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Acute Care Services
Long-Term Care Services


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Benefits by State: North Carolina (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes Specified services Services limited to published ASC procedure codes Fee for service CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes Specified services including more than 8 outpatient psychiatric visits 22 ambulatory visits/year to PH Clinic included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Federally Qualified Health Center Services
Yes $1-$3/visit for specified non-core services Specified services 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Prospective or cost based rate/visit up to Medicare PPS rate CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes Elective admissions and other specified services 3 administrative leave days to facilitate transfer to less restrictive setting Prospective payment/discharge using DRG or prospective per diem CN & MN
Outpatient Hospital Services
Yes $3/visit More than 8 outpatient psychiatric visits 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Prospective cost based rate or fee for service CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes Fee for service using quarter hour or hourly rates CN & MN
Rural Health Clinic Services
Yes $1-$3/visit for specified non-core services Specified services 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Prospective or cost based rate/visit up to Medicare PPS rate CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Surgeon must obtain for specified services Fee for service at 90% of physician fee without medical direction and at 50% of physician fee with medical direction CN & MN
Chiropractor Services
Yes $2/visit 8 visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Dental Services
Yes $3/episode of treatment Specified services including periodontal and orthodontic services and maxillofacial surgery Exam and cleaning 2/year, frequency of x-rays limited by type, root canals limited to anterior teeth, pulp caps, inlays, implants, bridges and crowns not covered Fee for service CN & MN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes $3/episode of treatment Specified services including complex oral surgeries Fee for service CN & MN
Nurse Midwife Services
Yes $3/visit 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Nurse Practitioner Services
Yes $3/visit Specified services 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Optometrist Services
Yes $3/visit Visual aids 8 visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Physician Services
Yes $3/visit Specified services 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Podiatrist Services
Yes $3/visit 8 visits/year included in limits with other specified practitioners - limits set annually by the legislature Fee for service CN & MN
Psychologist Services
Yes Fee for service CN & MN
Prescription Drugs
Prescription Drugs
Yes $3/Rx Specified high cost drugs 8 Rxs/month, pharmacist may override for 3 additional if necessary AWP-10%, plus $5.60 dispensing fee for generic Rx or OTC products; AWP-10%, plus $4.00 dispensing fee for brand Rx,, AWP-17% for specified specialty medications CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
Yes $3/episode of treatment Yes 1 full upper and/or lower denture or 1 partial upper and/or lower denture/10 years, 1 upper and/or lower reline/5 years Fee for service CN & MN
Eyeglasses
Yes $2/pair and for supplies or repairs costing more than $5 Yes 1 pair eyeglasses/2 years, minimum diopter correction criteria, repairs costing less than $5 not covered Most products provided by state's volume purchase contractor, dispensing fee paid fee for service CN & MN
Hearing Aids
No
Medical Equipment and Supplies
Yes Specified items and services including repairs Lifetime expectancy limitations applied to specified items Fee for service based on Medicare rates or reasonable cost CN & MN
Prosthetic and Orthotic Devices
Yes Specified services Frequency and quantity limits vary by service Fee for service CN & MN
Transportation Services
Ambulance Services
Yes Fee for service for private providers, cost based payment for public providers CN & MN
Non-Emergency Medical Transportation Services
Yes See service-specific FN CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes Specified services Services limited to programs for mental illness, developmental disability and substance abuse Fee for service CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Fee for service using Medicare payment ceilings CN & MN
Targeted Case Management
Yes Fee for service CN & MN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN Dependent upon the services provided CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Services must be ordered by physician and medically necessary, services not covered during same hours as personal care or private duty nursing Fee for service based on Medicare rates CN & MN
Hospice Care
Yes Prospective per diem rates based on Medicare methodology CN & MN
Personal Care Services
Yes Yes 3.5 hours/day up to 60 hours/month, services not covered during same hours as home health or private duty nursing, additional hours/day up to 20 hours/month if specified criteria met Negotiated hourly rates up to reasonable cost CN & MN
Private Duty Nursing Services
Yes Yes Approved hours based on care plan and medical need, not covered during same hours as home health or personal care Fee for service CN & MN
Program of All-Inclusive Care for the Elderly
Yes See service-specific FN Capitated payment CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes Admission Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year, 3 administrative leave days to facilitate transfer to less restrictive setting Prospective cost based per diem CN & MN
Inpatient Psychiatric Services, under age 21
Yes Admission Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year, 3 administrative leave days to facilitate transfer to less restrictive setting Prospective cost based per diem CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes Admission Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year Prospective cost based per diem with limits for private facilities, cost based payment for public facilities CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes Admission Hosp leave days not covered, 15 consecutive therapeutic leave days up to 60 days/year Prospective per diem based on cost, with limits CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: None
 
 
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