Understanding the Transition to Managed Care
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.
This year, most people in North Carolina with Medicaid will see 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 don’t pick a health plan by May 14, 2021, the State will choose one for you. On July 1, 2021, this health plan will start 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. To keep your doctor, clinic or other provider, find out which health plans they work with. Then choose one of those health plans.
NC Medicaid Direct was formerly known as fee-for-service. Some people will remain in NC Medicaid Direct because it provides services that meet specific needs. For example, it provides the same services currently covered for developmental disability, behavioral health, traumatic brain injury and substance use disorder. To learn more about NC Medicaid Direct, call the NC Medicaid Contact Center at 888-245-0179.
Most Medicaid beneficiaries must choose a health plan in the NC Medicaid Managed Care program. Some people will stay in NC Medicaid Direct (formerly known as fee-for-service). They will not need to choose a health plan. NC Medicaid Managed Care will send you a letter that tells you if you must enroll.
Even if you chose a health plan in 2019, you will need to choose again. If you don’t choose a health plan, the State will choose one for you. You know your needs best, so it’s better if you choose.
You have the option not to choose a health plan if you need extra services for a developmental disability, behavioral health, traumatic brain injury or substance use disorder. If you have one of these conditions, you may have the option to stay in NC Medicaid Direct.
You also have the option to choose a health plan if you are a federally recognized Tribal member or qualify for Indian Health Services (IHS).
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 NC Medicaid Managed Care Call Center at 833-870-5500.
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.
You have the right to:
- Get free advice over the phone from the NC Medicaid Managed Care Call Center, where someone can inform you whether you have to enroll in a health plan, and 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 cannot change your health plan until your NC Medicaid recertification date.
- Choose a health plan or stay in NC Medicaid Direct if you require services to address a developmental disability, behavioral health, traumatic brain injury or substance abuse disorder.
- 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.
Coverage under the NC Medicaid Managed Care program will begin July 1, 2021.
You will have between March 15, 2021, and May 14, 2021, to enroll in a health plan of your choice or to request not to enroll in a health plan. If you do not choose a health plan or request to stay in NC Medicaid Direct by May 14, 2021, you will be automatically enrolled in a health plan.
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. You can also use the website’s provider search tool to find out which health plans your providers have joined and to make sure you choose a health plan that allows you to continue seeing your doctors.
- 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).
- The NC Medicaid Managed Care Call Center can help people with Medicaid choose a health plan and get enrolled. If you’re not sure whether you need to choose a health plan, contact them. They can help you choose the best health plan and provider for you. If you think you should not have to choose a health plan, ask the NC Medicaid Managed Care Call Center how to request permission not to enroll.
- Visit ncmedicaidplans.gov or call at 833-870-5500 to learn more about this process. 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.
- Look for a letter from NC Medicaid Managed Care that tells you if you must enroll.
- If you’d like to keep your current doctors or specialists, you can call your provider’s office and ask which health plans they work with.
- Call the NC Medicaid Ombudsman at 877-201-3750 with any questions or concerns you have not been able to resolve with your health plan or provider.
Choosing a Health Plan
Because each 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 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.
Between March 15, 2021, and May 14, 2021, you can select a health plan and primary care provider (PCP) 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 do not choose a health plan and primary care provider by May 14, 2021, these will be chosen for you.
AmeriHealth Caritas (offered statewide)
855-375-8811 (TTY: 866-209-6421)
24 hours a day, seven days a week
Carolina 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
Healthy Blue (offered statewide)
844-594-5070 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
UnitedHealthcare Community Plan (offered statewide)
800-349-1855 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
WellCare (offered statewide)
866-799-5318 (TTY: 711)
7 a.m. to 6 p.m., Monday through Saturday
The 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
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.
Each health plan has its own set of doctors and health care providers, who make up its network. To keep your doctor, clinic or other provider, ask which health plans they accept, then choose to enroll in one of those health plans. 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.
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 cannot change your health plan until your next recertification date 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.
If you are enrolled in NC Medicaid Direct, call 888-245-0179. In NC Medicaid Direct, you may be able to get services from a Local Management Entity-Managed Care Organization (LME-MCO). For a list of NC Medicaid Direct behavioral health, I/DD and TBI services, go to NC Medicaid Direct services. To ask to stay in NC Medicaid Direct, including your LME-MCO, use the Request to stay in NC Medicaid Direct and LME-MCO: Beneficiary form.
If you are a provider, you may ask for a person to stay in NC Medicaid Direct. Use the Request to stay in NC Medicaid Direct (Fee for Service) and LME-MCO: Provider form.
You can use this website to submit your form. It is the fastest and best way to submit a form. To learn more, go to Submit forms online.
If you enroll in a health plan through NC Medicaid Managed Care, you may not be able to get certain NC Medicaid Direct services.
If you joined a health plan through NC Medicaid Managed Care and need certain services for developmental disability, behavioral health, TBI or substance use disorder, you may have more choices.
To learn more about your choices, call the NC Medicaid Enrollment Broker at 833-870-5500. The call is toll free.
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. Beginning June 1, 2021, you can request transportation for appointments and services taking place on or after July 1, 2021, with the health plan in which you are enrolled. 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.
Information & Assistance
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.
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.
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.
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.
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.
NC Medicaid Enrollment Broker
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
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.