Medicaid Costs and Coverage in North Carolina

“How much is Medicaid in North Carolina?” is a question that may be troublesome for many residents worried about Medicaid costs and coverage. Medicaid cost estimates can vary widely depending on the type of health service you are seeking and if you meet eligibility requirements for the program. Medicaid and its affiliate child-centric program in North Carolina, Health Choice,are designed to bring maximum health insurance coverage to low income or medically needy residents who might not otherwise be able to gain access to adequate medical care. Medicaid coverage in North Carolina sometimes includes copayments and deductibles for certain types of beneficiaries. Some medical procedures are not applicable to Medicaid cost estimates and still others require prior approval through a Primary Care Provider (PCP) in order to be covered by North Carolina Medicaid. To get information to help answer questions like, “How much does Medicaid cost in NC?” applicants can review the sections below to help decide if the Medicaid program is right for their household.

What services are covered by Medicaid in North Carolina?

Included in Medicaid cost estimates for North Carolina are any medicines that require a doctor’s prescription. Medicare beneficiaries with North Carolina Medicaid coverage cannot use the prescription drug benefit. Standard health services such as family planning, basic dental care for children, hospice care, most types of vision care, hospital visits, essential medical equipment, home health visits and nearly any medical procedures needed by children younger than 21 years of age. North Carolina specifies as part of its services covered by Medicaid that you can have up to 22 professional medical service visits in a year’s time for mandatory services, and these visits are recorded in the calendar year beginning from July 1 through June 30. Medicaid coverage can extend to further visits if needed, but medical need must be established directly by the PCP prior to any administered services in order for the services to be covered. When completing the application process for the program, consider the Medicaid costs of each plan before making a decision.

In evaluating what services are covered by Medicaid in North Carolina, pay special attention to the categories for which there are no limitations imposed. Medicaid cost estimates place no medical visit limitations of any sort on women receiving prenatal or other pregnancy care, services associated with a member younger than 21 years of age, services related to a participant in a Community Alternatives Program (CAP) or any patient receiving nursing home care. Further services covered by Medicaid in North Carolina for which there are no medical service visit limitations are services associated with acute sickle cell diseases, blood clotting disorders, end stage renal or lung disease, radiation or chemotherapy for cancer treatment, unstable diabetics or anyone who has been determined by a doctor to be afflicted with a life-threatening or terminal illness. Medicaid coverage in North Carolina also extends to up to eight total combined visits per year to optional service providers such as chiropractors, optometrists or podiatrists. To learn more about basic Medicaid coverage, download our free guide to the national Medicaid program today.

North Carolina Medicaid Coverage Copayments

Remember that the question, “How much does Medicaid cost in North Carolina?” has to accurately factor in applicable copayments where necessary. Not all North Carolina Medicaid cost estimates include co-payments for all eligible services. Some Medicaid beneficiaries will have to pay copayments and others will not, depending on the type of coverage that has been elected. However, if a Medicaid recipient is in imminent need of health services and cannot immediately afford the copayment, under the rules of Medicaid coverage in North Carolina, the practitioner cannot refuse medical services. Most Medicaid costs for copayments in North Carolina cost less than thirty dollars per visit. When completing the application process, you must make sure to provide accurate household information and income data, as this can affect your eligibility for a plan and potential costs.

A few examples of services covered by Medicaid in North Carolina that do require a co-payment are non-emergency visits to a hospital emergency room, services in state-run psychiatric hospitals, chiropractic care, both brand-name and generic prescription drugs, visits to ophthalmologists and non-hospital dialysis facility services. By contrast, most forms of Medicaid coverage in North Carolina do not impose co-payments for health services such as hearing aid parts and accessories, diagnostic X-rays, ambulance services, family planning services and Durable Medical Equipment (DME). Other factors that can influence whether or not co-payments are part of how much Medicaid costs are items such as whether you are eligible only for partial benefits or tax credits that will be applied to your monthly premiums.

What does Medicaid not cover in North Carolina?

The answer to the question, “How much does Medicaid cost in North Carolina?” can change when you begin to consider certain unsupported services. Medicaid cost estimates in North Carolina very rarely cover any form of cosmetic or elective surgeries. Procedures deemed medically unnecessary, experimental, will be excluded from Medicaid benefits in North Carolina. Additionally, other services Medicaid does not cover include many forms of cosmetic dentistry such as bonding, veneers, fixed bridgework and partial dentures.

What types of Medicaid insurance are available to me in North Carolina?

Medicaid coverage in North Carolina is broken into several subsets for applicants with different medical needs. The question of how much does Medicaid cost often relies on which of the categories of coverage your particular Medicaid eligibility falls into. Among the most common of the Medicaid programs available to residents of North Carolina are Medicaid for Older Citizens (MAA), Medicaid for the Blind or Visually Impaired (MAB) and Medicaid for Disabled Citizens (MAD).

Carolina ACCESS is a Managed Care Plan wherein Medicaid coverage for all types of medical care are provided by contracted doctors or health care facilities. Unless you are receiving North Carolina Medicaid coverage as a pregnant woman, are a recipient of Medicare or are receiving coverage as a child in foster care, you will most likely be enrolled in a Carolina ACCESS program. Another type of Medicaid insurance common in North Carolina is Health Maintenance Organization (HMO) care. Under an HMO program of care, all Medicaid services are covered though some may not be provided directly through the HMO. In many cases, the HMO will provide additional coverage beyond the minimum required by Medicaid. Always consult your PCP for prior approval if you have questions about out-of-network care, or if you need your physician to validate a health procedure’s recognition under Medicaid to avoid paying costly medical bills out-of-pocket. For more about potential Medicaid costs in the national program, download our comprehensive and free Medicaid guide.