Easing Provider Administrative Burden: Tailored Plan Flexibilities

The administrative complexities of providing care to your patients now covered under Tailored Plans can be frustrating. NC Medicaid hopes to ease provider administrative burden in the transition period, and ensure that beneficiaries receive uninterrupted care.

The Department has implemented the following policy flexibilities to ease provider administrative burden at launch and ensure beneficiaries receive uninterrupted care:  

1. Medical Prior Authorizations (PAs): Tailored Plans are required to implement strategies to minimize disruption of benefits at Tailored Plan launch specifically related to PAs. Between July 1, 2024, and Sept. 30, 2024, Tailored Plans will not deny covered services if the request meets medical necessity criteria in the following two scenarios: 
   
   a. )  provider fails to submit PA prior to the service being provided and submits PA after the date of service. 
   b.)  provider submits for retroactive PA. 
    
   *This exception does not apply to concurrent reviews for inpatient hospitalizations, which should still occur during this time period. 

   This flexibility applies to both in-network and out-of-network providers. Tailored Plans must also honor existing medical PAs for physical and behavioral health services for 91 days after Tailored Plan launch or until the expiration/completion of a PA, whichever occurs first.  

   Starting on Oct. 1, 2024, Tailored Plans may deny payment for services, which require prior authorization if the provider did not obtain authorization before delivering the service, except in cases of retro eligibility. 

2. Pharmacy PAs: For pharmacy PAs between July 1, 2024, and Sept. 30, 2024, Tailored Plans will honor existing pharmacy PAs (from NC Medicaid Direct and other health plans) for the life of the PA and will 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. 
    

3. Out of Network Provider Rates: Between July 1, 2024, and Sept. 30, 2024, in addition to out of network requirements found in the Department’s Transition of Care policy, Tailored Plans must also pay for services for Medicaid-eligible nonparticipating/out of network providers equal to those of in network providers for 91 days after Tailored Plan launch. 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.

   Starting on Oct. 1, 2024, out-of-network providers with whom the Tailored Plan has made a good faith effort to contract will be reimbursed at no more than 90% of the Medicaid fee-for-service rate. Note: Out of network providers must still be enrolled in NC Medicaid to be reimbursed by the Tailored Plan. 

4. Out of Network Providers Follow In-Network PA Rules: Between July 1, 2024, and Jan. 31, 2025, Tailored Plans will permit uncontracted, out-of-network providers enrolled in NC Medicaid to follow in-network provider prior authorization rules. Starting on Feb. 1, 2025, out-of-network providers must seek authorizations for all services. 
    
5. Primary Care Provider (PCP) Changes: Between July 1, 2024, and Jan. 31, 2025, Tailored Plan members may change their PCP for any reason. 

In addition to the above requirements, Tailored Plans are required to support transitioning beneficiaries who are currently being treated by providers. Therefore, Tailored Plans will also: 

• Honor existing and active medical PAs on file with NC Medicaid Direct or another health plan for services covered by the health plan for the first seven months after launch, through Jan. 31, 2025, or until the end of the authorization period, whichever occurs first.  
• Not deny claims for the first seven months after launch, though Jan. 31, 2025, for covered services if the request meets medical necessity criteria and will authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers until end of episode of care or seven months, whichever is less. 
  • Please Note: Extended transition periods may apply for circumstances covered in N.C. Gen. Stat. § 58-67-88(d), (e), (f), and (g). 
• Honor a PA from their original health plan for the life of the authorization by their new health plan for a beneficiary who transitions between health plans after July 1, 2024. 

The Department expects all providers to continue to provide all necessary care to beneficiaries throughout this transition, including but not limited to maintaining scheduled medical care for beneficiaries.

The Department expects Tailored Plans and providers to continue to work in good faith to finalize contracts so that Tailored Plans have adequate networks to care for their members.

NC Medicaid remains committed to working with provider and health plan partners to verify services are paid for without undue burden to beneficiaries and providers during this transition. If providers experience issues during this transition period, they can reach out to the Medicaid Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov or 919-527-6666. 

Source: https://medicaid.ncdhhs.gov/blog/2024/06/03/flexibilities-ease-provider-administrative-burden-tailored-plan-launch