North Carolina Department of Health and Human Services Division of Medical Assistance Recipient and Provider Services

Transcription

1 North Carolina Department of Health and Human Services Division of Medical Assistance Recipient and Provider Services 1985 Umstead Drive 2501 Mail Service Center Raleigh, N.C Dear Interested NC Resident: In an effort to provide information about the Family and Children s Health Care Coverage programs, we developed this handbook, A Consumer s Guide to North Carolina Health Care Coverage Programs for Families and Children. This handbook gives an overview of the programs, eligibility requirements, and covered services. Please keep this handbook as a reference. You may wish to write the telephone number of your local county department of social services (DSS) on the inside cover so it will be readily available. The people at your local DSS agency work hard to ensure our citizens receive all benefits for which they are eligible. If you have questions regarding Medicaid Programs for Adults, there is another handbook, A Consumer s Guide to North Carolina Medicaid Health Care Coverage for the Aged, Blind and Disabled. There is also a handbook for residents who are on Medicare, A Consumer s Guide to Medicare Savings Programs within North Carolina Medicaid. To receive these handbooks, you may contact your local DSS or the DHHS Customer Service Center that is referenced in this handbook and ask to speak to a representative in the Recipient and Provider Services Section, Medicaid Eligibility Unit. The handbooks may also be viewed on or downloaded from the internet at Thank you for your interest in our programs. We hope the information will be helpful.

2 Table of Contents Page # Introduction 1 Terms and Definitions..2-5 North Carolina Health Care Coverage Programs For Families and Children.6-7 What You Can Expect from the North Carolina Health Care Coverage Programs 7 Applying for a North Carolina Health Care Coverage Program 8 Income Limits 9 Reporting Changes in Your Situation...9 Medicaid Fraud and Abuse...10 Medicaid and NC Health Choice for Children (NCHC) Identification (ID) Card Community Care of North Carolina/Carolina ACCESS (CCNC/CA)...14 What North Carolina Health Care Coverage Programs Will Pay For...14 Annual Professional Services Visit Limits 15 Monthly Prescription Limits 16 Co-payments If a Medicaid or a NC Health Choice for Children Medical Claim Denied..19 Estate Recovery..19 North Carolina Health Insurance Premium Payment Program (HIPP)...20 Lifeline/Link-Up Discount Telephone Service.20 Health Check/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Be Smart Family Planning (FPW)...23 Medicaid for Pregnant Women (MPW).24 Baby Love Program.24 Pregnancy Medical Home (PMH)..25 Home Health Services.26 Behavioral Health and Substance Abuse Treatment Services.27 North Carolina Division of Medical Assistance Notice of Privacy Practices Covered Services Your Right to Appeal a Decision about a Medicaid Service...51 Your Right to Request a Review of a Decision about a NC Health Choice for Children Service

3 North Carolina Health Care Coverage Programs for Families and Children Welcome to A Consumer s Guide to North Carolina Health Care Coverage Programs for Families and Children. This information will help you understand what programs and services are available and what they cover. This Consumer s Guide contains information about Medicaid and the North Carolina Health Choice Program and coverage. This handbook is also for: Individuals or couples who have children living with them Individuals or couples expecting a child Health care providers Others seeking information about available North Carolina Health Care Coverage programs Medicaid and NC Health Choice for Children (NCHC) recipients THIS HANDBOOK IS ONLY A SUMMARY. Please read this handbook carefully so that you will understand the benefits. To get more information or find out if you qualify for a North Carolina Health Care Coverage Program call your local department of social services (DSS). The phone number will be in your local phone book. Look under the County Government section. If you still cannot find it, call the DHHS Customer Service Center at Hearing impaired callers may call the TTY dedicated line at DHHS Customer Service Center is available Monday through Friday 8 a.m. to 5 p.m. except for state holidays. A bilingual information and referral specialist is available to translate for persons with limited English proficiency. Visit our website at: For additional information 1

4 Community Alternatives Programs (CAP) Terms and Definitions Programs that help people who need long term care stay in their own homes. CAP provides both medical and non-medical services to prevent or delay care in a facility. Case Management Child A service that identifies, assesses, and finds resources that are needed to help recipients who have ongoing medical problems or other challenges. For Medicaid: A person under the age of 21 who lives in your household. For NC Health Choice for Children: A person age 6 through 18 who lives in your home. Community Care of North Carolina/ Carolina ACCESS (CCNC/CA) Co-payment (or co-pay) Coverage Category Covered Services Deductible (or spenddown) North Carolina s Medicaid managed care program. It provides you with a medical home and a primary care provider (PCP) who will coordinate your medical care. Part of the charge for a covered service that a recipient may have to pay. The type of North Carolina Health Care Coverage Program that you have with the package of medical services that are covered. Medical, mental health, dental, preventive, or treatment needs for which Medicaid and NC Health Choice for Children pays. A deductible is an amount of medical bills a recipient will have to be responsible for paying before they can get Medicaid. A deductible is usually required for people whose income is above certain dollar eligibility limits. 2

