NC Medicaid Managed Care launched on July 1, 2021. Within the first 90 days of launch, beneficiaries can change their prepaid health plan (PHP) for any reason. The 90-day choice period ends on Sept. 30, 2021 for beneficiaries who moved to Managed Care on July 1. Beginning Oct. 1, 2021, beneficiaries can change their PHP at their Medicaid recertification date, or “with cause” by contacting the Enrollment Broker and submitting the Health Plan Change Request form. For beneficiaries who enrolled in Managed Care after July 1, their choice period would end 90 days after their enrollment date.
A broad range of “with cause” reasons for beneficiaries includes:
- Moving out of their health plan’s service area
- Having a family member in a different health plan
- They cannot get all the related services they need from providers in their health plan and there is a risk to getting the services separately
- A different health plan may be better for their complex medical conditions
- Their Long-Term Services and Supports (LTSS) provider is not in their health plan
- Their health plan does not cover a service they need for moral or religious reasons
- Other reasons (poor quality of care, lack of access to covered services, lack of access to providers experienced in dealing with their health care needs)
If a “with cause” request is denied, a beneficiary may appeal the decision within 30 days of the date on the denial letter. Information on the appeal process is provided to the beneficiary with the letter, along with a State Fair Hearing Request Form that informs them how to request a faster appeal if they think their health is at serious risk due to the denial.
If providers receive questions from beneficiaries regarding the PHP choice period, they should refer them to the Enrollment Broker website or phone number: 833-870-5500 (TTY: 711 or RelayNC.com). Their standard hours of operation are 7 a.m. to 5 p.m., Monday through Saturday.
CONTACT:
NCTRACKS Contact Center: 800-688-6696