NC Medicaid implemented several policy flexibilities at the launch of Tailored Plans to ease the administrative burden on providers and to ensure members receive uninterrupted care during the transition to Tailored Plans. This included relaxing medical and pharmacy prior authorization (PA) requirements and implementing flexibilities for out-of-network provider rates and PA rules.
To ensure continuous care for members during the transition to Tailored Plans and to reduce provider burden, the Department is extending certain policy flexibilities originally scheduled to expire September 30, 2024. The transition period for these flexibilities will continue until January 31, 2025. The extension impacts the following flexibilities:
Medical PAs
Between July 1, 2024, and January 31, 2025, Tailored Plans are expected to cover services if a PA request meets medical necessity criteria in the following situations:
- A provider fails to submit PA prior to the service being provided and submits PA after the date of service; or
- A provider submits for retroactive PA.
*This exception does not apply to concurrent reviews for inpatient hospitalizations, which should still occur during this time.
Pharmacy PAs
For pharmacy PAs between July 1, 2024, and January 31, 2025, Tailored Plans are expected to honor existing pharmacy PAs (from NC Medicaid Direct and other health plans) for the life of the PA and to consider previous PA and current drug therapy as necessary, when making coverage determinations. This flexibility applies to both in-network and out-of-network providers.
Out-of-Network Provider Rates
In addition to out-of-network requirements found in the Department’s Transition of Care policy, Tailored Plans are expected to cover and reimburse for services for Medicaid-eligible nonparticipating/out-of-network providers equal to those of in-network providers for a period of 214 days after Tailored Plan launch (through January 31, 2025). Medically necessary services for physical and behavioral health will be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in and out-of-network providers during this period.
Note: Out-of-network providers must be enrolled in NC Medicaid to be reimbursed by the Tailored Plan.
Out-of-Network Providers Follow In-Network PA Rules
Between July 1, 2024, and May 31, 2025, Tailored Plans are expected to honor prior authorizations submitted by out-of-network providers enrolled in NC Medicaid that meet in-network provider prior authorization rules. Starting June 1, 2025, out-of-network providers must seek authorizations for all services and be approved to provide services to be reimbursed for those services.
Additional details about each Tailored Plan’s PA requirements are available at:
Members can still change their PCP for any reason an unlimited number of times through January 31, 2025.
The Department expects Tailored Plans and providers to continue to work in good faith to finalize contracts so Tailored Plans have adequate networks to care for their members.
NC Medicaid is committed to working with providers and health plans to verify services are reimbursed without undue burden to members or providers during the transition.
Contact
For questions related to NC Medicaid Managed Care, contact the health plans for more information. Contact information is available on the Health Plan Contacts and Resources webpage.
Providers can also reach out to the Provider Ombudsman at [email protected] or 866-304-7062.