This bulletin provides guidance to providers caring for NC Medicaid beneficiaries also enrolled in Marketplace coverage through HealthCare.gov.
This bulletin addresses:
- Information about beneficiaries enrolled in NC Medicaid and Affordable Care Act (ACA) Marketplace coverage;
- Actions a provider or beneficiary can take to file a complaint concerning potential fraudulent enrollment into an ACA Marketplace plan; and
- Prior authorizations and third-party billing.
Beneficiaries enrolled in NC Medicaid and Marketplace Coverage
An individual who qualifies for full Medicaid coverage is not eligible for financial help with the cost of their Marketplace plan. Therefore, they probably will not want to keep their Marketplace coverage because it will cost more than coverage through NC Medicaid. To avoid paying the full cost of their Marketplace plan premium and covered services, they should cancel their Marketplace coverage as soon as they find out they are approved for Medicaid. For more information, see the More North Carolinians can now get coverage through Medicaid flyer.
If beneficiaries are enrolled in NC Medicaid coverage and an ACA Marketplace plan, the federal government may stop paying for part of their Marketplace plan premium (called advance payments of the premium tax credit), and the beneficiary will have to cover the full cost. Beneficiaries do not have to pay back premium tax credits for the months they had both Medicaid and Marketplace insurance.
Canceling ACA Marketplace Coverage
If a provider has been informed by a beneficiary enrolled in NC Medicaid coverage that the beneficiary wishes to cancel their ACA Marketplace coverage plan, please instruct the beneficiary to contact the ACA Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) or visit HealthCare.gov.
For more information about when and how to cancel a ACA Marketplace plan, visit the Canceling a Marketplace plan when you get Medicaid or CHIP webpage on HealthCare.gov.
Fraudulent Enrollment
In cases where a beneficiary believes there has been a fraudulent action of being enrolled into an ACA Marketplace plan by a broker, the beneficiary should first contact the Marketplace at 1-800-318-2596 to file a complaint and ask for an escalation due to fraudulent enrollment into a health plan without their consent or knowledge.
The beneficiary should also file a complaint with the North Carolina Department of Insurance (NCDOI) on their Assistance or File a Complaint webpage.
Prior authorizations and third-party billing
In instances where a beneficiary has NC Medicaid and ACA Marketplace coverage, the ACA Marketplace plan must accept prior authorizations provided by NC Medicaid for individuals eligible to receive medical assistance instead of denying the covered service due to the ACA Marketplace plan’s prior authorization requirements not being met, as required by Section 9E.23.(d1) of Session Law 2023-134 (amending NCGS § 108A-55.4). Acceptance of prior authorization provided by NC Medicaid includes:
- The ACA Marketplace plan shall not apply additional prior authorization in instances where NC Medicaid Direct or an NC Medicaid Managed Care health plan has authorized the service.
- The ACA Marketplace plan shall not apply additional prior authorization in instances where NC Medicaid Direct or an NC Medicaid Managed Care health plan would not otherwise require prior authorization of the service.
Contact
NC Medicaid Contact Center, 888-245-0179
NC Medicaid Managed Care health plans