Nc Medicaid Requirements For Adults


Is There A Nc Medicaid Transportation Benefit

Medicaid and NC Health Choice 101

While non-emergency transportation is not a nationally required Medicaid benefit, the NC Medicaid program does provide non-emergency medical transportation coverage. There are three versions of this benefit: gas cards, lift vans, and County vehicles. This coverage relates to non-emergency transportation, not ambulance rides. When possible, always call to make your arrangements at least five days in advance to be sure that you have a ride.

  • If you own or have access to a vehicle, you can qualify for gas vouchers whenever you need to get to a Medicaid-covered appointment. Call 828-695-2135 for more information.
  • If you cannot use a wheelchair or cannot successfully get into a vehicle, you can get a lift van to transport you to and from your Medicaid-covered appointments. Call 828-695-55608 to schedule transportation.
  • If you have the physical ability to get to a vehicle , you can get Medicaid appointment transportation from a county vehicle. Call 828-695-5608 to schedule transportation

Nc Medicaid Dental Coverage For Adults

The North Carolina Medicaid dental program covers preventative, restorative, periodontal, and orthodontic dental services as well as oral surgeries and dentures. Adults and kids alike can find dentists who accept North Carolina Medicaid here. Before you go in for your appointment, make sure to call the dentist office and verify that they will accept your plan.

Generally, you can receive exams, cleanings, fillings, sealants, x-rays, extractions, and dentures. Surgeries and periodontal services are available when medically necessary, and root canals are available for those under 21. Those under 21 can also receive crowns for baby teeth, space maintainers, fluoride treatments, sealants, and x-rays. In most cases, bridgework, implants/transplants, and prescription drugs are not included.

Apply For Medicaid In North Carolina

Online at or at ePass. You can enroll by phone at 1-800-318-2596. You can also apply in person at your local County Department of Social Services office or complete a paper application.

Eligibility: The aged, blind, and disabled. Also, parents with dependent children are eligible for Medicaid with a household income up to 45% of poverty level, and children are eligible for Medicaid or CHIP with incomes up to 211% of poverty maternity-related coverage is available for pregnant women with incomes up to 196% of poverty.

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The Nc Medicaid Preferred Drug List And Formulary

The NC Medicaid program includes a comprehensive prescription drug benefit plan. There is a formulary called the preferred drug list that pharmacists and doctors are encouraged to use when awarding prescription to Medicaid beneficiaries. To get a prescription that is not included in the preferred list, you will need prior approval from NC Medicaid. Always be sure that your doctor or pharmacist knows that you receive Medicaid coverage to be sure that your prescriptions are compatible with your health care plan.

to view the most up-to-date NC Medicaid Preferred Drug List.

Move To Managed Medicaid

NC Medicaid: Mogamulizumab

On September 22, 2015, North Carolina lawmakers passed House Bill 372, known as the Medicaid Transformation and Reorganization Act, to privatize the states Medicaid system then-Governor Pat McCrory signed it into law the next day. Most states were already using Medicaid managed care systems for the majority of their enrollees, but the idea remains controversial.

H. 372 called for the privatization of Medicaid in North Carolina, switching to a model that involves the state contracting with for-profit managed care companies. These managed care organizations, called Prepaid Health Plans , will receive a per-patient payment from the state Medicaid system, and will be responsible for any cost over-runs beyond what they receive up-front from the Medicaid system. This provision is designed to encourage innovation on the part of carriers and providers, in order to keep patients healthy and reduce overall healthcare costs .

Governor Roy Cooper, who was North Carolinas Attorney General at the time, said that turning to MCOs is a risky move.

Medicaid managed care repeatedly delayed took effect in mid-2021

North Carolinas waiver proposal was approved in October 2018, and is effective from 2019 through 2024. Initially, it was to take effect in January 2019, but that was delayed quite a bit.

The state had originally planned to have the managed care transition take effect in , with a phased-in transition .

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North Carolina Medicaid Eligibility Requirements

This page provides general guidelines for the North Carolina Medicaid eligibility requirements. This is an assistance program that provides medical coverage for low-income people of all ages. The department that handles the Medicaid program is North Carolina Department of Health and Human Services. If you have questions or issues about the Medicaid application or the eligibility requirements, contact the North Carolina Medicaid office.

How Can A Lawyer Help Me Meet The Medicaid Eligibility Limits

An experienced Medicaid planning attorney can help you manage your assets in a way that maximizes your ability to secure Medicaid coverage when you need it. A lawyer can advise on the type of assets that will be counted when assessing your eligibility. A few examples of these complexities include:

  • Equity in a home is not counted for Medicaid purposes, but it is susceptible to Medicaid Estate Recovery after your death, meaning it could be sold to recover payments for Medicaid services.
  • A single individual can retain $2,000 in countable assets and still qualify for Medicaid, but you must understand what qualifies as a countable asset to make smart choices about what to accrue towards this limit.
  • If the individual who requires care has an independent spouse, a spousal allowance will be determined based on the marital assets in the 30 days prior to entering a nursing home. The couple should plan strategically to ensure the snapshot captures the maximum possible amount so that the spouse receives the maximum compensation.

