Understanding the Transition to Managed Care
- Are the eligibility rules changing for NC Medicaid?
There are no changes to who is eligible to receive NC Medicaid. If you have questions about your eligibility, contact your local Department of Social Services (DSS) office.
- What is NC Medicaid Managed Care?
In July 2021, most people in North Carolina with Medicaid saw a change in how they receive their health care. If you have NC Medicaid, you may have received a letter asking you to enroll in a health plan. If you didn’t pick a health plan by the deadline, the State chose one for you so that you could continue to receive care. On July 1, 2021, this health plan started managing your health care.
NC Medicaid Managed Care helps you get the most out of your Medicaid benefits and there are many health plans to choose from. All health plans are required to have the same Medicaid services, such as office visits, blood tests and X-rays. Health plans may also offer added services such as programs to help you quit smoking, eat healthier and have a healthy pregnancy. Health plans work with different doctors and health care professionals. Each health plan has its own network of qualified doctors and health care professionals.
You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 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. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.
- What are Standard Plans?
Standard plans provide integrated physical health, behavioral health, pharmacy and long-term services and support to most Medicaid beneficiaries, as well as other programs and services that address unmet health-related resource needs
- What is NC Medicaid Direct?
NC Medicaid Direct is North Carolina’s health care program for Medicaid beneficiaries who are not enrolled in health plans. It includes care management by Community Care or North Carolina (CCNC), for physical health services. Four Local Management Entity-Managed Care Organizations (LME-MCOs) coordinate services for mental health disorder, substance use disorder, intellectual/developmental (I/DD) or traumatic brain injury (TBI). Some people are enrolled in NC Medicaid Direct because it provides services that meet specific needs.
These populations include:
* People who receive both Medicare and Medicaid
* People who are medically needy
* People in the NC Health Insurance Premium Payment (HIPP) Program
* Children who receive Community Alternatives Program for Children (CAP/C) services
* People who receive Community Alternatives Program for Disabled Adults (CAP/DA) services
* Children and youth in foster care
- Who must enroll in Medicaid Managed Care?
Most NC Medicaid beneficiaries have been enrolled in the NC Medicaid Managed Care program. Some people will stay in NC Medicaid Direct. They will not need to choose a health plan. Those who are now in managed care should have received a new Medicaid ID card and other important information from their new health plan. If you have not received information, please call the Enrollment Broker at 833-870-5500 or visit ncmedicaidplans.gov.
- Who has the option to choose a health plan?
Some people can change their health plan at any time. You can change your health plan at any time for these reasons:
* You need services to address a mental health disorder, substance use disorder, intellectual/developmental (I/DD) or traumatic brain injury (TBI)
* You are a federally recognized tribal member or qualify for services through Indian Health Services (IHS). Some people will not need to choose or are unable to choose a health plan because of the type of health services they need. Some people will be enrolled in Tailored Plans and will be auto-assigned based on their administrative county, others will remain in NC Medicaid Direct. For example, individuals who receive Innovations Waiver services, Traumatic Brain Injury (TBI) Waiver services will be auto-enrolled in Tailored Plans by administrative county. If you qualify, you can choose the EBCI Tribal Option and keep receiving waiver services.
- What if I don’t think I should have to enroll in a new health plan?
Some people will not need to choose a health plan because of the type of health services they need. They will stay enrolled in NC Medicaid Direct. For example, individuals who receive Innovations Waiver services, Traumatic Brain Injury (TBI) Waiver services or Community Alternatives Programs for Children or Disabled Adults (CAP/C or CAP/DA) services will stay enrolled in NC Medicaid Direct. If you qualify, you can choose the EBCI Tribal Option and keep receiving waiver services.
If you don’t think you should have to enroll in a health plan but got a letter telling you to do so, you can request to remain in NC Medicaid Direct by filling out a form you can find at ncmedicaidplans.gov.
If you are unsure about what type of Medicaid coverage you have, call the Enrollment Broker at 833-870-5500.
- What is the Eastern Band of Cherokee Indians (EBCI) Tribal Option?
