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Medicaid Transformation in NC

On July 1, 2021, the way you get health care through North Carolina Medicaid and NC Health Choice (CHIP) changed. 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)

Your Rights under Medicaid Managed Care and Key Things to Know:

  • Most Medicaid beneficiaries enrolled in a new Prepaid Health Plan (also known as Standard Plans, PHPs, or health plans), with coverage beginning July 1, 2021. These health plans are private health insurance companies the state has contracted with to manage health care for most NC residents who receive health coverage through Medicaid and NC Health Choice (CHIP).
  • Who can get Medicaid has NOT changed. The same services are still covered as before the July 1 transition, including hospitalizations, check-ups, prescriptions and more, and health plans may offer added services. However, your health plan will decide whether to approve some services your doctor requests.
  • Each health plan will work with a provider network, which is a group of doctors, hospitals, and health care providers that have signed up with your health plan. To continue visiting your current doctors and health care providers, you must generally be in a health plan that includes those providers in its network.
  • 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 enroll in a Medicaid Managed Care plan with coverage beginning on July 1. These individuals remained in traditional Medicaid, also known as NC Medicaid Direct.
  • You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. (For those whose coverage began July 1, this was September 30, 2021.) After the 90 days, you must wait until your next recertification date to change your health plan, unless you have a special reason. Learn more about special reasons for changing your 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 (the group of doctors, hospitals, and other health care providers that have signed up with that health plan).
  2. If your providers are not in your health plan’s network (meaning they have not agreed to accept your health plan), ask your providers or the Enrollment Broker, or use the provider search tool to find out what plans they are enrolled with. 
  3. You can ask the Enrollment Broker to help you switch to a plan that has your providers in its network. While the deadline to change plans for any reason was September 30 for beneficiaries whose coverage began July 1, you may still be able to change if you show good cause.
  4. If you are happy with your health plan, you do not need to do anything.  
  5. Call the NC Medicaid Ombudsman at 877-201-3750 or visit them online if you are experiencing problems with your care or cannot access the services you need.
What if I want to remain in NC Medicaid Direct?

While most Medicaid beneficiaries were required to move to NC Medicaid Managed Care on July 1, 2021, 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, unless they choose to enroll in one of the new health plans. However, changing from NC Medicaid Direct to a Medicaid Managed Care health plan may affect their ability to continue receiving these services.  

 

Requests to Move to NC Medicaid Direct

  • If you are enrolled in a Medicaid Managed Care health plan but you need services for severe behavioral or intellectual/developmental disabilities, you must complete the “Request to Move to NC Medicaid Direct” form, or you can ask your provider to fill out the provider version, in order to receive services for these needs. These forms can be found at ncmedicaidplans.gov/submit-forms-online.  
  • If you need a service immediately, ask your provider to submit a Service Authorization Request along with the Request to Move to NC Medicaid Direct form.
  • If your request is denied, you have the right to appeal.

Non-emergency medical transportation services (NEMT)

Non-emergency medical transportation services (NEMT) services under Medicaid Managed Care

Under Medicaid Managed Care, the new health plans must provide non-emergency medical transportation (NEMT) services to enrolled individuals who need and request transportation assistance. If you are enrolled in Medicaid Managed Care, you should always contact your health plan’s member services phone line or their dedicated transportation phone line, rather than your local County Department of Social Services (DSS You should continue to receive the same NEMT services from your health plan that you received under 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.  

What other rights do you have under NC Medicaid Managed Care?

  • Get free advice in your preferred language from the Enrollment Broker about whether you have to be enrolled in a managed care health plan and what health plan is the best choice for you and your family.  
  • 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.

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, please review the following informational webinars about the Medicaid Transformation and how to help those you serve:

March 11, 2021 Webinar

August 11, 2021 Webinar