How To Apply For Pregnancy Medicaid Nc

Medicaid And Health Choice Programs

How to Apply for Medicaid in North Carolina and What is Covered

Medicaid is a federal program designed to assist families and children with the cost of health care. Health Choice is North Carolinas free or low-cost health insurance plan for children ages 6-18 whose families cannot pay for private insurance and who do not qualify for Medicaid.

Medicaid also offers assistance to the uninsured with breast and cervical cancer. Other programs offered are Medicaid for pregnant women, family planning Medicaid, and emergency Medicaid for undocumented aliens.

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Submitting Requests For Prior Approval

The preferred method to submit prior approval requests is online using the NCTracks Provider Portal. However, providers can also submit paper forms via mail or fax. PA forms are available on NCTracks.

All requests for PA must be submitted according to DMA clinical coverage policies and published procedures.

Providers must request reauthorization of a service before the end of the current authorization period for services to continue. The date that the request is submitted affects payment authorization for services that are denied, reduced or terminated.

Providers must request authorization of a continuing services 10 calendar days before the end of the current authorization period for authorization to continue without interruption for 10 calendar days after the date an adverse decision notice is mailed to the Medicaid beneficiary or to the beneficiaryâs legal guardian and copied to the provider.

Some requests are submitted for review to a specific utilization review contractor, as described on the Prior Approval Fact Sheet on NCTracks.

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Maternity Or Pregnancy Insurance Options In North Carolina

If you are currently pregnant, your options, in order of desirability, are Medicaid, group insurance, and prepayment plans. After you are pregnant, it is not possible to issue an individual policy. Application will automatically be declined. If you are in the process of planning your pregnancy, the best options for minimizing your maternity costs are Medicaid, group insurance, individual insurance with Blue Cross Blue Shield, prepayment plans, in order of descending desirability.

The average total maternity charges submitted to Blue Cross Blue Shield of North Carolina in 2007 was $20,015 per pregnancy 1. A patient may be required to pay this full amount, however many families negotiate with hospitals and providers to pay a discounted rate when the only option is to pay out of pocket.

When planning to cover the costs of maternity the four primary options in North Carolina are as follows:

1. Group maternity insurance coverage. This is often the most advantageous way to pay for maternity costs because many group policies cover maternity for all females on the policy without an additional rider. Also, if you are already pregnant, and dont meet the income requirements for Medicaid, this is your best shot at getting your pregnancy covered by an insurance company. Additionally, some group policies do not consider pregnancy a preexisting condition, so this is a good option to consider if you are already pregnant.

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Medicare Faqs And Information To Consider

Automatic Enrollment:

If you are already receiving Social Security benefits, Railroad Retirement benefits, or Federal Retiree benefits, your enrollment in Medicare is automatic. Your Medicare card should arrive in the mail shortly before your 65th birthday. Check the card when you receive it to verify that you are entitled to both Medicare Parts A and B.

Initial Enrollment Period:

If you are not eligible for Automatic Enrollment, contact the Social Security Administration at 800-772-1213 or enroll online at, or visit the nearest Social Security office to enroll in Medicare Part A and Medicare Part B. You have a seven month window in which to enroll in Medicare without incurring a penalty. If youre not automatically enrolled in premium-free Part A, you can sign up for it once your Initial Enrollment Period starts. Your Part A coverage will start six months back from the date you apply for Medicare, but no earlier than the first month you were eligible for Medicare. However, you can only sign up for Part B during the times listed below.

General Enrollment Period:

  • General Enrollment Period for Medicare Parts A & B

If you have coverage through a current employer, you are not required to enroll in Medicare Part A and B. Below are some things to keep in mind about each part of Medicare.

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Family Planning Medicaid Or Be Smart Medicaid

Toe River Health District

The NC Medicaid Family Planning Program or Be Smart program is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina. Family planning, reproductive health and contraceptive services are provided to eligible men and women, whose income is at or below 195% of the federal poverty level, with no age restrictions.

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Action Steps For States

  • States must add counseling and pharmacotherapy benefits for pregnant women, which under Section 4107 of the Affordable Care Act are now mandatory benefits under Medicaid. This coverage is defined as diagnostic, therapy, counseling services, and pharmacotherapy for cessation of tobacco use by pregnant women. For more information, please see State Medicaid Director Letter #11-007 and contact your regional CMS office.
  • Promote cessation benefits to pregnant women and all women of reproductive age.
  • Make use of the many resources available to the public and to health care providers to help women quit smoking. See this Resource Guide for a list of highlighted resources.

For technical assistance and additional resources, contact .

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Smart Start For Your Baby

We want to help you and your baby grow healthy and stay healthy. Start Smart for Your Baby® is our program for pregnant and new moms. It is designed to customize the support and care you need for a healthy pregnancy.

Carolina Complete Health members get up to $100 value for an infant car seat, diaper bag, or a breast pump. To receive one of these items, please complete the form below.

