Medicaid Transformation in NC
***Due to the N.C. General Assembly’s inability to pass a budget. Medicaid Transformation is on hold until funding to implement the program can be made available.***
North Carolina’s Medicaid program is changing. The state has contracted with private health insurance companies to manage health care for most N.C. 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.
Five things to know:
- There is no change to who can get Medicaid. The same services will continued to be covered, including hospitalizations, check-ups, prescriptions and more. However, now your health plan will decide whether to approve coverage for the services your doctor requests.
- You will have to choose a health plan and a doctor to provide your health care unless you are in certain populations that are exempt or excluded. If you don’t choose by December 13, 2019, Medicaid will chose a health plan and doctor for you.
- People living with serious developmental disabilities or mental illness, people who have Medicare coverage, or people in a Medicaid waiver program, as well as some others do not have to choose a health plan at this time.
- Enrollment for selecting a health plan begins October 14 and lasts until December 13. If you do not select a plan during this open enrollment period, a plan will be assigned to you unless you are “exempt” or “excluded” (such as individuals in the populations listed above).
- Coverage under these plans for 2020 begins for all Medicaid/CHIP beneficiaries on February 1, 2020.
What are your rights under managed care?
Get free advice over the phone from N.C. Medicaid about whether you are exempt or excluded and learn about which plan is the best choice for you and your family. You have the right to receive information from N.C. Medicaid and health care services in your preferred language for free.
You can request an exemption from enrolling in a N.C. Medicaid Managed Care plan (meaning you would be able to choose to stay in fee-for-service Medicaid, also known as Medicaid Direct). You have the right to appeal if your request for an exemption is denied.
You have the right to continue receiving the same N.C. Medicaid coverage and services you currently receive.
You can receive out-of-network care if it is deemed medically necessary and the same services are not available in your health plan’s network.
There should be no interruption of care when changing between plans or out of managed care.
You have the right to appeal if your health plan denies, reduces or stops coverage for the health care you need.
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 to ensure you receive all important notices about this change.
- Mecklenburg County Department of Social Services
- Cabarrus County Department of Human Services
- Union County Department of Social Services
Contact NC Medicaid to learn more about the changes and to find out if you are exempt or excluded from selecting a new managed care plan: ncmedicaidplans.gov or 1-833-870-5500 (TTY: 1-833-870-5588). If you are not exempt or excluded, ask N.C. Medicaid to help you choose your preferred health plan and doctor.
You can also use the free N.C. Managed Care mobile app to stay informed. Find the app by searching for “NC Medicaid” on Google Play or the App Store.
(Please note these dates are subject to change.)
October 1, 2019: Packets about changes to Medicaid program should have been mailed out to current Medicaid/CHIP recipients
October 14, 2019: Beneficiaries can begin signing up for managed care plans, also known as Prepaid Health Plans/PHPs. Open Enrollment lasts 60 days and ends December 13.
December 13, 2019: Deadline to enroll in a plan.
December 16, 2019: Auto-assignment begins for those who did not enroll in a Prepaid Health Plan.
February 1, 2020: Coverage under new Prepaid Health Plans begins. Beginning today, beneficiaries have 90 days (through April 30, 2020) to change their plans for any reason.
May 1, 2020: End of 90-day period for beneficiaries to change their Prepaid Health Plan for any reason.
Disagree with a Decision Related to Your N.C. Medicaid Care?
Get free legal assistance and learn about your rights under N.C. Medicaid Care by contacting one of these organizations:
Charlotte Center for Legal Advocacy
(Cabarrus, Mecklenburg and Union counties)
1-800-438-1254 | 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
(Buncombe, Henderson, Madison, Mitchell, Polk, Rutherford, Transylvania and Yancey counties)
1-800-489-6144 | pisgahlegal.org
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