managing long-term services and supports.
Webinar for Support Center Overview: A webinar was held on September 20, 2023, to guide providers on accessing NCLIFTSS.

While transitioning to NCLIFTSS, NC Medicaid is taking steps to ensure no service gaps for PCS beneficiaries. One such measure was the extension of prior authorizations (PAs) for Medicaid Direct PCS beneficiaries while annual assessments are being scheduled by Kepro/Acentra. Annual appointment scheduling began after October 2023.

Extending Beneficiary Prior Authorizations (PAs)

To prevent service disruptions due to delayed annual assessments, NC Medicaid has implemented a process for automatic PA extensions.

Automatic PA Extension Process:

Monthly System Check: At each month’s end, the system identifies beneficiaries without an annual assessment in the past year and whose authorizations are expiring.
Automatic PA Generation: QiReport automatically generates PA extensions and transmits them to NC Tracks on the last day of the month.
Provider Verification: Providers should check NC Tracks two business days after month-end to confirm PA extensions for their beneficiaries.
Medicaid Contact (Exception): Only contact Medicaid if a PA extension was not processed for a beneficiary whose authorization expired the previous month.

This automated system is designed to ensure continuity of care within the personal care services program.

Electronic Visit Verification (EVV) Implementation

Electronic Visit Verification (EVV) is now a requirement for personal care services, mandated by the 21st Century Cures Act. NC Medicaid has implemented EVV to verify service delivery for in-home visits.

EVV Program Details:

Mandate: Required for State Plan Personal Care (PCS) [In-Home] and various waiver programs.
Purpose: To ensure accountability and verify that authorized services are indeed received.
Statewide Vendor: Sandata Technologies, LLC is NC’s EVV vendor, contracted in September 2020.
Implementation Date: EVV implementation became effective January 1, 2021.

NC Medicaid has provided resources and webinars to assist providers with EVV implementation and onboarding with Sandata.

Conclusion: Staying Informed and Engaged with PCS Program Updates

Keeping abreast of changes within the North Carolina Medicaid personal care services program is essential for providers to deliver seamless, compliant, and high-quality care. Regularly reviewing official Medicaid bulletins and participating in webinars and stakeholder meetings are vital steps to stay informed.

Key Takeaways for Providers:

Monitor Official Channels: Regularly check the NC Medicaid website and NCLIFTSS portal for announcements.
Attend Webinars: Participate in informational webinars to understand policy and system changes directly from NC Medicaid.
Utilize QiRePort and NC Tracks: Become proficient in using these portals for compliance submissions and PA verification.
Stay Updated on Reimbursement Policies: Understand the nuances of the new daily per diem reimbursement model for congregate settings.
Ensure Form Compliance: Always use the latest versions of required forms, like DHB 3051, NC Medicaid 3136, and NC Medicaid 3085.

By staying informed and proactive, providers can effectively navigate the evolving landscape of the personal care services program and continue to provide essential services to North Carolina Medicaid beneficiaries. For further inquiries or support, always refer to the official NC Medicaid contacts provided in this article and on their website.