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NC Medicaid »   Counties »   County Playbook: Medicaid Managed Care »   Beneficiary Notices

Beneficiary Notices

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

Beneficiary Notices

Enrollment Packet

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

 

Other
English Español
Medicaid Recertification Reminder Medicaid Recertification Reminder

 

This page was last modified on 06/29/2022

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Contact Information

NC Medicaid
Division of Health Benefits

2501 Mail Service Center
Raleigh, NC 27699-2501
 
NC Medicaid Contact Center
Phone: 888-245-0179
Monday-Friday 8 a.m. to 5 p.m.
Closed on State holidays. 
 
Visit RelayNC for information about TTY services. 
 
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https://medicaid.ncdhhs.gov/counties/county-playbook-medicaid-managed-care/beneficiary-notices