5 Department of Social Services (DSS) Terms and Definitions Under state law, county departments of social services (DSS) are responsible for determining the eligibility for the North Carolina Health Care Coverage Programs, including Medicaid and NC Health Choice for Children. The phone number will be in your local phone book. Look under the county governmental section, call the DHHS Customer Service Center, or go to to locate. Division of Medical Assistance (DMA) Family Planning Medicaid Health Check/EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) In Home Care (IHC) Low Income Subsidy (LIS) Managed Care The NC state agency responsible for administration of the North Carolina Medicaid and NC Health Choice for Children Programs. A program that provides family planning services for non-sterilized men and women, with income at or below 185% of the federal poverty level. A Medicaid program only for children in North Carolina. Health Check/EPSDT covers medical and dental services for children between the ages of Sick visits and well visits (check-ups) are covered as well as medically necessary services ordered by a doctor. Provides person-to- person hands on assistance with common activities of daily living, such as bathing, toileting, and taking and recording of vital signs, delivered by a paraprofessional aide in the recipient s home. Two programs are available: IHC for Adults (IHCA) age 21 and over and IHC for Children (IHCC) under age 21. A Medicare subsidy benefit that provides assistance with paying the premium of the Medicare Part D, prescription drug plan, for individuals with income less than 150% of the federal poverty level. Eligibility for this subsidy is based on income and resources. Subsidy amount may vary depending on income. A primary care network that uses a variety of techniques intended to improve the quality of care for individuals, and reduce the cost of providing health benefits. 3

6 Medicaid Medical Home Medicare Part D Terms and Definitions A health care coverage program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. The primary care provider where you go for help when you need health care. A voluntary prescription drug program through Medicare that provides all Medicare beneficiaries with prescription drug assistance. Medicare beneficiaries must also enroll in a prescription drug plan (PDP) to have prescription coverage. Medicaid recipients who receive Medicare receive prescription drug coverage through Part D. NC Health Choice for Children (NCHC) Health care coverage for children ages 6 through 18 with family income from 101% - 200% of the federal poverty level. Children cannot be eligible for Medicaid or be covered by comprehensive private health insurance. Non-covered Services Pregnancy Medical Home Premium Prescription Drug Primary Care Physician (PCP) Certain medical, mental health, dental, preventive, long-term care, or other services for which Medicaid or NC Health Choice for Children does not pay. A group of prenatal care providers who agree to provide a higher standard of care to Medicaid pregnant women to help the mothers and their babies be as healthy as possible. The amount of money paid for health insurance coverage for a specific period of time. A drug that can only be bought with a doctor s written order. Medicaid and NC Health Choice for Children do not cover drugs that are experimental. The U.S. Food and Drug Administration (FDA) must approve the drug. Medicaid will only cover prescription drugs for Medicare beneficiaries under certain circumstances. A Community Care of North Carolina/Carolina ACCESS (CCNC/CA) enrolled medical provider who either provides or arranges medical services to meet the patient s health care needs. 4

7 Prior Approval Program Limits Terms and Definitions A request made by the treating licensed healthcare professional, to be sure that a service meets the definition of medically necessary prior to providing the service. Income limit: the highest amount of countable monthly income a recipient can receive and still qualify for Medicaid or NC Health Choice for Children as determined by federal regulations. Coverage limits: how many times and how often Medicaid or NC Health Choice for Children will pay for a covered service, or when only certain kinds of doctors or medical professionals can give the care. Resource limits: the highest amount of countable resources or assets a recipient can have and still qualify for Medicaid. (Example: cash, money in a bank account, life insurance, stocks, bonds, trust funds). 5

8 What are the North Carolina Health Care Coverage Programs for Families and Children? North Carolina Health Choice for Children (NCHC): NC Health Choice for Children (NCHC) is a health care coverage program funded by the federal and state governments. A child may be eligible if the child: lives in the state of North Carolina, is age 6 through 18, has no comprehensive private health insurance and does not qualify for Medicaid, Medicare, or other federal government sponsored health insurance, such as TRICARE, CHAMPVA. A child may be eligible depending on the family s income. NC Health Choice for Children may be stopped or suspended at any time if federal or state money is no longer available. NC Health Choice for Children is not an entitlement program. A program enrollment fee may be required. For more information on NC Health Choice for Children, visit the website at Legal information and requirements for the NC Health Choice for Children program are in Chapter 108A of the North Carolina General Statutes. See: Medicaid: Medicaid is a health care coverage program for low income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities. Medicaid is governed by federal and state laws. There are several eligibility programs within Medicaid. Below are the most common programs. Medicaid for Families with Dependent Children (MAF) Health Care coverage for single parents or couples with children under age 19 in their household or for children ages 19 and 20. Medicaid for Infants and Children (MIC) Medical coverage for children under the age of 19. Medicaid for Pregnant Women (MPW) Medical coverage for pregnant women. Work First Family Assistance (WFFA) A cash payment program for families with children (also known as TANF). If eligible for WFFA, Medicaid is included. Family Planning Medicaid (FPW) Medical coverage for family planning services only. 6