The Eastern Band of Cherokee Indians (EBCI) Tribal Option is a health plan managed by the Cherokee Indian Hospital Authority (CIHA) to meet the primary care coordination needs of federally recognized Tribal members and others eligible for services through Indian Health Service (IHS). Only IHS-eligible beneficiaries associated with the EBCI can participate in this health plan. The EBCI Tribal Option will build on the Tribe’s strong medical model and deliver high quality care at the local level. The EBCI Tribal Option offers care coordination and management of Medicaid medical, behavioral health, pharmacy and support services to address the health needs of American Indian/Alaskan Native Medicaid beneficiaries. The EBCI Tribal Option is primarily offered in five counties: Cherokee, Graham, Haywood, Jackson and Swain. Eligible beneficiaries in the following surrounding counties may opt in: Buncombe, Clay, Henderson, Macon, Madison and Transylvania.
- What are my rights under NC Medicaid Managed Care?
You have the right to:
* Get free advice over the phone from the NC Medicaid Enrollment Broker Call Center, where someone can inform you whether you have to enroll in a health plan, and help you decide which health plan is the best choice for you and your family.
* Get information in your preferred language for free.
* Switch health plans for any reason within 90 days of being enrolled. After 90 days, unless you have a special reason, you must wait until your next NC Medicaid recertification date to change health plans.
* Continue to receive the same NC Medicaid coverage and services you receive now.
* Get care from a provider outside your health plan’s network if medically necessary services are not available in the health plan’s group of providers.
* Receive care without interruption when transitioning between health plans or into or out of managed care.
* Ask for an appeal from your health plan if they deny, reduce or stop coverage for health care you need.
- When are these changes happening?
Coverage under the NC Medicaid Managed Care program begins July 1, 2021.
If you did not choose a health plan or request to stay in NC Medicaid Direct by May 21, 2021, you were automatically enrolled in a health plan to ensure you could continue to get care. Most people were able to keep their same doctors. You should have received a welcome packet from your new health plan that includes a new Medicaid ID card. The card has the name of your primary care provider (PCP).
You can learn more about the available health plans and the services they provide by visiting ncmedicaidplans.gov or calling 833-870-5500.
You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 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. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.
- What should I do to prepare for the change?
Make sure your local Department of Social Services (DSS) has your current mailing address, phone number and email address so you get all important notices about this change (especially if your contact information has changed due to COVID-19).
Visit ncmedicaidplans.gov or call 833-870-5500 to learn more. You can also stay up-to-date by using the free NC Medicaid Managed Care mobile app, available on Google Play or in the App Store.
You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 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. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.
Choosing a Health Plan
- How and when do I choose a health plan?
Each Standard health plan works with a network, or group of doctors, hospitals and other health care providers. You should choose a health plan that will let you keep going to your doctors and other health care providers. All health plans offer the same basic benefits and services. Some may also offer added services. When choosing a Standard health plan, you may want to ask:
- How do I keep my current doctors, hospitals and specialists?
- What are my choices if I change doctors?
- What added services does each health plan have?
- You can learn more about what health plans are available to you and the services they provide by visiting ncmedicaidplans.gov or calling 833-870-5500.
If you are new to Medicaid, you can get help in plan selection/change in one of the following ways:
- Call 833-870-5500 (toll-free)
- Go to ncmedicaidplans.gov
- Complete and return a paper enrollment form by fax or mail
- Use the NC Medicaid Managed Care mobile app
If you want to change your health plan, you can do so for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification (renewal) date to change your health plan unless you have a special reason.* Learn more about special reasons for changing your health plan. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.
*Note: There is only one Tailored Plan in each county. Beneficiaries eligible for a Tailored Plan will be assigned the plan that serves the county where they get their Medicaid.
- What are the health plans I can choose from/change to?
