What is happening?

The NC Department of Health and Human Services has instituted policy flexibilities for Medicaid Expansion members and providers delivering services to those Expansion members in order to ensure beneficiaries receive the care they need, while easing provider administrative burden.  Flexibilities will be available on December 1, 2023.

What do providers need to know?

The NC Department of Health and Human Services (NCDHHS) has instituted policy flexibilities for expansion members and providers delivering services to those expansion members in order to ensure beneficiaries receive the care they need, while easing provider administrative burden.

              How do providers identify Medicaid Expansion members?

  • Providers can identify expansion members by checking the member’s eligibility in the NCTracks Recipient Eligibility Verification feature in the Category of Eligibility section.
  • Expansion members will have eligibility categories MXPNNor MXPGN

Medicaid Expansion Flexibilities

*Unless otherwise noted, the flexibilities below apply only to Medicaid Expansion members.

  1. Medical Prior Authorizations (PA):Between December 1, 2023 and May 31, 2024, Partners will honor existing NC Medicaid medical prior authorizations for Medicaid Expansion members. Medical PAs are any prior authorization for physical or behavioral health services. This flexibility applies to both in-network and out-of-network providers who are active, enrolled NC Medicaid providers.
  2. Expedited PA Requests/Reviews for Expansion Members:Partners is required to implement strategies related to prior authorizations to minimize disruption of benefits at launch of Medicaid Expansion on December 1, 2024. All health plans must implement processes that allow providers to submit expedited prior authorizations to prevent disruption of services for Expansion members. This flexibility applies to both in-network and out-of-network providers who are active enrolled NC Medicaid providers.
  3. Out of Network Provider Rates:In addition to out-of-network requirements found in the NCDHHS’ Transition of Care policy, between December 1, 2023, and May 31, 2024, Partners must reimburse Medicaid-eligible nonparticipating/out-of-network providers at the same rate as in-network providers. This means that medically necessary services will be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in- and out-of-network providers.

Starting on June 1, 2024, out-of-network providers who have not contracted with Partners will be reimbursed at no more than 90% of the Medicaid fee-for-service rate. Note: Out-of-network providers must be enrolled in NC Medicaid to be reimbursed by the health plans.

  1. Out-of-Network Providers Follow In-Network PA Rules:Between June 1, 2024, and August 31, 2024, Partners will permit uncontracted, out-of-network providers enrolled in NC Medicaid to follow in-network provider prior authorization rules. (For more information, review our Benefit Grids.) Starting on September 1, 2024, out-of-network providers must seek authorization for all services.
  2. Primary Care Provider (PCP) Changes for All Beneficiaries:Between December 1, 2023, and August 31, 2024, all members may change their PCP for any reason.

What if providers have questions?

NC Medicaid remains committed to working with provider and health plan partners to verify services are paid without undue burden to members and providers during the launch of Medicaid Expansion. Providers who experience issues during this transition period should reach out to the contacts below.