9 Other programs that are offered under the Medicaid program are for individuals who are aged, blind or disabled with low income who cannot afford health care costs. These programs include: Medicaid for the Aged, Blind or Disabled (MAABD) - Medical coverage for individuals who are age 65 or older, blind, or disabled. Eligibility for these programs is based on the family s monthly income and the amount of resources the family owns. Community Alternatives Programs (CAP) CAP participants must meet all Medicaid eligibility requirements. These programs provide home and community based services for persons who are at risk of being institutionalized, but for whom care can be provided cost-effectively and safely in the community. CAP categories are: Community Alternatives Program for Persons with Intellectual and Developmental Disabilities (CAP-I/DD) Community Alternatives Program for Children (CAP-C) Community Alternatives Program for Disabled Adults (CAP/DA) CAP/Choice. Money Follows the Person (MFP) - A project that assists Medicaid-eligible North Carolinians who live in inpatient facilities, but would be able to live in a private living arrangement, or to move into their own homes and communities with supports. Program for All-Inclusive Care for the Elderly (PACE) A managed care program that allows elderly Medicaid-eligible individuals who need nursing facility care to live in a private living arrangement and as independently as possible. All the participant s medical needs are met by the services of the PACE agency. Contact your local county DSS for more information about these programs or visit our website at What You Can Expect From North Carolina Health Care Coverage Programs: Individuals will receive a NC Health Care Coverage Identification Card. There are co-payments for some services. North Carolina Health Care Coverage programs have several different types of coverage for people with different needs. For instance, pregnant women have a special package of benefits all their own under Medicaid. NC Health Choice for Children does not cover pregnancy related services. You cannot be rejected because of a health condition you already have. Instead, North Carolina Health Care Coverage program eligibility is based on your family s finances. You do not have to have a medical need when application is made. Provides you with a medical home with a primary care physician. The medical home will help you receive the services you need. 7

10 Applying for North Carolina Health Care Coverage Programs As with any health coverage, you will need to fill out an application. The same application is used for both Medicaid and NC Health Choice for Children. You may download an application from the DMA website at You may also visit the website for information regarding your local department of social services. You may also call directory assistance or find the telephone number for your local department of social services in the county government section of your phone book. These pages are usually blue. A caseworker at the local DSS will give you an application and if needed assist you in completing it. The caseworker will also review the information you provide and evaluate you and your family for the most appropriate program. You may ask to have an application mailed to you if you prefer. Information you provide to the county department of social services, to establish your eligibility for Medicaid and NC Health Choice for Children, may be checked by a State or Federal reviewer. You must cooperate with the reviewer s investigation. If a child is not eligible for Medicaid, he or she will be evaluated for NC Health Choice for Children eligibility. You do not need to fill out a separate application. You will need to provide items to prove you qualify for a North Carolina Health Care Coverage Program. If possible, have everything on this checklist when you go to apply. If you cannot get all of these items, please apply anyway. You may provide information after you apply, and the caseworker can help if you need assistance. A copy of all pay stubs for last month. Your social security card or proof that you have applied for one for yourself or anyone you are applying for. Copies of all medical or life insurance policies you have for yourself and the members of your family who want North Carolina Health Care Coverage Program assistance. A list of all cars, trucks, motorcycles, or other vehicles you or anyone in your household own. Most recent financial statements from financial institutions (such as bank statements). Current financial statements from other sources of family income, such as social security, retirement benefits or pensions, veteran benefits, SSI, child support, or other sources. For applicants who are not citizens, but have specific lawfully residing immigration status, proof of the immigration status is required. Proof of pregnancy (doctor s statement or note from other health professional indicating due date) if you are applying for Medicaid for Pregnant Women (MPW). While the local DSS caseworker is determining your eligibility, you may be asked to give them more information. Once you have given them all the information they have asked for, you will receive a notice in the mail that will tell you whether or not you can receive Medicaid or NC Health Choice for Children. If you are told you do not qualify, this notice will also give you information regarding your right to appeal the decision made by the agency. If you knowingly provide false information or if you withhold information, you may be prosecuted by law enforcement and/or made to repay any medical bills that were paid incorrectly. Any time your case is changed by the county, or you no longer meet the eligibility requirements, you will receive a notice saying why it is being changed or terminated and explaining your right to appeal. 8

