Medicaid Transformation

medicaid transformationStarting July 1, 2021, most Medicaid beneficiaries began receiving the same Medicaid services in a new way. Called "NC Medicaid Managed Care," beneficiaries choose a health plan and get care through a health plan's network of doctors. Some beneficiaries are remaining in traditional Medicaid, which is called NC Medicaid Direct.

Medicaid Programs

The Medicaid program was established to provide medical assistance to low-income individuals and families. The Medicaid program covers groups of people based on certain categorical requirements. To be eligible, the individual or family must make an application and must meet certain financial and non-financial criteria. If eligible, Medicaid provides coverage for the aged, blind, and disabled, including Health Care Coverage for workers with disabilities. This program provides full coverage for persons who are:

  • Age 65 or older, or
  • Blind, as defined by the Social Security Administration, or
  • Disabled, as defined by the Social Security Administration, and
  • Who meet all other financial and non-financial eligibility requirements

Medicare Savings Programs

These Medicaid programs provide limited assistance in paying Medicare premiums, deductibles, and co-payments for individuals receiving Medicare. If eligible, what Medicaid will pay is based on the applicant’s income. (The Social Security Administration agency is responsible for determining eligibility for Medicare – not the Department of Social Services.)

Medicaid for Families & Children

These programs provide full coverage to eligible children under age 21, caretaker relatives of children under age 19, pregnant women, and women enrolled, screened, and diagnosed with breast or cervical cancer including pre-cancerous conditions and early stage cancer. Family Planning Waiver Medicaid provides limited Medicaid coverage in order to assist in the reduction of the number of unplanned pregnancies. Women and men over the age of 19 and with income up to 185% of the federal poverty may qualify.

North Carolina Health Choice

This program provides health insurance coverage for eligible children age 6 through age 18 who are ineligible for Medicaid and who have family incomes equal to or less than 200% of the federal poverty level. Children are evaluated for and enrolled in North Carolina Health Choice only after they are determined to be ineligible for Medicaid.

Medicaid Primary Care Providers