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Medicaid Transformation in NC

On July 1, 2021, North Carolina’s Medicaid program changed. The state has contracted with private health insurance companies to manage health care for most NC residents who receive health coverage through Medicaid and NC Health Choice (CHIP). Find out what you need to know to prepare your family or your patients for these changes. 

Questions? Find out what you need to know to make the most out of these changes for you and your family. Contact Charlotte Center for Legal Advocacy for help.
Becca Friedman (English)
Natalie Marles (Spanish)

Medicaid beneficiaries were asked to select a health plan by May 21. If you were required to join one of the new health plans, but did not choose by May 21, the State auto-enrolled you into a health plan. However, you have until September 30 to change your plan for any reason. After September 30, unless you have a special reason, you cannot change your health plan until your next Medicaid recertification date.  

If you were auto-enrolled in a health plan, what should you do now?

  1. Call the NC Medicaid Enrollment Broker at 833-870-5500 or use the provider search tool at ncmedicaidplans.gov to learn if your doctors and other health care providers are enrolled in your health plan’s network (a group of doctors, hospitals, and other health care providers that have signed up with that health plan).
  2. If they are not enrolled in your plan, ask your providers, the Enrollment Broker, or use the provider search tool to find out what plans they are enrolled with. 
  3. The Enrollment Broker can help you change to a plan that has your providers in its network. 
  4. The deadline to change your plan for any reason is September 30. 
  5. If you are happy with your health plan, you do not need to do anything.  

Each health plan works with a network, which is a group of doctors, hospitals, and health care providers that have signed up with that plan. To continue visiting your current doctors and health care providers, you must be in a health plan that includes them in its network. So it is important that you pick your own health plan to make sure you keep getting the care you need. All health plans will provide the same basic benefits and services; however, health plans may offer added services. If you need more information about what health plans and services are available to you, call 833-870-5500 or visit ncmedicaidplans.gov.

What if I want to remain in NC Medicaid Direct?

While most Medicaid beneficiaries are enrolled in a NC Medicaid Managed Care health plan, some people are staying in NC Medicaid Direct (formerly known as fee-for-service Medicaid) because it provides certain services that meet specific needs. Individuals who need services for severe behavioral health, substance use, intellectual and developmental disabilities and traumatic brain injuries will continue to get their Medicaid services through NC Medicaid Direct. At a later date, these individuals will have the option to enroll in one of the new health plans, but changing from NC Medicaid Direct to a Medicaid Managed Care health plan may affect their ability to continue receiving these services.  

Request to Stay in NC Medicaid Direct

  • If you have serious behavioral and intellectual disabilities but you received a letter telling you that you must enroll in a health plan or you received a packet from a health plan informing you that you will be covered by that plan, then you must complete the “Request to Stay in NC Medicaid Direct” form, or you can ask your provider to fill out the provider version, in order to continue receiving services for these needs. These forms can be found at ncmedicaidplans.gov/submit-forms-online.  
  • If your request is denied, you have the right to appeal. 

Non-emergency medical transportation services (NEMT)

Under Medicaid Managed Care, the new health plans must provide non-emergency medical transportation (NEMT) services to individuals in their plan who need and request transportation assistance. 

NEMT services for Medicaid Managed Care

If you are enrolled in Medicaid Managed Care, you should always contact your health plan’s member services phone line or the Where’s my Ride phone line for transportation assistance, rather than your local County Department of Social Services (DSS). If you are enrolled in Medicaid Managed Care, you will continue to receive the same NEMT services from your health plan that you received from NC Medicaid Direct. 

NEMT services for NC Medicaid Direct and the EBCI Tribal Option

If you are in NC Medicaid Direct or enrolled in the Eastern Band of Cherokee Indians (EBCI) Tribal Option, you should continue to contact your local County DSS for transportation assistance.  

