Cost and Coverage of Medicaid in North Carolina

Medicaid services in North Carolina enable eligible residents to obtain essential health care by paying for some or all of the medical costs through various government-sponsored programs. Through North Carolina Medicaid coverage, individual patients and households with certain resources and income limits receive affordable health care.How much is Medicaid, and what services are covered by Medicaid?

Learn the answers and more about Medicaid coverage by reviewing the following topics:

  • What services are covered by Medicaid in North Carolina?

  • How much does Medicaid cost in North Carolina?

  • What does Medicaid not cover in North Carolina?

What services are covered by Medicaid in North Carolina?

North Carolina Medicaid coverage has some limits depending on the services sought. Some health services require prior approval. NC Medicaid coverage includes the following:

  • Family planning services (contraceptives only for NC Health Choice for Children)

  • Hospice care

  • Most essential medical services for children under 21 years

  • Medical equipment and various home health services

  • Dental care

  • Vision care

  • Prescription drugs, excluding those covered under Medicare

  • Hospital visits

  • Doctor bills

Ask your doctor about Medicaid cost estimates if the medical assistance you need is not listed above. Before looking at what is not covered by Medicaid in North Carolina, you should also know the limits imposed on some medical services covered.

North Carolina Medicaid coverage allows members a total of 22 professional service visits in a year. The visits are recorded from July 1 through June 30. If you have a medical condition that your provider anticipates will require additional visits, a request for exception to the annual visitation limit can be made. The request must be filed before the medical service is provided or administered.

Some NC Medicaid services have no limitations. These include patients receiving nursing facility care or an ICF-MR, pregnant members receiving pre-natal and other pregnancy-related services, members enrolled in a Community Alternatives Program (CAP), and members that are below 21 years of age.

In addition, members of NC Medicaid who have terminal or life-threatening illnesses that have been determined by a doctor, blood clotting disorders (for example, hemophilia), unstable diabetes (does not apply to diabetic patients taking insulin, diet or medication to control the condition), acute sickle cell diseases, radiation therapy and chemotherapy for cancer, end stage renal disease or end stage lung disease are not subjected to the service limit requirements.

Medicaid services also cover professional visits by federally-qualified health workers, rural health clinics, health departments, nurse midwives, nurse practitioners and physicians (except those with specialties in nuclear medicine, radiology or oncology). North Carolina Medicaid coverage also caters to up to eight visits to a podiatrist, an optometrist or a chiropractor, combined.

But, what does Medicaid not cover under the professional service limits? Some of the services not covered include: health check examinations, dental services, inpatient hospital services and in-home care services. Review further information below.

How much does Medicaid cost in North Carolina?

Exactly how much is Medicaid in North Carolina? This question is very common among people looking to apply for NC Medicaid. The estimate Medicaid costs vary from member to member. The cost of monthly premiums will depend on different factors, including the types of Medicaid insurance different patients elect. You can apply for NC Medicaid coverage online to find out the average cost you will pay.

Keep in mind, members may have to pay a co-payment for certain Medicaid services. This means that when you go to the doctor’s office, a pharmacy, or an emergency room, you may have to pay a pre-determined amount of money to the facility prior to receiving coverage.

If a member eligible for Medicaid coverage cannot handle the co-payment, a medical professional cannot refuse to provide treatment. If a patient covered under NC Health Choice for Children cannot submit the co-payment, a provider can offer the service and later bill the patient for the co-payment. Alternatively, the provider can refuse to treat the patient. Inquire about working out a payment plan with your provider if need be.

So, how much does North Carolina Medicaid cost? The amount of co-payment you are responsible for varies on the type of medical service or item you require. The payments start at $1 and can go up to $100. The majority of the payments are under $30.

Some North Carolina Medicaid services require a co-payment. These services include:

  • Brand name and generic prescriptions

  • Chiropractic care

  • Visits to ophthalmologists, podiatrists, dentist and doctors

  • In-home care are for adults and children

  • Non-emergency visits to a hospital emergency room

  • Non-hospital dialysis facility services

  • Services covered by both NC Medicaid and Medicare

  • Services in psychiatric hospitals run by the state

  • Services provided to CAP participants

If your provider pays you a visit while you are hospitalized, you may have to a submit co-payment. However, North Carolina Medicaid services providers are not always allowed to charge co-payments. Some of the services that do not attract co-pays include ambulance services, auditory implant external parts and accessories, diagnostic X-rays,Durable Medical Equipment (DME) and family planning services.

Other Medicaid services that don’t require co-pays include health check-related services, hearing aid services, HIV case management, home health services, home infusion therapy, hospice services, hospital emergency department services, hospital inpatient services, laboratory services performed in the hospital and optical supplies and services.

Remember, types of Medicaid insurance plans also impact your co-pays, especially if you only qualify to receive partial medical coverage or tax credits from Medicaid applied to your monthly healthcare premium.

What does Medicaid not cover in North Carolina?

North Carolina Medicaid coverage excludes some items and services, including investigational or experimental drugs, prescription drugs for people covered with Medicare, EPSDT services, prenatal care and childbirth.

When it comes to what is not covered by Medicaid, typically, medical services deemed unnecessary or elective come into play. For instance, various dental services, including cosmetic procedures (bleaching, whitening, bonding, veneers), experimental procedures, TMJ splints, night guards and mouthpieces, upper and lower cast metal partial dentures and fixed bridgework, are not covered by Medicaid.

Finally, NC Medicaid coverage excludes various chiropractic services, physical therapy and therapeutic and diagnostic services, along with nutritional supplements.

Regarding Medicaid cost estimates and Medicaid types of insurance, it is most important to review coverage, and discuss any concerns regarding conditions with both your healthcare provider and your physician. Do not consent for a medical service that is not covered without speaking to a healthcare professional first, or you may be faced with a dispute thereafter.



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