11 INCOME LIMITS (Effective April 1, 2012) The amounts listed below may change every April To obtain updated income limits, visit our website at Medicaid and NC Health Choice for Children are health care coverage programs for low income families that cannot afford health care costs. Eligibility is determined based on the family s income. This means that income after allowable deductions is compared to an income level for number of persons in the family. This chart shows highest monthly income amounts allowed. Number in family Pregnant women & Family planning Medicaid for children under age 6 and NC Health Choice for Children (children 6-18) Medicaid for Children age 6-18 Families with children under age19. Individuals age 19 & 20 1 $ 1,723 $ 1,862 $ 931 $ 362 2* $ 2,333 $ 2,522 $ 1,261 $ $ 2,944 $ 3,182 $ 1,591 $ $ 3,554 $ 3,842 $ 1,921 $ $ 4,165 $ 4,502 $ 2,251 $ $ 4,775 $ 5,162 $ 2,581 $ $ 5,386 $ 5,822 $ 2,911 $ $ 5,996 $ 6,482 $ 3,241 $ 772 *Pregnant woman counts as family of 2 If your income is more than one of the amounts listed above, you may still qualify if you have medical bills or if you expect that you will need medical treatment in the near future. However, you may have to meet a deductible before you can receive Medicaid IT IS IMPORTANT TO LET YOUR DSS WORKER KNOW WITHIN 10 DAYS IF ANY CHANGES OCCUR IN YOUR SITUATON: Some changes that need to be reported are: Change in income for you, your family and anyone getting Medicaid or NC Health Choice for Children (This includes parents of children getting Medicaid or NC Health Choice for Children). Change in the amount of child support or alimony that you pay or receive. Change in the amount of childcare you pay. If anyone who receives Medicaid or NC Health Choice for Children starts getting private health insurance. Change in health insurance coverage for anyone currently receiving Medicaid or NC Health Choice for Children. Change in your home or mailing address. If anyone moved into or out of your home. You start or stop receiving unemployment, workers compensation, disability, social security, VA, and/or any other income. Change in your primary care physician. 9

12 Use of the North Carolina Health Care Coverage ID card or ID Number by anyone not listed on the North Carolina Health Care Coverage ID card is fraud and punishable by a fine, imprisonment, or both. For questions about your North Carolina Health Care Coverage Program or to report fraud, waste or program abuse, please contact DHHS Customer Service Center at

13 If you qualify for a North Carolina Health Care Coverage Program, you will get an Identification (ID) card Your caseworker will mail you a notice to tell you if your application was approved. You will receive a gray colored identification card in the mail (See examples on the following pages.) You will only receive one ID card per year, so please take special care of your ID card. Review the information on the ID card to make sure it is correct. If the information on the ID card is incorrect, contact your caseworker immediately. Sign the ID card and present the signed ID card along with picture identification to each medical provider. Failure to present this ID card or identification to a medical provider could result in the provider refusing to provide service or they may bill you! Contact the Community Care of North Carolina/Carolina ACCESS (CCNC/CA) Medical Home primary care provider (PCP) on the ID card to make an appointment to get a medical history established. You must see your PCP for most health care services; otherwise, you may be responsible for paying the bill. If you need to change the PCP listed on your ID card, call your caseworker at your local county department of social services. Do not allow anyone else to use your ID card. Keep your ID card with you at all times. Before you receive services, make sure that the provider accepts the North Carolina Health Care Coverage Program you are eligible to receive (Medicaid or NC Health Choice for Children). Only go to the emergency room when you have a life threatening problem; otherwise, call your PCP before going. If you need medical advice after the office closes, call the PCP s afterhours number on your ID card. If you lose your ID card, notify the county DSS immediately. They can request a replacement ID card be sent to you at no charge. ALWAYS TAKE YOUR NORTH CAROLINA HEALTH CARE COVERAGE PROGRAM ID CARD WITH YOU Always show your Health Care Coverage ID card when you go to a doctor, clinic, hospital or other health care professional for medical care or to the drug store when you get a prescription drug. If you do not show your ID card, the person treating you may not know that you are covered under a North Carolina Health Care Coverage program. You may then be charged for the full cost of the service or a prescription drug. Use of the North Carolina Health Care Coverage ID card or ID Number by anyone not listed on the North Carolina Health Care Coverage ID card is fraud and punishable by a fine, imprisonment, or both. For questions about your North Carolina Health Care Coverage program or to report fraud, waste or program abuse, please contact DHHS Customer Service Center at

14 The North Carolina Health Choice for Children (NCHC) Identification (ID) Card: Front of ID Card (Sample) The front of the NC Health Choice for Children ID card has the NC Health Choice for Children logo and important information such as the child s: Name Date of Birth NC Health Choice for Children ID Number Date the ID card was issued Medical Home (Primary care provider) Medical Home Telephone number and after-hours contact Co-pay information You will receive one (1) ID card in the mail for each child enrolled in NC Health Choice for Children. If more than one child is covered, please make sure you present the correct ID card for each child. The ID card is not proof of NC Health Choice for Children eligibility. It is mandatory that all recipients be enrolled with the medical home of a Primary Care Physician (PCP). The ID card lists the name, address and telephone numbers of your PCP. Use of the ID card by anyone not listed on the ID card is fraud and is punishable by a fine, imprisonment or both. Back of ID Card (Sample) The back of the NC Health Choice for Children ID card also has important information. Before receiving a service from a provider, ask if they are a Medicaid-enrolled provider. If they are not, you will be required to pay for their service. Some services, like out-of-state services, require prior approval. The doctor is responsible for asking for prior approval. 12

