Medicaid Managed Care: How Can You Assist Your Beneficiaries After The Transition

HOW CAN I SEE WHICH BENEFICIARIES ARE ASSIGNED TO ME?

Once the beneficiary has been assigned to the PCP/AMH, a provider can see these assignments by:

Working with your contracted health plan
Accessing information through the NCTracks Provider Portal
Using the Recipient Eligibility function in NCTracks to verify this information for a single beneficiary.
Using the NCTracks batch eligibility verification function.
If you are an AMH, you can review the beneficiary assignment file you will receive from the health plan.

Providers cannot currently view their assigned beneficiaries as a list in NCTracks. DHHS will announce new functionality prior to the launch of NC Medicaid Managed Care, where providers will receive a monthly report to view the beneficiaries assigned to them.

HOW WILL BENEFICIARIES BE INFORMED OF THEIR ASSIGNMENTS?

Medicaid Once the beneficiary has been assigned a health plan and/or PCP/AMH, the beneficiary will be notified by mail as follows:

The Enrollment Broker will send each head of household a notice listing the health plan and PCP/AMH assignments for all members of the household.
The health plan will send each member a welcome letter, a member handbook, Medicaid ID card, and information about their PCP/AMH.

Note: Beneficiaries will also be able to view their health plan and PCP/AMH assignments on the enrollment website (ncmedicaidplans.gov) and mobile app. Within eight days of being enrolled with a health plan, beneficiaries should receive their Member Welcome Packet, Member Handbook, and Medicaid Card from their health plan.

HOW CAN BENEFICIARIES CHANGE THEIR HEALTH PLAN?

Beneficiaries can contact the Enrollment Broker to change health plans for the first 90 days after their coverage effective date. If a beneficiary wants to change their health plan outside of the 90-day choice period “with cause”, they will have to contact the Enrollment Broker and submit the Health Plan Change Request form. With cause reasons are detailed in the PHP Contract Section VII. Attachment M.1. page 84 of 110. In addition, during their yearly eligibility recertification process, beneficiaries have the option to choose a new health plan.

Note: Beneficiaries who are exempt can change their health plan at any time.

HOW CAN BENEFICIARIES CHANGE THEIR PCP/AMH?

Beneficiaries can change their PCP/AMH without cause twice each year. Beneficiaries have thirty (30) days from receipt of notification of their PCP/AMH assignment to change their PCP/AMH without cause (1st instance) and can change their PCP/AMH without cause up to one time per year thereafter (2nd instance).

Below are the different ways beneficiaries can change their PCP/AMH:

Beneficiaries can select a PCP/AMH at application, recertification, or through choice counseling with the Enrollment Broker when they select a health plan.
Beneficiaries can contact their health plan to change their PCP/AMH. Contact information can be found in the Member Handbook on the Health Plan Contacts and Resources Page.
Beneficiaries can change their PCP/AMH through the Enrollment Broker if they are also changing or selecting a health plan.

Beneficiaries can change their PCP or health plan at any time over the course of the year if they have care or quality concerns.

WHAT IF BENEFICIARIES HAVE QUESTIONS?

Most questions beneficiaries have about choosing a health plan or PCP can be answered by the Enrollment Broker. The Enrollment Broker Call Center will open beginning March 1, 2021 from 7 a.m. to 8 p.m., Monday through Sunday.

To select a Primary Care Provider (PCP) and health plan through the Enrollment Broker, beneficiaries can:

Call 833-870-5500 (toll free), (TTY: 1-833-870-5588)
Go online at ncmedicaidplans.gov
Complete and return a paper enrollment form by fax or mail
Use the NC Medicaid Managed Care mobile app

DHHS will be posting a Question and Answer document to the NC Medicaid Managed Care website to address common beneficiary questions about the transition to Managed Care.

Once a beneficiary is enrolled with a health plan, information and a new Medicaid card will be mailed within five days. At that point, if beneficiaries have questions about their health plan or services covered, they should contact their health plan. Contact information for health plans can be found at the number on their new Medicaid card or on the NC Medicaid website here.

NC Medicaid Ombudsman

In addition, DHHS will partner with the NC Medicaid Ombudsman, who is appointed to help resolve beneficiary concerns. Learn more in the NC Medicaid Ombudsman Overview Fact Sheet.

WHEN SHOULD BENEFICIARIES CALL THE OMBUDSMAN?

Beneficiaries should call the NC Medicaid Ombudsman when:

They are not getting the care they need.
They have questions about a notice or bill they have received.
They have already talked with their health care provider or health plan and have not been able to solve the problem.
They have questions about the complaint or appeal process.

You can contact the NC Medicaid Ombudsman at 1-877-201-3750 or visit their website for more information at www.ncmedicaidombudsman.org.

The Ombudsman CALL CENTER will be open at least five days a week from 8 a.m. to 5 p.m., Monday through Friday (except for state holidays) and can accommodate after-hour calls