Medicaid Transformation

MEDICAID CANCELED? Free legal assistance may be available. Click here for information about what you need to do.

North Carolina Medicaid has gone through a major change in how Medicaid services are provided. This change is called Medicaid Transformation.

Most Medicaid-eligible individuals have been switched from traditional Medicaid Direct, managed by the state of North Carolina, to health plans managed by private insurance companies instead—a system known as Medicaid Managed Care. Click here for answers to frequently asked questions about Medicaid Managed Care.

Here are four important things you need to know.

  1. There is no change to who can get Medicaid, and the same services will continue to be covered, including hospitalizations, check-ups, prescriptions, and more. But now, your health plan will decide whether to approve the services your doctor requests.
  2. You will have to choose a health plan and a doctor to provide your health care, unless you are exempt. If you don’t, Medicaid will choose a health plan and doctor for you.
  3. People who have serious developmental disabilities or mental illness, persons who have Medicare, persons in a Medicaid waiver program, and some others are “exempt” and do not have to choose a health plan.
  4. Medicaid Tailored Plans, which are for people with serious developmental disabilities or behavioral health needs, are delayed until July 2024. Anyone eligible for a Tailored Plan will continue to be in Medicaid Direct until the Tailored Plans are ready.

What Are My Rights Under Managed Care?

If you have a problem or questions: Contact the NC Medicaid Ombudsman to get your questions answered and help resolve issues about the move to Medicaid Managed Care. You can reach them at 877-201-3750 from 8 a.m. to 5 p.m. Monday through Friday, except state holidays, or you can visit their website at ncmedicaidombudsman.org.

  • Get free advice over the phone from NC Medicaid about whether you are exempt and, if not, learn which plan is the best choice for you and your family. You have the right to receive information from NC Medicaid and health care services in your preferred language for free.
  • Switch plans for any reason within 90 days of being enrolled, or for “good cause” at any time during the year. However, you can still switch to a different health plan after this choice period if you have a special reason to do so, If you want to switch to a different plan, call the Enrollment Broker at 833-870-5500 (TTY: 833-870-5588) or submit the Health Plan Change Request form, found here.
  • Request an “exemption” from NC Medicaid Managed Care and appeal if the exemption is denied.
  • Continue to receive the same NC Medicaid coverage and services you receive now.
  • Get out-of-network care if medically necessary services are not available in the health plan’s network.
  • No interruption of care when transitioning between plans or out of managed care.
  • Appeal if your health plan denies, reduces, or stops coverage for health care you need.

Disagree with a Decision Related to Your NC Medicaid Care?

Get free legal assistance by contacting one of the following organizations:

Disability Rights NC
(Statewide for persons with disabilities)
1-877-235-4210 | www.disabilityrightsnc.org

Legal Aid of NC
(Statewide except counties served by Charlotte and Pisgah Legal groups below)
1-866-219-LANC (5262) | www.legalaidnc.org

Charlotte Center for Legal Advocacy
(Cabarrus, Mecklenburg, and Union counties)
1-800-438-1254 | www.charlottelegaladvocacy.org

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

Información en español

Cambios importantes que vienen a NC Medicaid