AmeriHealth Caritas (offered statewide)
855-375-8811 (TTY: 866-209-6421)
24 hours a day, seven days a week
amerihealthcaritasnc.comCarolina Complete Health (only available in certain regions of the state)
833-552-3876 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
carolinacompletehealth.comHealthy Blue (offered statewide)
844-594-5070 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
HealthyBlueNC.comUnitedHealthcare Community Plan (offered statewide)
800-349-1855 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
uhccommunityplan.com/ncWellCare (offered statewide)
866-799-5318 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
wellcare.com/NCThe Eastern Band of Cherokee Indian (EBCI) Tribal Option
(The EBCI Tribal Option is primarily offered in five counties: Cherokee, Graham, Haywood, Jackson and Swain. Eligible beneficiaries in the following counties may opt in: Buncombe, Clay, Henderson, Macon, Madison and Transylvania.)800-260-9992 (TTY: 711)
8 a.m. to 4:30 p.m., Monday through Friday
EBCITribalOption.com - Will the types of health care services I can receive change?
The same services will continue to be covered. However, the doctors you can go to will be based on the health plan’s provider network. Your Medicaid copays will not change.
- Do I have to change doctors?
Each health plan has its own set of doctors and health care providers, who make up its network. Most people were able to keep their same doctors when moving to managed care. The NC Medicaid Managed Care website also features a provider search tool that will tell you which health plans your providers have joined, but ask your doctor’s office to be sure.
- When can I switch health plans?
You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change health plans unless you have a special reason. You can change your health plan at any time for these reasons:
- You moved out of your health plan’s area.
- You need a service that your health plan does not cover for moral or religious reasons.
- Your health plan says you need multiple services they cannot provide and your PCP says you need services right away.
- You need services that meet specific needs, such as developmental disability, behavioral health, traumatic brain injury or substance use disorder.
- You are a federally recognized Tribal member or qualify for Indian Health Services (IHS).
- Every year at your recertification, you will be given a 90-day period to change your health plan.
You can find more information about what this means by clicking here or by calling the NC Medicaid Enrollment Broker at 833-870-5500. The call is toll-free.
- What if I need Non-Emergency Medical Transportation (NEMT)?
Under Medicaid Managed Care, the new health plans must provide non-emergency medical transportation (NEMT) services for all Medicaid eligible individuals who need and request assistance with transportation. Health plans may use transportation brokers to arrange and provide transportation or contract directly with transportation providers. For beneficiaries in NC Medicaid Direct and the Eastern Band of Cherokee Indians (EBCI) Tribal Option, local Departments of Social Services (DSS) will continue to arrange NEMT services.
Beneficiaries will receive the same transportation service from the health plans that they are used to receiving from DSS, and these services will continue to be provided for free. If you have problems getting the transportation you need and are unable to resolve by working with your health plan or broker, call the NC Medicaid Ombudsman at 877-201-3750.
Authorized Representative Information
- What is an Authorized Representative?
An Authorized Representative (AR) is a person chosen by the someone applying for NC Medicaid or a beneficiary.
As an AR, they can discuss the Medicaid application, see the person’s or household’s information and act for the person or household on items regarding the application and benefit information.
The AR can be named in writing or via telephonic voice signature. The Medicaid-approved DHB 5202c Designation of Authorized Representative Appendix C form can also be used.
The AR and the person applying can call their local Department of Social Services (DSS) and give their voice signature to confirm the person as the AR.
The AR has permission to:
- Report changes
- Give information
- Get Medicaid notices
- Complete recertification and redetermination
- Get updates on the beneficiary’s case
- See information in the case file or about the case except for information marked “Confidential” or “Do not Release.”
- Who can be an Authorized Representative?
A person applying for Medicaid or a beneficiary can choose someone they trust with their protected health information (PHI) to be their AR. The person applying must understand the kind of information their AR is allowed to see and discuss on their behalf before deciding who to choose.
For minors in the custody of a NC County Child Welfare Agency, the Child Welfare Director will be the AR first, then assign an AR for child.
- Who cannot be an Authorized Representative?
Staff of a qualified Medicaid provider cannot be an AR for a person applying for or getting Medicaid.
- Why would someone need an AR?
An AR is needed in cases where a person applying for Medicaid, or a beneficiary cannot make decisions for themselves about their Medicaid.
