Sample notices for beneficiaries about NC Medicaid.

Confirmation Notices

Standard Plan Mandatory - Notice to beneficiaries who were enrolled in a Standard Plan
English | Spanish 

Tailored Plan Mandatory - Notice to beneficiaries who were enrolled in the Tailored Plan
English | Spanish

Tailored Plan (Standard Plan) - Notice to beneficiaries who were enrolled in the Tailored Plan and can choose a Standard Plan
English | Spanish

NC Medicaid Direct (Tailored Plan) - Notice to federally recognized tribal member or IHS-eligible beneficiary living outside the 11-county region who were enrolled in NC Medicaid Direct and can choose the Tailored Plan or stay in NC Medicaid Direct
English | Spanish

EBCI Tribal Option (Tailored Plan of NC Medicaid Direct) - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in EBCI Tribal Option and can choose the Tailored Plan or NC Medicaid Direct
English | Spanish

Standard Plan (EBCI Tribal Option, Tailored Plan of NC Medicaid Direct) - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in a Standard plan and can choose the Tailored Plan, EBCI Tribal Option, or NC Medicaid Direct
English | Spanish

Standard Plan Exempt (NC Medicaid Direct) - Notice to federally recognized tribal member or IHS-eligible beneficiary living outside the 11-county region who were enrolled in a Standard Plan and can choose NC Medicaid Direct
English | Spanish

NC Medicaid Direct (Standard Plan Exempt) - to Notice to federally recognized tribal member or IHS-eligible beneficiary living outside the 11-county region who were enrolled in NC Medicaid Direct and can choose a Standard Plan
English | Spanish

Standard Plan Exempt (NC Medicaid Direct) - Plan Change - Notice to beneficiaries who were enrolled in a new Standard Plan and may choose NC Medicaid Direct
English | Spanish

Standard Plan (EBCI Tribal Option and NC Medicaid Direct) - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in a Standard Plan and can choose or change their Standard Plan or choose the EBCI Tribal Option or NC Medicaid Direct
English | Spanish

NC Medicaid Direct (EBCI Tribal Option and Standard Plan) - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in NC Medicaid Direct and can choose the EBCI Tribal Option or a Standard Plan
English | Spanish

EBCI Tribal Option (Standard Plan and NC Medicaid Direct) - Notice to federally recognized tribal member or IHS-eligible beneficiary enrolled in the EBCI Tribal Option and can choose a Standard Plan or NC Medicaid Direct
English | Spanish

NC Medicaid Direct - LME/MCO - Notice to beneficiaries who were enrolled in NC Medicaid Direct and have an LME/MCO
English | Spanish

NC Medicaid Direct - No LME/MCO - Notice to beneficiaries who were enrolled in NC Medicaid Direct and do not have an LME/MCO
English | Spanish

Transition Notices

Tailored Plan Mandatory Transition - Notice to beneficiaries who were enrolled in the Tailored Plan.
English | Spanish 

Tailored Plan (Standard Plan) Transition - Notice to beneficiaries who were enrolled in the Tailored Plan and can choose a Standard Plan.
English | Spanish 

Tailored Plan (NC Medicaid Direct) Transition -  Notice to beneficiary who were enrolled in NC Medicaid Direct and can choose the Tailored Plan or stay in NC Medicaid Direct.
English | Spanish 

Tailored Plan (Standard Plan, NC Medicaid Direct) Transition - Notice to beneficiaries who were enrolled in another health care option and can choose the Tailored Plan, a Standard Plan or stay in NC Medicaid Direct.
English | Spanish 

Tailored Plan (EBCI Tribal Option, NC Medicaid Direct) Transition - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in another health care option and can choose the Tailored Plan, EBCI Tribal Option, or NC Medicaid Direct.
English | Spanish 

Tailored Plan (EBCI Tribal Option, Standard Plan, NC Medicaid Direct) Transition - Notice to federally recognized tribal member or IHS-eligible beneficiary who were enrolled in another health care option and can choose the Tailored Plan, a Standard Plan, EBCI Tribal Option, or NC Medicaid Direct.
English | Spanish 

Enrollment Packet

Services Covered Outside Health Plans 
English l Spanish

Drug List and Copays Insert 
English l Spanish

Health Care Option Guide 
English l Spanish

Enrollment Form - Standard Plan 
English l Spanish

Enrollment Form - Tailored Plan
English l Spanish

Enrollment Form – Exempt Tribal 
English l Spanish

Tailored Plan - Disenrollment Rights Insert - Version 1 
English l Spanish

Tailored Plan - Disenrollment Rights Insert - Version 2 
English l Spanish

Appeals and Grievances

Grievance Acknowledgement Notice
English l Spanish

Grievance Resolution Notice 
English l Spanish

Other Beneficiary Notices

Tailored Care Management Assignment 
English l Spanish

Medicaid Recertification Reminder 
English l Spanish

Family Planning Program Benefit Change Notice (Child in Home)
English | Spanish (see page 2 of notice)