Learn about NC Medicaid Managed Care
Most people are getting the same Medicaid services in a new way – through health plans. A health plan is a group of doctors, hospitals and other health care providers. They work together to give you the health care you need. This includes physical health, behavioral health and medicine. Some health plans provide added services like programs to help you quit smoking.
Health plans have a provider network. In most cases, you must get care from a provider in your health plan’s provider network, such as primary care provider (PCP). A PCP is doctor, nurse practitioner or physician assistant. They care for your health, coordinate your needs,and refer you to specialists when you need them.
Most people receiving NC Medicaid must get health care services from a Standard Plan. Standard Plans offer physical health, pharmacy, care management and basic behavioral health services for members. To learn more, go to NC Medicaid Managed Care health plans
If you are a federally recognized tribal member or qualify for services through Indian Health Service (IHS) and live in Buncombe, Clay, Cherokee, Graham, Haywood, Henderson, Jackson, Macon, Madison, Swain or Transylvania counties, you may qualify for the Eastern Band of Cherokee Indians (EBCI) Tribal Option. As a member of the EBCI Tribal Option, you can get services from any NC Medicaid provider. To learn more, go to Get answers.
If you need services related to a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI), you may qualify for the Tailored Plan that serves your county. Tailored Plans offer physical health, pharmacy, care management and behavioral health services. Tailored Plans offer added services for members who qualify.
Tailored Plans will start October 1, 2023. Some people will be automatically enrolled in a Tailored Plan based on their needs. For example, individuals receiving Innovations or TBI waiver services will be enrolled in the Tailored Plan. Others may have the option to choose a Tailored Plan. If you are enrolled in the Tailored Plan or have the option to choose the Tailored Plan, you will get a notice in the mail to tell you. To learn more, go to Tailored Plan services.
Some people do not qualify for a health plan because of the type of health care services they need. They are enrolled in NC Medicaid Direct. To learn more, go to NC Medicaid Direct services.
To learn about the basic benefits and services that all health plans offer and services that are not covered, go to Benefits and services.