- Do I have to fill out DHB 5202c Designation of Authorized Representative Appendix C form to be an AR?
No. A person applying for Medicaid, or a beneficiary can call their local DSS and give their voice signature naming the person as their AR. The person who will be the AR must confirm they will be the AR by giving their voice signature.
- How long can a person be an AR?
A person can be an AR until the person applying for Medicaid, or the beneficiary does one of the following:
- Changes the authorization or contacts their local DSS to let them know person is no longer allowed be their AR.
- The AR contacts the local DSS for the person applying for Medicaid or beneficiary to tell DSS he or she no longer is acting in as the AR.
- If there is a change in the legal authority that was granted to the AR or organization, the person applying for Medicaid or beneficiary must provide a notice that includes the AR or applicant/beneficiary’s signature.
Information & Assistance
- What problems can the NC Medicaid Ombudsman help address?
The Ombudsman can help with these issues and more if you have been unable to resolve them by working with your health plan or the Enrollment Broker:
Enrolling in a health plan, if:
- You think you should not have to enroll in a health plan
- You have trouble enrolling in a health plan
- You can’t find any health plan that includes the doctors you need to see
- The State has denied your request not to enroll in a health plan
Accessing care, if:
- You can’t continue getting the services you are getting now
- Your health plan denies care that you need
- Your health plan won’t cover services from a provider who is not in your health plan’s network, when the service is not otherwise available
- It takes too long before you can get the care you need
- Your plan says you have to travel too far to get the care you need
- You have trouble getting transportation to your doctor appointments
- You need services for behavioral health or an intellectual/developmental disability your health plan won’t cover
Changing care, if:
- You have problems changing to a different health plan
- You have problems changing to a different primary care provider
Experience barriers to care and coverage, if:
- You can’t access material or information in your preferred language
- You feel a health plan, provider or enrollment representative has discriminated against you
The NC Medicaid Ombudsman can also help you understand information you receive, explain your rights, and connect to the right people at health plans and the Enrollment Broker.
- What information will the NC Medicaid Ombudsman ask me?
We will start by asking your name, how to reach you, what county you live in and what health plan you are enrolled in (or trying to enroll in). We will ask you if you have attempted to resolve your issue directly with the entity at issue. We will then ask you for other information about your concerns or questions. If you have received any paperwork, please have it in front of you when you call. If you don’t, please call us anyway.
- Can the NC Medicaid Ombudsman help me appeal if I am denied care?
The NC Medicaid Ombudsman cannot provide legal advice or represent you in your appeal. However, if you have already talked with your health plan and were not able to resolve your issue, we can contact your health plan to try to resolve your issue informally. For example, we can give your health plan new information, and ask your health plan to change their decision or find another solution to the problem. We can help you understand how to file your own appeal with the health plan, and what things you can do to get the health plan to change its decision.
If our assistance doesn’t resolve your issue or you want legal representation instead of informal assistance, we can refer you to your local legal services office who may be able to handle your appeal for free.
- Does the NC Medicaid Ombudsman work for the government or health plans?
The NC Medicaid Ombudsman is contracted by the State of North Carolina but operates as an independent organization serving as a resource to Medicaid beneficiaries.
- What is the best way to reach the NC Medicaid Ombudsman?
You can call us at 877-201-3750 from 8 a.m. to 5 p.m., Monday through Friday except for State holidays. We do our best to answer every call, but if we are unable to answer, please leave a message with your name and phone number. We’ll call you back by the next business day. You can also send us a message using our online Contact Form.
Tailored Plans
- What are Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans (Tailored Plans)?
Tailored Plans are a new kind of NC Medicaid Managed Care health plan. They start July 1, 2024.
Tailored Plans cover your physical care, prescription drugs, and services for serious mental illness, severe substance use disorders, intellectual/developmental disabilities (I/DD) and traumatic brain injury (TBI) in one health plan.
Tailored Plans will also serve people on the NC Innovations Waiver or Traumatic Brain Injury (TBI) Waiver. People will not lose their spots on the waitlist.