The above are just examples of the type of strategic planning a Medicaid attorney in North Carolina can provide.

Contact us today to discuss your options when it comes to Medicaid eligibility in North Carolina.

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Medicaid Eligibility Limits In North Carolina

Your ability to receive Medicaid will depend on the total income of your household. The threshold that constitutes low-income depends on the Medicaid program needed based on age and health. Examples of income limits include:

  • Individuals 65 and Older: For full Medicaid covered, the household monthly income at or below poverty level meaning a family of one must have an income at or below $1,064 a month and a household of two must have an income at or below $1,437 a month.
  • Pregnant Women: The income limits are higher for pregnant women, but the covered care is limited to treatment for conditions that affect the pregnancy. The household income must be at or below 196% of the poverty level.
  • Disabled Individuals: Disabled individuals are eligible for full Medicaid coverage if the monthly household income is at or below 100% of the poverty level.
  • Social Security Income Recipients: Individuals who receive SSI due to age, blindness, or disability are automatically entitled to Medicaid without an additional application. SSI is a federal program that provides basic monthly payments to meet basic needs for food, clothing, and shelter. A tool is available to determine if you qualify for SSI payments.

The above are examples of the different eligibility requirements and limits for receiving Medicaid in North Carolina. A skilled Medicaid planning attorney can assess your situation and advise on your options.

Provider Reverification Requirements To Be Reinstated

Part of what Medicaid expansion in NC could mean

With the end of the federal Public Health Emergency expected later this year, NC Medicaid providers will begin receiving reverification notices. These notices will be sent to providers with approaching reverification due dates, as well as those whose reverification was suspended during the federal PHE.

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North Carolina Medicaid Benefits

Regular Medicaid: Doctor visits, Hospital visits, Prescriptions, Dental, Vision, Medicare premiums, Nursing home care, In-home care, Mental health care, Most medically necessary services for children under age 21, Personal care services, Medical equipment, and other home health services.Medicaid for Pregnant Women: Maternity services only. Prenatal care, delivery and 60 days postpartum care, treating medical conditions which may complicate the pregnancy , childbirth and parenting classes, family planning, Maternity Care Coordination services.

When Should I Start Medicaid Planning

Medicaid is an important resource for any eligible individual, but it becomes increasingly important for the aging population who must consider long-term care. Long-term care is necessary but very expensive, with the average monthly cost of a private room in a nursing home in North Carolina at $8,060.

North Carolina Medicaid will only cover the costs of a nursing home if it is medically necessary meaning that the individual needs the type of care that can only be provided at a nursing home. If your needs meet this requirement, you can only secure Medicaid if:

  • You receive SSI
  • You meet the income limits
  • Your income is over the income limit, but you have medical expenses that meet or exceed your extra income. You will be required to meet a deductible before you qualify for Medicaid coverage, and you can have no more than $2,000 in resources.

The above calculations are further complicated if you have a spouse who will continue to live independently. Because nursing home care is so expensive and Medicaid coverage is complicated, it is important to plan ahead for Medicaid coverage.

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What Do You Need To Apply For Adult Medicaid

The process of making an application for Medicaid can be complex and require a considerable amount of information. Here is a list of information that may be needed in making an application:

  • Recent Medical Bills
  • Canceled checks to medical providers
  • Health insurance receipts
  • Proof of medical transportation costs
  • Statements and payments made to medical providers
  • Proof of Income for the Last Several Months
  • Bank Statements and Account Numbers
  • Bankbooks. Current savings statements
  • Checking account statements for the last several months
  • Copies of stock certificates
  • Life Insurance Policies and Policy Numbers
  • Social Security Card or Number for Client and Family Members
  • Health Insurance Information
  • Proof of Legal Alien Status
  • Nc Medicaid Managed Care Mandatory

    Toe River Health District

    To learn more about NC Medicaid Managed Care, go to the NC Medicaid Managed Care Website. Most beneficiaries receiving Medicaid or NC Health Choice will be required to transition to NC Medicaid Managed Care. This means you must choose a health plan and a Primary Care Provider . If you must choose, NCDHHS – Division of Health Benefits will send you a letter that tells you how to transition to Managed Care. You will be required to transition to NC Medicaid Managed Care if you:

    • Receive full benefits through the Family and Childrens or the Aged, Blind and Disabled Medicaid programs, or through the NC Health Choice or Medicaid for Pregnant Women program.

    If you are transitioning to NC Medicaid Managed Care and want to keep the PCP you have now:

    • Choose a health plan that your provider works with. If you have questions about the instructions in the letter you received ,

    To find a doctor, go to Find a provider.

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    To Be Eligible For Ltc:

    • Individual must be over 65 or under 65 and deemed disabled or blind by the definition set by SSA.
    • Individual must meet state residency & citizenship requirements
    • Gross total income for the individual being institutionalized must be less than the facilitys assigned Medicaid reimbursement rate for 31 days Client statement in not acceptable verification.
    • Meet resource limit of $2000 for an individual
    • Cannot have any Transfer of Assets within the last 5 years
    • STATE Approved FL2/MR2
    • 30 consecutive days in a medical facility or combination of two or more medical facilities. A medical facility could be: A Medicare-Medicaid certified nursing facility, Skilled nursing care in a general hospital, Psychiatric unit in a state mental hospital .

