Which NC Medicaid Plan Is Best for You?

North Carolina Medicaid has transitioned to a managed care model to enhance care coordination and improve health outcomes for beneficiaries. For eligible individuals, understanding available health plans and making an informed choice is important. This guide aims to provide clarity on the options and processes involved in navigating NC Medicaid.

Understanding NC Medicaid Managed Care

North Carolina Medicaid transitioned to a managed care model on July 1, 2021. Under this model, the state contracts with private Managed Care Organizations (MCOs) to manage and provide healthcare services to beneficiaries. MCOs coordinate care, manage provider networks, and ensure members receive necessary medical, behavioral health, and pharmacy services.

Beneficiaries choose a Primary Care Provider (PCP) as their main point of contact. The PCP coordinates referrals to specialists and other services within the MCO’s network, promoting integrated care and continuity. All health plans offer the same basic Medicaid benefits, but may provide additional services.

NC Medicaid Managed Care includes Standard Plans and Tailored Plans. Most beneficiaries use Standard Plans, covering physical health, pharmacy, and basic behavioral health services. Tailored Plans, launched July 1, 2024, are for individuals with complex needs, including serious mental illness, severe substance use disorders, intellectual/developmental disabilities, or traumatic brain injuries.

Determining Eligibility for NC Medicaid

Eligibility for NC Medicaid is based on residency, citizenship, and income. To qualify, individuals must be North Carolina residents, U.S. citizens or have eligible immigration status, and have or apply for a Social Security number.

Income and household size are primary factors in determining eligibility, with limits set relative to the Federal Poverty Level (FPL). Adults aged 19 through 64 may be eligible if their household income is at or below 138% of the FPL.

Eligibility pathways also exist for specific populations. Children aged 0-18 have varying, higher income limits. Pregnant individuals may qualify with incomes up to 201% of the FPL and retain coverage for 12 months postpartum. Specific programs also exist for individuals who are aged, blind, or disabled, with different financial requirements.

North Carolina Medicaid generally does not have an asset test for programs based on Modified Adjusted Gross Income (MAGI), including those for children, pregnant individuals, and most adults under 65. To determine eligibility, individuals should gather documentation such as proof of income, household member details, and residency verification. The application process for eligibility is a separate step.

Comparing Available Medicaid Health Plans in North Carolina

Choosing a Medicaid health plan depends on individual healthcare needs and preferences. In North Carolina, beneficiaries can select from several Standard Plan Managed Care Organizations, including:
Healthy Blue
AmeriHealth Caritas
WellCare
UnitedHealthcare Community Plan
Carolina Complete Health

When comparing plans, a primary consideration is the provider network. Verify if current doctors, specialists, hospitals, and pharmacies are included in a plan’s network to ensure continuity of care. The NC Medicaid Managed Care website offers a tool to search for providers and see which plans they accept.

Prescription drug coverage is another area to examine, as formularies and any applicable copayments can vary. While all plans cover essential medical benefits, many offer additional services beyond standard care. These might include vision and dental care, transportation assistance, wellness programs, or allowances for over-the-counter health items.

Evaluate customer service and member support quality, as some plans offer 24/7 member service lines. Individuals with specific health conditions should also investigate a plan’s care management programs, such as those for long-term services and supports (LTSS) or behavioral health needs. The NC Medicaid Enrollment Broker serves as an unbiased resource, offering information and assistance to compare plans.

Enrolling in a Medicaid Health Plan

Once eligibility for NC Medicaid is determined and a health plan chosen, the next step is enrollment. Individuals can apply through several methods. Online applications can be submitted via ePASS or HealthCare.gov, requiring an NCID account for ePASS.

Alternatively, applications can be submitted by mail or in person at a local Department of Social Services (DSS) office. Some counties offer the option to apply over the phone through their local DSS. After eligibility is determined, individuals can select a managed care plan through the NC Medicaid Enrollment Center’s website or by calling their toll-free number.

Upon successful enrollment in a chosen health plan, the beneficiary receives a welcome packet containing a member identification card and handbook. This packet provides details about the selected plan, covered benefits, and how to access healthcare services. Review this information carefully to understand the plan’s offerings.

Beneficiaries have a 90-day period after initial enrollment to switch plans for any reason. After this period, plan changes are limited to the annual recertification period or specific “special reasons.” These may include moving out of the plan’s service area or needing services not adequately provided within the current plan’s network.