Tailored Plans offer more behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and state-funded services.
There are four Tailored Plans: Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health.
Alliance Health is the only Tailored Plan that currently offers TBI Waiver services.
- What is a Tailored Plan Company?
A Tailored Plan company coordinates services for Tailored Plan members. There are four Tailored Plans in North Carolina: Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health.
- How are Tailored Plans different from what the LME/MCOs do now?
LME/MCOs currently only manage behavioral health services. Once Tailored Plans launch, they will manage all Medicaid services for their members, including physical health services. Your primary care provider (PCP) must be in the Tailored Plan’s network. If they are not, you will likely have to change to a different PCP.
- How will the move to Tailored Plans happen?
NC Medicaid beneficiaries will be assessed for Tailored Plan eligibility. Eligible beneficiaries will get a letter from the NC Medicaid Enrollment Broker in mid-April. The letter will tell you if you have been auto-enrolled in a tailored Plan or if you have the choice to opt-in.
To learn more about the move to Tailored Plans, visit https://medicaid.ncdhhs.gov/tailored-plans/moving-to-a-tailored-plan
- When are Tailored Plan changes happening?
NC Medicaid will transition beneficiaries who may need certain services for a severe mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) to Tailored Plans) July 1, 2024. Until then, potential Tailored Plan beneficiaries will receive health care services the same way they do today, through NC Medicaid Direct or Standard Plans.
- How can I choose my Primary Care Provider (PCP) or Tailored Care Management provider?
To choose a PCP or Tailored Care Management (TCM) provider with your Tailored Plan, contact your Tailored Plan directly. If you are getting TCM services now, you will keep your TCM provider.
If you do not choose a PCP by May 15, 2024, one will be assigned to you.
- What should I do to prepare for Tailored Plan launch?
Make sure your local Department of Social Services (DSS) has your current mailing address, phone number and email address so you receive all important information. You can find your local county DSS at dhhs.gov/localdss.
* Report all changes, including your address and any changes such as income or a change in household (the number of family members) that may impact the type of coverage you qualify for.
* Check your mail.
You can also learn more about Tailored Plans at medicaid.nc.gov/tailored-plans.
- Will Tailored Plans provide Non-Emergency Medical Transportation (NEMT)?
Tailored Plans will provide NEMT for all Medicaid-covered services, including carved-out services. This means you will need to call your Tailored Plan, not your local Department of Social Services (DSS), when you need to schedule a ride to a doctor, pharmacy or other health provider.
You can begin scheduling rides for appointments on or after July 1, 2024, on May 16, 2024.
- Will I receive a new Medicaid ID card?
Yes. Tailored Plans will begin mailing Welcome Packets including a Welcome Letter, Medicaid ID card and Member Handbook May 23, 2024. Make sure your local DSS has your current mailing address, phone number and email address to ensure you get all important information from your Tailored Plan.
- What is Tailored Care Management?
TCM is a new kind of care management for eligible NC Medicaid beneficiaries. The goal of the program is to provide whole person care management to help beneficiaries meet their health goals.
Whole person care looks at all the beneficiary’s needs including:
- Physical health
- Behavioral health
- Intellectual and developmental disabilities (I/DD)
- Traumatic brain injuries (TBI)
- Pharmacy/medications
- Long term services and supports
- Unmet resource needs (or gaps in a person’s health care which make it hard to meet their health goals)
- What services are only offered by Tailored Plan?
Tailored Plans offer some behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and State-funded services.
To see a list of services offered by Tailored Plans, visit https://ncmedicaidplans.gov/en/tailored-plan-services.
Other Resources
NC Medicaid Enrollment Broker
833-870-5500
ncmedicaidplans.gov
You can learn more about what health plans are available to you and the services they provide. You can also use the website’s provider search tool to find out which health plans your providers have joined to make sure you choose a health plan that allows you to continue seeing your doctors.
NC Medicaid Contact Center
888-245-0179
This video from the North Carolina Department of Health and Human Services (NCDHHS) also explains the change to NC Medicaid Managed Care and what you should do to prepare.