15 The North Carolina Medicaid Identification (ID) Card: Front of Card: (Sample) The front of the Medicaid ID card has important information such as the person s: Name Date of Birth Medicaid ID Number Date the ID card was issued Medical Home (Primary care physician) Medical Home Telephone number and after-hours contact You will receive one (1) ID card in the mail for each recipient enrolled in Medicaid. If more than one child is covered, please make sure you present the correct ID card for each person. The ID card is not proof of Medicaid eligibility. If the recipient is enrolled with the medical home of a Primary Care Physician (PCP), the ID card lists the name, address and telephone numbers of your PCP. Use of the ID card by anyone not listed on the ID card is fraud and is punishable by a fine, imprisonment or both. Back of ID Card: (Sample) The back of the Medicaid ID card also has important information. Before receiving services from providers, ask if they are Medicaid-enrolled providers. If they are not, you will be required to pay for their service. Some services, like out-of-state services, require prior approval. The doctor is responsible for asking for prior approval. If you have other insurance, please inform your provider, as Medicaid is the last to pay and other insurance needs to be filed first. 13

16 Community Care of North Carolina/Carolina ACCESS (CCNC/CA) Community Care of North Carolina/Carolina ACCESS (CCNC/CA) is North Carolina s Medicaid managed care program. It provides you with a Medical home and a primary care physician (PCP) who will coordinate your medical care. Most Medicaid and NC Health Choice for Children recipients are required to participate in CCNC/CA. As a Community Care of North Carolina/Carolina ACCESS (CCNC/CA) member, you are eligible for all the services that Medicaid or NC Health Choice for Children covers. Being a member also has the following advantages: You can choose a medical home with a primary care doctor. A medical home can be chosen for each family member. Your local county department of social services (DSS) office has a complete list of participating primary care doctors. If you do not choose a medical home, you may be automatically assigned to one. The name, address, and phone number of your primary care doctor is on your ID card. If you have never had a visit with your primary care doctor, call and make an appointment IMMEDIATELY after you get your ID card. You can call your primary care doctor 24 hours a day, 7 days a week for medical advice. Check your ID card for your doctor s daytime and after-hours phone numbers. You may have a care manager who can help you understand and manage your health care. A care manager can show you how to stay healthy. Ask your doctor for more information about obtaining a care manager and how a care manager can help you. You receive regular sick care and well care at your medical home. These services include: Yearly physical check-ups Immunizations Pap smears and Prescriptions for medicines when necessary Your primary care doctor will make referrals to other doctors if you need special care not provided in your primary care doctor s office. What the North Carolina Health Care Coverage Programs for Families and Children Will Pay For It is always a good idea to ask you doctor or pharmacist whether the specific service or item you need is covered by North Carolina Health Care Coverage programs. There are some limits to these services and some may require you or your doctor to get permission from Medicaid or NC Health Choice for Children first (this is called prior approval). Generally, Medicaid and NC Health Choice for Children cover the following: Doctor Bills Hospital Bills Prescription drugs (Excluding prescriptions for Medicare beneficiaries) Vision Care Dental Care Medical Equipment, and Other Home Health Services Mental Health Care Most medically necessary services for children under age 21 Hospice care Family planning services (contraceptives only for NC Health Choice for Children) 14

17 Annual Professional Services Visit Limit Under Medicaid, you are usually allowed a total of 22 professional service visits per year (July 1 through June 30). If your provider anticipates additional care is needed for a specific condition, the provider may request an exception to the annual Professional Services visit limit. The exception must be requested before you receive the service. Some Recipients Are Not Subject to the Annual Professional Service Visit Limitation These recipients include: Recipients under the age of 21 Recipients enrolled in a Community Alternatives Program (CAP) Pregnant recipients who are receiving prenatal and pregnancy-related services Residents of nursing facilities or an ICF-MR Recipients who have one of the following: 1. End Stage lung disease 2. End stage renal disease 3. Chemotherapy and radiation therapy for cancer 4. Acute sickle cell disease 5. Unstable diabetes (does not apply to diabetic recipient whose condition is controlled by oral medications, diet or insulin.) 6. Hemophilia or other blood clotting disorders 7. Any life threatening illness or terminal stage of any illness (as supported by a doctor s documentation). Additional information regarding the annual professional services visit limitations can be found online at Provider types that are included in the professional services visit limit are: Physicians (except for physicians enrolled in N.C. Medicaid with a specialty of oncology, radiology, or nuclear medicine) Nurse practitioners Nurse midwives Health departments Rural health clinics Federally qualified health centers Medicaid will also cover up to 8 visits to a chiropractor, optometrist, or a podiatrist. (This means a total of 8 visits for example, 2 visits to the podiatrist and 6 visits to the chiropractor.) However, some services do not count toward the 22 annual professional services visit limits. These services include: In-Home Care services Inpatient hospital services Dental services Mental health services requiring prior approval Services covered by both Medicare and Medicaid Physical, Occupational and Speech therapy Health Check Examinations 15

