Extensive report via the APTA showing eight conditions to start.  This is a blockbuster! 

Due to the impact of Hurricane Helene, NC Medicaid Direct and NC Managed Care will allow temporary telehealth flexibilities for the delivery of select outpatient specialized therapies (OST) evaluation and treatment services.

States Affected by Helene are Eligible for Temporary Regulatory Waivers. CMS is offering flexibility in some regulatory requirements as well as advance or accelerated payment to affected states.  

On April 30, 2024, APTA NC submitted a letter to Medicaid NC in support of proposed changes to Clinical Coverage Policy 10A that would remove the requirement for the first prior authorization request to be no more than three visits and one month, and expand the adult visit limit as detailed below. 

• Max of 30 combined OT and PT habilitative services treatment visits per calendar year
• Max of 30 combined OT and PT rehabilitative services treatment visits per calendar year
• Max of 30 SLP habilitative services treatment visits per calendar year
• Max of 30 SLP rehabilitative services treatment visits per calendar year

While APTA NC applauds these critical steps toward expanding access to outpatient specialized therapy services, facilitating timely access to essential therapy services and reducing unnecessary administrative burden, we requested NC Medicaid consider modifying the maximum visit limits from 30 PT and OT visits combined to 30 treatment visits per discipline. Physical therapy and OT are distinct services that each provide unique value, and we believe separate visit limits will provide each discipline the opportunity to maximize benefits and allow for more comprehensive care that can be tailored to individual needs.

On March 11, 2024, APTA NC submitted a letter to Medicaid in support of a proposed change to eliminate the age restriction on independent practitioner providers (IPPs) to align with Medicare, private insurers, and other Medicaid state agencies. The elimination of this restriction would allow IPPs to bill for outpatient specialized therapy services (OT, PT, and ST) for beneficiaries 21 years and older in private settings. This would improve access to care for those beneficiaries who live in communities that do not have a hospital-based or physician-owned practice available.

Did you know that less than 1/5th of all licensed PTs belong to our professional Association?  Yet, the work of members benefits all licensees.  We understand that third-party reimbursement is crucial to our profession.  Join us and make our voice more influential!

Marissa Carvalho, PT, DPT, MSQM graduated from the Duke Doctor of Physical Therapy program in 2012 and attained her Master of Science in Quantitative Management degree with a focus in Health Analytics through Duke University’s Fuqua School of Business in 2023. Marissa is a board-certified clinical specialist in Orthopaedic Physical Therapy and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. She is passionate about the utilization of data in health care to drive positive change and optimize care.