Beneficiary Notices

Sample notices for beneficiaries regarding NC Medicaid Managed Care. Please click the “+” to expand the list for each section.

**Transition Notices**
Transition Notice - Tailored Plan
Transition Notice - Tailored Plan and Standard Plan
Transition Notice - Tailored Plan and NC Medicaid Direct
Transition Notice - Tailored Plan, NC Medicaid Direct and Standard Plan
Transition Notice - Tailored Plan, NC Medicaid Direct and Tribal Option
Transition Notice - Tailored Plan, NC Medicaid Direct, Standard Plan and Tribal Option
Transition Notice - Tailored Plan Reminder

**Enrollment Packet**
English	Spanish
Services Covered Outside Health Plans, Drug List and Copays Insert	Services Covered Outside Health Plans, Drug List and Copays Insert
Enrollment Form – Mandatory	Enrollment Form – Mandatory
Enrollment Form – Exempt	Enrollment Form – Exempt
Enrollment Form – Exempt Tribal	Enrollment Form – Exempt ECBI Tribal
Health Care Option Guide
Tailored Plan - Disenrollment Rights Insert - Version 1
Tailored Plan - Disenrollment Rights Insert - Version 2

**Confirmation Notices**
English	Español
Standard Plan – Mandatory	Standard Plan – Mandatory
Standard Plan – Exempt – NC Medicaid Direct	Standard Plan – Exempt – NC Medicaid Direct
Standard Plan – Exempt – Standard Plan	Standard Plan – Exempt – Standard Plan
Standard Plan – Exempt Tribal – EBCI Tribal Option	Standard Plan – Exempt Tribal – EBCI Tribal Option
Standard Plan – Exempt Tribal – NC Medicaid Direct	Standard Plan – Exempt Tribal – NC Medicaid Direct
Standard Plan – Exempt Tribal – Standard Plan	Standard Plan – Exempt Tribal – Standard Plan
Standard Plan – Excluded Tribal – EBCI Tribal Option	Standard Plan – Excluded Tribal – EBCI Tribal Option
Standard Plan – Excluded Tribal – NC Medicaid Direct	Standard Plan – Excluded – Tribal – NC Medicaid Direct
Standard Plan – Excluded – NC Medicaid Direct	Standard Plan – Excluded – NC Medicaid Direct

**Appeals and Grievances**
English	Español
Grievance Acknowledgement Notice	Grievance Acknowledgement Notice
Grievance Resolution Notice	Grievance Resolution Notice

This page was last modified on 06/29/2022

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https://medicaid.ncdhhs.gov/counties/county-playbook-medicaid-managed-care/beneficiary-notices