 

Key things to know:

  1. There is no change to who can get Medicaid. The same services will continue to be covered, including hospitalizations, check-ups, prescriptions and more. However, which doctors you can go to will be limited and your health plan will decide whether to approve some services your doctor requests.
  2. Most people with Medicaid had to choose a health plan and a doctor with that plan, unless they are in certain populations that are exempt or excluded. If you had to transition to a new health plan but did not choose by May 21, 2021, Medicaid chose a health plan for you.
  3. People who have serious mental illness or developmental disabilities, people who have Medicare coverage, people in a Medicaid waiver program, and some others did not have to move to a Medicaid Managed Care plan with coverage beginning on July 1.
  4. If you are enrolled in a Medicaid Managed Care health plan, you have until September 30 to change your health plan for any reason. After September 30, Medicaid members cannot change their health plan until their next Medicaid recertification date, unless they have a special reason.

What are your rights under NC Medicaid Managed Care?

Get free advice in your preferred language from NC Medicaid Managed Care about whether you are exempt (have the option to enroll in a health plan) or excluded (cannot enroll in a health plan). If you do need to enroll, NC Medicaid should help you understand which plan is the best choice for you and your family. 

Switch plans for any reason within 90 days of coverage starting with the first plan, or for good reason at any time. 

Request not to enroll in a Medicaid Managed Care health plan (meaning you would be able to choose to stay in fee-for-service Medicaid, also known as Medicaid Direct) and appeal if the request is denied.

Continue receiving the same NC Medicaid coverage and services you currently receive.

Get out-of-network care if medically necessary services are not available in your health plan’s network.

Have no interruption of care when moving in or out of Medicaid Managed Care or between health plans. 

Appeal if your health plan denies, reduces or stops coverage for health care you need.

Contact the NC Medicaid Ombudsman at 877-201-3750 if you experience any problems.

What you can do to prepare:

Make sure your local Department of Social Services (DSS) has your current mailing address, phone number and email address so you can receive all important notices about this change.

You can contact the Enrollment Broker at 833-870-5500 or ncmedicaidplans.gov.

Use the free NC Managed Care mobile app to stay informed. Find the app by searching for “NC Medicaid Managed Care” on Google Play or the App Store.

Look for a letter telling you that you have been enrolled in a health plan and a Welcome Packet and new ID card from your new health plan. 

You can also contact the NC Medicaid Ombudsman if you need information, guidance or referrals related to the Medicaid Transformation at 877-201-3750 or ncmedicaidombudsman.org. 

Important dates:

(Please note these dates are subject to change.)

July 1, 2021: Coverage under new Prepaid Health Plans begins. Beginning today, beneficiaries have 90 days (through September 30, 2021) to change their plans for any reason.

September 30, 2021: End of 90-day period for beneficiaries to change their Prepaid Health Plan for any reason.

Disagree with a Decision Related to Your NC Medicaid Care?

Get legal assistance and learn about your rights under NC Medicaid by contacting one of these organizations:

Charlotte Center for Legal Advocacy
(Cabarrus, Mecklenburg and Union counties)
1-980-265-3712 | charlottelegaladvocacy.org

Disability Rights NC
(statewide for people living with disabilities)
1-877-235-4210 | disabilityrightsnc.org

Legal Aid of NC
(statewide except for counties served by Charlotte Center for Legal Advocacy and Pisgah Legal Services)
1-866-219-LANC (5262) | legalaidnc.org

Pisgah Legal Services
(Avery, Buncombe, Henderson, Jackson, Macon, Madison, Mitchell, Polk, Rutherford, Transylvania and Yancey counties)
1-800-489-6144 | pisgahlegal.org

Additional Resources:

NC Managed Care: What’s Going On?
NC Medicaid One Pager (Eng)
NC Medicaid One Pager (Esp)

NC Medicaid Beneficiary Portal

NC DHHS Medicaid Transformation

CLASP Presentation: Immigrant Access to Health Care in NC

Charlotte Center for Legal Advocacy Family Support & Health Care Services (Eng)
Charlotte Center for Legal Advocacy Family Support & Health Care Services (Esp)
Charlotte Center for Legal Advocacy Health Insurance Navigator

If you advocate for or work with Medicaid beneficiaries, click here for an informational webinar about the Medicaid Transformation and how to help those you serve.