Eligibility Statement: Eligible members may choose only one of the below items. Do not fill out multiple forms as you will only receive one item. Eligibility will be confirmed by the Carolina Complete Care Management Team and include members who are expecting a new baby or have given birth to a new baby within the past 60 days. To qualify, you should have filled out a Notification of Pregnancy form. One request every 12 months.

Note: Please allow a minimum of 14 days for review and processing of your request. If you need one of these items faster, please call us at .

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What Is Nc Medicaid/health Choice Outreach

NC Medicaid and Health Choice are publicly funded childrenâs health insurance programs open to North Carolina residents who meet income, age, and immigration guidelines. Your child may qualify for healthcare coverage through Medicaid or Health Choice, NCâs CHIP program â both offer free or low-cost health insurance for children and teens. For more information on wellness visits, and treatment services, click here.

To meet outreach goals, our staff work with community and faith-based organizations across the State to:

  • Partner with local family-centered activities: health fairs, school sports/events, community-ethnic festivals.
  • Distribute materials to families by ordering available materials at no cost or downloading copies of PDFs provided.
  • Partner with local minority media outlets to extend the reach of critical enrollment and reenrollment messages as needed.

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Food And Nutrition Services

Medicaid and NC Health Choice 101

The Food and Nutrition Program is a federal food assistance program that provides low-income families a monthly supplemental allotment of benefits issues via Electronic Benefit Transfer cards . The Food stamp program is an entitlement program, so all eligible individual and households can receive assistance.

You may be eligible for Food and Nutrition Services if your total income falls below the appropriate gross income limits for your household size. Eligibility workers determine which income limit applies to your household.

Eligible individuals will receive Food and Nutrition benefits no later than thirty days from the date of application. Individuals with special circumstances will be given an opportunity to receive Food and Nutrition benefits within seven days of the application. View more information apply through the North Carolina Health and Human Servicess online program.

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North Carolina Medicaid Expansion Update

North Carolina is one of 12 states that has not yet expanded Medicaid under the Affordable Care Act .

If Medicaid is expanded in North Carolina, it is estimated that 624,000 residents would become newly eligible for coverage.

Governor Cooper has long pushed for Medicaid expansion, but GOP lawmakers oppose expansion.

North Carolinas Medicaid program is transitioning to a managed care model in 2021 after several delays.

Medicaid Coverage And State

Private health insurance covers the cost of substance-use disorder treatment and services to varying degrees. Each insurer has its own policy, and insured individuals will need to refer to the policy of their respective insurance companies to determine the extent of services that are covered. Many women needing treatment, including pregnant women, may have once had private insurance but have lost that insurance. This section presents information for women who are uninsured, women who may qualify for Medicaid insurance, and women who are currently insured with Medicaid.

Medicaid Services for Women and Children

  • Medicaid for Infants and Children

Medicaid for Infants and Children provides medical coverage for children younger than 19 years old. The income limits are determined by the family size and the age of the child or children applying for benefits. There is no limit on resources.

  • Medicaid for Families with Dependent Children

Medicaid for Families with Dependent Children provides medical coverage for parent or other caretaker/relative with a child 18 years or younger in the household and for children under age 21. A pregnant woman may also qualify.

The family cannot have more than $3,000 in assets such as savings in the bank.

If the family income is above the cut-off and the child and/or family has high medical bills, the family might still qualify for Medicaid .

  • Medicaid for Pregnant Women

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North Carolina Medicaid Covers Pregnant Women

Medicaid is a public form of health insurance that exists in every state. Part of the Medicaid program is designed to cover the health care needs of women. In North Carolina, there is a Medicaid for Pregnant Women program.

Medicaid is a public, or government run, form of health insurance. It is designed to provide health insurance coverage for individuals and families who are low-income and who cannot afford to purchase a health plan from a private insurance company. Medicaid is funded, in part, by the federal government. It is also funded by the government of an individual state.

North Carolina has two Medicaid programs that will cover the health care needs of women who are pregnant and who are low income. One of them is the Medicaid for Families with Dependent Children program.

To qualify for this program, a woman must be pregnant. She must also have a monthly countable income that is lower than the amounts listed in a chart of the Medicaid website. The woman also cannot be from a family that has more than $3,000 in assets, .

The other program that covers women who are pregnant is simply called Medicaid for Pregnant Women. It only covers services related to pregnancy. Those services include: prenatal care, delivery, and 60 days postpartum care. It also includes services to treat medical conditions which may complicate the pregnancy, childbirth classes, and family planning services.

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Learn About Requirements For Medicaid In North Carolina

Toe River Health District

What are the requirements for Medicaid in North Carolina? is a crucial question for applicants, because understanding how to qualify for Medicaid assistance is the first step toward receiving benefits. Whether or not an applicant meets Medicaid eligibility requirements in NC is determined by a local county Division of Social Services caseworker based on various established Medicaid benefits eligibility criteria involving age, health needs, income and resources. To find out who is eligible for Medicaid in North Carolina and to learn more about the states established qualifications, review the sections below.

