Beneficiary Notices

This page contains sample notices that will be sent to beneficiaries during the transition to Managed Care. Please click the “+” to expand the list for each section.

Enrollment Packet

Enrollment Packet

English	Spanish
Mandatory Transition Notice	Mandatory Transition Notice
Exempt Transition Notice	Exempt Transition Notice
Mandatory and Exempt in Household Transition Notice	Mandatory and Exempt in Household Transition Notice
Tribal-Exempt Transition Notice	Tribal-Exempt Transition Notice
Tribal-Excluded Transition Notice	Tribal-Excluded Transition Notice
Information Sheet	Information Sheet
Health Plan Choice Guide	Health Plan Choice Guide
Enrollment Form – Regions 1, 2, 6	Enrollment Form – Regions 1, 2, 6
Enrollment Form – Regions 3, 4, 5	Enrollment Form – Regions 3, 4, 5
Enrollment Form – Tribal	Enrollment Form – Tribal

Reminder Notices

Reminder Notices

English	Spanish
Reminder Notice	Reminder Notice

Confirmation Notices

Confirmation Notices

English	Spanish
Mandatory – Health Plan Confirmation Notice	Mandatory – Health Plan Confirmation Notice
Exempt – NC Medicaid Direct Confirmation Notice	Exempt – NC Medicaid Direct Confirmation Notice
Exempt – Health Plan Confirmation Notice	Exempt – Health Plan Confirmation Notice
Exempt – Newly Exempt Confirmation Notice	Exempt – Newly Exempt Confirmation Notice
Excluded – Newly Excluded Confirmation Notice	Excluded – Newly Excluded Confirmation Notice
Tribal-Exempt – EBCI Tribal Option Confirmation Notice	Tribal-Exempt – EBCI Tribal Option Confirmation Notice
Tribal-Exempt – Health Plan Confirmation Notice	Tribal-Exempt – Health Plan Confirmation Notice
Tribal-Exempt – NC Medicaid Direct Confirmation Notice	Tribal-Exempt – NC Medicaid Direct Confirmation Notice
Tribal-Excluded – EBCI Tribal Option Confirmation Notice	Tribal-Excluded – EBCI Tribal Option Confirmation Notice
Tribal-Excluded – NC Medicaid Direct Confirmation Notice	Tribal-Excluded – NC Medicaid Direct Confirmation Notice

Appeals and Grievances

Appeals and Grievances

English	Spanish
Grievance Acknowledgement Notice	Grievance Acknowledgement Notice
Grievance Resolution Notice	Grievance Resolution Notice

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