The North Carolina Medicaid Transformation in a Nutshell

By Meike Wiest-MSW, NC Triangle Area President 

You may have heard that there are changes happening to the North Carolina Medicaid program. Open enrollment for Medicaid Managed Care began this week on July 15th in 27 counties. From now through September 13, 2019, approximately 540,000 people under the Medicaid program can choose a health plan to provide their Medicaid services, along with a primary care provider. According to the North Carolina Division of Health and Human Services, enrollment packets were mailed last week in Alamance, Alleghany, Ashe, Caswell, Chatham, Durham, Davidson, Davie, Forsyth, Franklin, Granville, Guilford, Johnston, Nash, Orange, Person, Randolph, Rockingham, Stokes, Surry, Vance, Wake, Warren, Watauga, Wilkes, Wilson and Yadkin counties, so be on the lookout if you or a loved one is a recipient! Packets should include a letter, an enrollment form, a general information sheet, a comparison chart and postage-paid business reply envelope. Coverage for these beneficiaries under managed care will begin Nov. 1, 2019. The remaining counties will begin the process in October of 2019. Not all users will receive such a letter, as not ALL Medicaid users will have to choose a plan and can choose to stay in NC Medicaid Direct and will not need to choose a plan. This affects only those that are part of a federally recognized tribe or those that have unique services related to intellectual and developmental disabilities, mental illness, traumatic brain injury or substance use. This is the case if services are provided through a Medicaid waiver program, such as the I/DD Innovations Waiver, the TBI Waiver, CAP/C or CAP/DA. Change can be scary and knowledge is power, so here are a few answers to questions you may have:

Does the Eligibility Criteria Change?

Unfortunately, the answer is no! Medicaid eligibility is NOT changing at this time. The same income and asset restrictions remain in effect. 


The motivation behind the NC Department of Health and Human Services’ effort to transform our Medicaid system is “Improving the health and well-being of North Carolinians through an innovative, whole-person centered and well-coordinated system of care that addresses both medical and non-medical drivers of health.” DHHS has been seeking feedback from a wide variety of stakeholders since 2015, as they were planning and preparing for this change. 

As a result, all health plans are required to have the same Medicaid services, such as office visits, blood tests and X-rays. Similar to private insurance, Medicaid health plans work with different doctors and health care professionals. Each plan has its own network of qualified doctors and health care professionals. DHHS awarded contracts to five health plans: AmeriHealth Caritas North Carolina, Inc.; Blue Cross and Blue Shield of North Carolina; UnitedHealthcare of North Carolina, Inc.; and WellCare of North Carolina, Inc.

A big change will be the integration of physical health care with behavioral health care to ensure more comprehensive and holistic care with fewer boundaries to care. This involves services and supports for physical, pharmaceutical, behavioral, and social needs. 


How Do I choose?   

Things to consider when choosing a plan:

  • Do you want to keep your current primary doctor or certain specialists? 
  • Do you have special health needs that you need to consider?
  • What added services does the plan offer? Some plans will offer gym memberships, family planning/pregnancy care options or other specialty services

The “Compare Plans” feature can be helpful as you weigh your options:


Need Additional Help?

Several tools are available to help people choose and enroll in a health plan or if you are unsure whether you can stay under NC Medicaid Direct. You can call the Medicaid Managed Care Call Center at 833-870-5500 and the website went live in late June and can be found here: There is also a NC Medicaid Managed Care mobile app available on Google Play and the App Store.  

If you are worried about how these changes may affect you or your aging family member, speaking to an Aging Life Care Professional may be helpful. Our care managers at LifeLinks NC are keeping a close eye on how this implementation unfolds so we can best advise our current and future clients.

In complicated situations, we can refer you to a vetted professional, specializing in Medicaid planning and insurance plans to ensure you get the care you or your loved one needs. 

Then What?

Once the transformation is completed in February of 2020, most Medicaid recipients in North Carolina will have their health services managed by private insurance companies as NC Medicaid switches from a public fee-for-service system to a private managed-care model. Instead of the state of North Carolina managing the program directly, insurance companies will be paid a per-member, per-month fee to work with people on Medicaid to manage their health services, similar to how health care works for people with private health-care coverage. 

After you enroll, your new health plan provider will mail you information and a NEW Medicaid card, which you can then use to access health care services. 

You have up to 90 days to change your mind after you receive your approval notice. After that, you can only change plans in special circumstances. 


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