18 Monthly Prescription Limit Anyone 21 years of age and older can only receive up to eight (8) prescriptions per month. (Medicare recipients, see *NOTE below) Recipients under the age of 21 or residents of Intermediate Care Facility /Intellectual and Developmental Disability center are not limited. At the discretion of the pharmacist, the monthly prescription limit may be increased to three (3) additional prescriptions. Unsafe, ineffective or experimental/investigational drugs are not covered. Medicaid recipients needing more than eleven (11) prescriptions per month are limited to using one pharmacy each month and are enrolled in a Recipient Opt-In Program. Recipients must elect to participate in the opt-in program to receive more than 11 prescriptions per month; however, written consent is not required. Medicaid recipients who overuse certain pain medications or antidepressants will be limited to one prescriber and one pharmacy in order to obtain these prescription drugs. These recipients are identified under the Recipient Management Lock-in Program and will be notified by mail. Recipients under 21 years of age, recipients in a nursing facility, or recipients in an Intermediate Care facility/ Intellectual and Developmental Disability center are not limited to using one pharmacy each month. * NOTE: Medicaid does not cover prescription drugs for Medicare beneficiaries. Medicare recipients have prescription drug coverage through Medicare Part D, unless they have coverage through a private insurance company. Drugs excluded by Medicare may be covered under Medicaid in certain circumstances. 16

19 Co-payments Medicaid and NC Health Choice for Children recipients may be required to pay a co-payment. This means that you may have to pay the first few dollars of a charge when you go to the doctor s office, outpatient therapist for counseling, hospital for outpatient care, emergency room, or pharmacy. You must pay any required co-pays directly to the doctor, pharmacy, or hospital when the service is provided. If a Medicaid recipient is not able to pay the co-payment, a provider cannot refuse treatment, however the patient is still responsible for the co-payment. Providers may open an account for the patient and collect the amount owed as co-payments at a later date. If a NC Health Choice for Children recipient is not able to pay the co-payment, a provider may permit the patient to be billed for the co-payment after the service is provided, or refuse treatment to the patient. Providers may not charge co-payments for the following services: Ambulance services Auditory implant external parts and accessories Diagnostic X-ray Durable Medical Equipment (DME) Family planning services Federally Qualified Health Center (FQHC) core services Health Check (EPSDT) related services Hearing aid services HIV case management Home health services Home infusion therapy Hospice services Hospital emergency department services, including physician services delivered in the emergency department Hospital inpatient services (inpatient physician services may be charged a co-pay) Laboratory services performed in the hospital Optical supplies and services Services that DO require co-payments include the following: Doctor Dentist (only one co-pay for services requiring more than one visit) Generic prescriptions Brand name prescriptions Chiropractic care Podiatrist Optometrist Outpatient visits Ophthalmologist Clinic and outpatient services, including local health department visits and outpatient behavioral health services Non-emergency visits to a hospital emergency room 17

20 Non-hospital dialysis facility services In-Home Care for Children and Adults Private Duty Nursing (PDN) services Rural Health Clinic (RHC) core services Services covered by both Medicare and Medicaid Services in state-owned psychiatric hospitals Services provided to CAP participants Services provided to residents of nursing facilities, ICF-MRs, and psychiatric hospitals Services related to pregnancy Services to individuals under the age of 21 If a provider visits you while you are an inpatient in a hospital, you may have to pay a copayment. Below is a list of the co-payments required for the North Carolina Health Care Coverage Programs. For NC Health Choice for Children (NCHC) recipients, the total co-payment amount in a 12 month certification period may not exceed 5% of the family s income for that 12 month period. NOTE: These are the current copayment amounts upon this printing and are subject to change. Services Medicaid co-payments NC Health Choice for Children (NCHC) co-payments (Appropriate Co-payments are listed on your child s ID card ) All recipients except those exempt and listed above Recipients under 150% of Federal Poverty Level (FPL) Recipients over 150% of FPL (Enrollment fee $50.00 per child, Professional visits (provider and outpatient hospital) Prescription Drug Covered Over-the- Counter Medication Non- Emergency ER Visit $3.00 per professional service visits $2.00 Chiropractic $0.00 per professional service visit $3.00 Generic Brand without generic available Brand with generic available $1.00 $1.00 $3.00 maximum $ per family) $5.00 per professional service visit (excludes well-child visits and ageappropriate immunizations) $1.00 $1.00 $10.00 $3.00 $1.00 $1.00 $0.00 $10.00 $25.00 *For all members of federally recognized Native American tribes and Alaska Natives, there is no cost sharing or enrollment fee imposed. A $0 co-payment is printed on each qualified recipient s health insurance card. 18