    Medicaid applications may be submitted: in-person, by mail/fax/email, or online.

    If you choose to apply online, you may do so at:.

    Nc Medicaid Managed Care Excluded

    • Some beneficiaries will remain in NC Medicaid Direct, which is the fee-for-service program. This is how you receive health care services now. This means you cannot choose a health plan and you do not need to choose a new PCP unless you want to change to your current PCP. You will stay in NC Medicaid Direct if you:
    • Receive Family Planning Medicaid, Refugee Medicaid, Foster Care/Adoption Medicaid , or must meet a deductible before getting Medicaid benefits
    • Are part of the Health insurance premium payment or Program of all-inclusive care for the elderly programs, or
    • Have both Medicare and Medicaid or receive long-stay nursing home services,
    • Receive Innovations Waiver services, Traumatic Brain Injury Waiver services, or Community Alternatives Program for Children or Community Alternative Program for Disabled Adults services.

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    Family And Childrens Medicaid

    • Covers children through age 20, parents and caretakers of minor children under the age of 18, and pregnant women who meet income requirements.
    • Family Planning Program is designed to reduce unintended pregnancies and improve the well-being of children and families. Services are provided to eligible persons of any age who are ineligible for all other Medicaid programs.
    • North Carolina Health Choice Health Insurance for Children provides reduced price comprehensive coverage for children six to 18 years whose family income meets certain limits but is too high to qualify for Medicaid.

    Tailored Plans Will Start December 1 2022

    Medicaid Spotlight: Eligibility

    On December 1, 2022, NC Medicaid will have a new type of health plan. It is called the Behavioral Health and Intellectual/Developmental Disabilities Tailored Plan . People who need certain services to address a mental health disorder, substance use disorder, intellectual/developmental disability or traumatic brain injury may qualify for the Tailored Plan that serves their county.To learn more, go to Tailored Plan services.

    Meetings and events

    You can schedule rides to medical appointments. Learn more about transportation services.

    Get the free mobile app

    To get the app, search for NC Medicaid Managed Care on or the App Store.

    Use the app to find and view primary care providers and health plans for you and your family. Learn more about the free mobile app at .

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    Adult Medicaid And Long Term Care Medicaid


    Adult Medicaid is health insurance for low-income individuals, seniors, and people with disabilities. Eligibility is based on your familys monthly income and resources that are owned. To receive Medicaid for disability or blindness, you must meet Social Securitys definition of disability or blindness. Adult Medicaid covers individuals living at home in a Private Living Arrangement or individuals in Long Term Care living arrangements. The Medicare Savings Program is a limited assistance Adult Medicaid program for individuals enrolled in Medicare Part A and/or Part B. The Medicare Savings Program can help pay for Medicare premiums, coinsurance, and deductibles.


    • Apply online at or print here to mail in the application.
    • You may also request that an application be mailed to you by calling 919-580-4034.
    • Applications can be dropped off in the Social Services mail drop box located in the parking lot of Wayne County Social Services at 301 N Herman St, Goldsboro, NC 27530.
    • Apply in person at the Wayne County Dept. of Social Services located on the 2nd floor at 301 N. Herman St, Goldsboro NC. Applications are taken between 8:00 am to 5:00 pm, Monday Friday .


    Report changes by calling 919-731-1022


    Find And View Providers And Health Plans

    This website has tools to help you find and view primary care providers and health plans.

    Medicaid and NC Health Choice Provider and Health Plan Lookup ToolYou can use the Medicaid and NC Health Choice Provider and Health Plan Lookup Tool to find a PCP. Our provider search will help you find the best PCP for you and your family.

    To search for a provider, go to Find a provider.

    Health Care Option GuideYou can use the Health Care Option Guide to view health plans. It will help you choose the best health plan to meet your health care needs.

    To view health plans, go to View health plans.

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    Nc Medicaid Managed Care Exempt

    Some beneficiaries can choose to stay in NC Medicaid Direct. This means you are not required to choose a health plan and a PCP. NCDHHS – Division of Health Benefits will send you a letter that tells you if you have the choice to enroll. You have the option to choose a health plan if you:

    • Are a federally-recognized tribal member or individual eligible for services through Indian Health Service .
    • Need certain services to address needs related to developmental disability, behavioral health or traumatic brain injury. BH covers MH and SUD

    If you are transitioning to NC Medicaid Managed Care and want to keep the PCP you have now:

    • Choose a health plan that your provider works with. If you have questions about the instructions in the letter you received ,

    To find a doctor, go to Find a provider.

    How To Apply For Medicaid In Nc

    Medicaid Income Eligibility Priorities in North Carolina: Current and ...

    You can apply for Medicaid in NC either online, in person, by phone, or by mail. To apply in person, visit your local Department of Social Services office. To apply by mail, . To apply by phone, call your local Department of Social Services office.

    If you think you may qualify for Medicare as well, call us! A Medicare Plan Finder licensed agent can go over all of your options with you.

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