What are the requirements for Medicaid in North Carolina?

North Carolina Medicaid eligibility is based on a number of factors. In order to meet the basic eligibility requirements for Medicaid assistance, you must satisfy one of the following criteria:

  • You require long-term care.
  • You are a low-income individual or family.
  • You are younger than 21 years of age.
  • You are blind or disabled .
  • You are 65 years of age or older.
  • You are/were recently pregnant

Medicaid benefits are available for pregnant women before or after the baby is delivered, and in cases where women experience pregnancy loss.

What are the income requirements for Medicaid in North Carolina?
  • Stocks and bonds.

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Information You May Need When Applying For Services

To assist you with the Medicaid and Food and Nutrition Services applications, listed below are verifications you may be asked to provide in order to determine your eligibility. If you do not have any of this information you may still complete an application and interview for services. Individuals can apply at or in person at the Social Service building, no appointment is necessary.

To submit required verification electronically, email them to:


  • Mail received at your address

Earned Income:

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What Benefits Does Pregnancy Medicaid Provide

Similar to other health care assistance programs, Medicaid does not pay monetary benefits directly to covered participants. Certain health care providers and health care facilities have a contract with Medicaid to treat those who are covered by Medicaid insurance.

When receiving Medicaid benefits, you should be given a list of medical providers who accept Medicaid or given a website to look for a provider in your area. As long as you receive care from a Medicaid provider, your health care costs will be submitted through Medicaid and will be covered. Pregnant women are covered for all care related to the pregnancy, delivery and any complications that may occur during pregnancy and up to 60 days postpartum.

Additionally, pregnant women also may qualify for care that was received for their pregnancy before they applied and received Medicaid. Some states call this Presumptive Eligibility and it was put in place so that all women would start necessary prenatal care as early in pregnancy as possible.

Talk with your local office to find out if you qualify for presumptive eligibility.

Pregnant women are usually given priority in determining Medicaid eligibility. Most offices try to qualify a pregnant woman within about 2-4 weeks. If you need medical treatment before then, talk with your local office about a temporary card.

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North Carolina Medicaid Income Limits Summary

We hope this post on North Carolina Medicaid Income Limits was helpful to you.

If you have any questions about Medicaid in the state of North Carolina, you can ask us in the comments section below.

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Be sure to check out our other articles about Medicaid.

Can A Pregnant Woman Be Denied Medicaid

What is Medicaid & How Do I Apply?

Medicaid eligibility can also be denied to pregnant women if their household income is too low in comparison to the size of their household. Since a result, you do not want to forget to count a dependant or include an additional income earner, as this might reduce the benefits to which you are entitled.

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Medicaid Or Medicare Savings Programs

Medicare beneficiaries with limited income or very high medical costs may be eligible to receive assistance from the Medicaid program. There are also Medicare Savings Programs for other limited-income beneficiaries that may help pay for Medicare premiums, deductibles, and coinsurance. There are specified income and resources limits for both programs. Contact your local county Department of Social Services or SHIIP to apply for one of these programs.

Which Plans Are Good In North Carolina

CHIP or Childrens Health Insurance Program is a program designed for families with children that are not eligible to receive Medicaid but still need medical insurance for their children. While they may seem as if they are part of the same program, the rules and regulations that govern them are different.

The eligibility requirements for CHIP are:

  • Applicant must be 19 or younger
  • Must be a citizen of the U.S or legal resident
  • Applicant must meet the income guidelines set for the program
  • Applicant must not be on any type of private health insurance or Medicaid

The services offered to those on CHIP are pretty much the same as those with Medicaid. From Doctors visits to prescription drugs and emergency services and transportation. CHIP may also cover some expenses that Medicaid does not cover. Applying for CHIP can be done in the same way as Medicaid, by phone, mail or in person at your local social services department. Be sure that when applying that you give all information that is required, as giving any false information can result in criminal charges being brought against you. For more info on the CHIP benefits, you can download the guide.

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North Carolina Medicaid Income Limit

The North Carolina Medicaid Income Limit is calculated as a percentage of the Federal Poverty Line.

To qualify, you must meet the North Carolina Medicaid Income limits listed below.

Here is the Federal Poverty Level for 2021.

2021 Federal Poverty Levels for the 48 Contiguous States & D.C.
Household Size

Additionally, to be eligible for Medicaid, you cannot make more than the income guidelines outlined below:

  • Children up to age 1 with family income up to 210 percent of FPL
  • Any child age 1-5 with a family income up to 210 percent of FPL
  • Children ages 6- 18 with family income up to 133 percent of FPL
  • CHIP for children with family income up to 211 percent of FPL
  • Pregnant women with family income up to 196 percent of FPL
  • Parents of minor children with family income up to 41 percent of FPL
  • Individuals who are elderly, blind, and disabled with family income up to 100% of the FPL

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