21 If a Medicaid or a North Carolina Health Choice (NCHC) for Children medical claim is denied If you receive a bill for a service that Medicaid or NC Health Choice for Children covers after you were told you qualified for Medicaid or NC Health Choice for Children, and your doctor agreed to accept Medicaid or NC Health Choice for Children as payment, you may not be responsible for the bill. You have the right to a reconsideration review if Medicaid or NC Health Choice for Children denies payment of a bill. If you want a reconsideration review, you have to ask for it no later than 60 days after the first bill. Send a copy of the bill to: Claims Analysis N.C. Division of Medical Assistance 2501 Mail Service Center Raleigh, NC You also should write a letter and send that in with a copy of the bill. In the letter, please state: 1. The reason you are requesting the review. 2. Your Medicaid or NC Health Choice for Children identification number. Your review will take place within 20 days after Claims Analysis gets your letter. They will send you their decision in writing. You may contact the DMA Claims Unit by calling the DHHS Customer Service Center at Estate Recovery (Estate recovery does not apply to NC Health Choice for Children) Estate Recovery means a claim is filed against the estate of a deceased recipient to recover Medicaid dollars paid on behalf of the individual. It is important to understand that estate recovery does not include placing a lien on the property. Recovery is not initiated until the recipient s death. In some situations, recovery is waived. The DMA Third Party Recovery Section (TPR) is responsible for collection activities after a claim is filed against the estate. TPR works directly with the representative/administrator of the estate to ensure claims against an estate are paid to the extent the assets are available and in accordance with the order of payment in state law. The estates of Medicaid recipients may be subject to estate recovery if the recipient applied or reapplied on or after October 1, 1994, and is under age 55 and an inpatient in a nursing facility, intermediate care facility for the intellectual developmentally disabled, or other medical institution, and cannot reasonably be discharged to return home, or is 55 years of age or older and is living in medical facility and receiving medical care services, or home and community-based services, or In Home Care Services (IHC). In Home Care Services (IHC) claims for SA recipients ages 55 and over are subject to Medicaid Estate Recovery. 19

22 The following pages contain information on some programs that a person receiving assistance through the North Carolina Health Care Coverage Programs for Families and Children may be eligible for. NC HIPP reimburses its members for the cost of a health insurance policy that covers the policyholder and their dependants that are Medicaid beneficiaries. In some cases, NC HIPP will even reimburse the cost of a family policy that includes coverage for those that are not Medicaid members. In addition, NC HIPP eliminates out-of-pocket medical expenses for eligible Medicaid members. With NC HIPP, Medicaid members keep their Medicaid coverage as well as receive benefits of other insurance. You may enroll in NC HIPP at any time during the year. To qualify, there must be at least one family member receiving Medicaid coverage, and there also must be a qualified family member that has access to health insurance provided by an employer or COBRA. Not currently insured through your job or COBRA? A HIPP representative may be able to help you understand the types of health insurance policies your employer may offer that could qualify you for the HIPP program. If you have questions about the program, or need help completing the NC HIPP application, contact NC HIPP at their toll free number My.NCHIPP ( ), Monday through Friday between 9am-6pm. Submit an application: On the NC HIPP website: By fax: , Or By mail: NC HIPP Program, 4441 Six Forks Rd # , Raleigh, North Carolina Did you know By providing premium reimbursements to Medicaid members, NC HIPP helps save state and taxpayer money. You can help these efforts by applying to the NC HIPP program today. Learn more about NC HIPP by visiting our website at Life Line/Link-Up Discount Telephone Service Link-Up provides a 50% discount, up to $30, off the cost of having a telephone installed. Lifeline provides up to $13.50 off the monthly cost of local telephone service. Medicaid recipients are eligible for Lifeline/Link-Up benefits. Contact a telephone company of your choice. Request a LIFELINE/LINK-UP SELF-CERTIFICATION FORM. Complete the SELF-CERTIFICATION FORM and return it to the telephone company, and make an application for local telephone service. If you are eligible for Lifeline/Link-Up benefits, you will receive the installation discount and the monthly local service discount. Note: If your telephone service has been disconnected for unpaid bills, you may still be able to obtain local telephone service and these discounts. Ask your telephone company for details. Attorney General Roy Cooper, Chair of the Lifeline/Link-Up Task Force, urges you to contact your local telephone company to learn more about these discounts. 20

23 HEALTH CHECK/EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) COMPLETE CHECK-UPS AND TREATMENT FOR CHILDREN RECEIVING MEDICAID (NC Health Choice for Children (NCHC) recipients are not covered for EPSDT services) Definition: Health Check is the N.C. Medicaid program that means Early and Periodic Screening, Diagnosis, and Treatment. EPSDT services are covered free of charge. These services are required to be offered by federal law for children EPSDT covers: Regular medical check-ups. Check-ups prevent illness and find problems early. Dental services. Your child should go to the dentist every six months. Mental health services, if medically necessary. Rehabilitative services for children with disabilities, such as In-home nursing care with a licensed nurse or nurse aide, therapy, and medical equipment. Any other medically necessary treatment needed to reduce your child s illness, improve or maintain his/her condition, or restore his/her functioning as long as all EPSDT criteria are met and the service is covered at 1905(a) of the Social Security Act Who Qualifies: Medicaid recipients are eligible from birth through age 20. How Often Will My Child Be Seen: With Health Check, your child should have regular screenings (medical exams) as follows: Within 1 st month 2 months 4 months 6 months 9 or 15 months 12 months 18 months For children ages 2 through 20, annual visits are recommended The EPSDT medical screening exam should include: a health history and physical exam; measurement of height and weight; developmental level and mental health assessment; immunizations (shots); other tests, including tuberculosis and lead poisoning; and health education. What Treatment Services Will EPSDT Pay For: EPSDT covers medically necessary treatments a child needs to ameliorate or improve their condition and to stay as healthy as possible. This includes some services that Medicaid does not provide for adults. The treatment services for each child will be determined by the child s individual needs. To be covered by Medicaid, many EPSDT services must be prescribed by your child s doctor or another licensed clinician. Prior approval from the N.C. Medicaid agency, the Division of Medical Assistance, or its vendors may be needed for some treatment services. Your child s provider will know whether the service requires prior approval. EPSDT can cover services that your child needs to correct a health problem, to improve the problem, to prevent it from getting worse, or to help the child live with the problem. Even if the service, including requests for specialized treatments, will not cure your child s condition, the service must be covered if the service is coverable at 1905(a) of the Social Security Act and all EPSDT criteria are met including medical necessity to improve your child s symptoms or maintain functioning. If your child has a Medicaid card, and your child s doctor or other clinician says your child needs treatment, there is: 21

24 no Medicaid imposed waiting list for EPSDT services no upper limit on the total cost of treatment* no upper limit on the number of hours necessary health care services are provided* no limit on the number of visits to a doctor or therapist no requirement that the service or equipment your child needs has to be on Medicaid s usual list of covered services no co-payment or other cost to you coverage for services that are never covered for adults, and coverage for services not listed in the N.C. Medicaid State Plan. *If your child is enrolled in a Community Alternatives Program (CAP), services are provided in accordance with the waiver requirements. EPSDT only applies to waiver services if the service is both a waiver service and an EPSDT service. An EPSDT service is a service coverable at 1905(a) of the Social Security Act. Following is a list of some of the services that can be covered by EPSDT if needed to correct or ameliorate a child s health problem Inpatient and outpatient hospital services Laboratory and x-ray services Family planning (birth control), including sexually transmitted disease screening Physician services (including pediatricians and pediatric specialists) Routine eye exams and eyeglasses Hearing testing and hearing aid(s) Home health care services Therapy services physical, occupational, and speech/language Private duty nursing services Clinic services (including rural health clinics) Prescribed and over-the-counter drugs Dental care, including preventive and restorative care Durable medical equipment, including wheelchairs and assistive devices Case management Medical or remedial services recommended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level (rehabilitation) Intermediate care facilities for the mentally retarded Maternity care Respiratory care In-Home Care for Children (assistance with feeding, bathing, dressing grooming) Substance abuse services Transportation services For a complete listing of Medicaid/EPSDT services and their definitions, please visit For more information about EPSDT Treatment Services, visit: or 22

25 Be Smart Family Planning (FPW) (NC Health Choice for Children recipients do not qualify for FPW) The Be Smart Family Planning is a Medicaid program for men and women to receive family planning services. Who Qualifies? Women age 19 through 55 Men age 19 through 60 US citizens or documented immigrants NC residents who: Have income below 185% of the federal poverty level Are not incarcerated, pregnant or permanently sterilized What Medicaid Will Pay For: Be Smart Family Planning Medicaid pays for one family planning annual exam and six follow-up family planning exams during the year. You may also choose an approved method of birth control. A family planning service is: Annual physical exam (includes one pap test and some other limited labs, STD testing and treatment, and HIV testing) Follow-up family planning visits Pregnancy testing and counseling Referrals Birth control methods(medicaid-covered and FDA-approved) Birth control methods* include: Birth control pills Depo shots Contraceptive implants Diaphragm fitting Emergency contraception Intrauterine device (IUD) Natural family planning The patch The ring Male and female sterilizations * NOTE: For a complete list of covered services, please consult with your health care provider or visit There is no co-payment for Family Planning Medicaid visits or prescriptions, and you are not required to participate in Community Care of North Carolina/Carolina ACCESS (CCNC/CA). Check with your health care provider or pharmacist before receiving services For more information on Be Smart Family Planning Medicaid Visit our website at: Or Call the DHHS Customer Service Center at Hearing impaired callers may call the TTY dedicated line at DHHS Customer Service Center is available Monday through Friday 8 a.m. to 5 p.m. except for state holidays. A bilingual information and referral specialist is available to translate for persons with limited English proficiency. 23