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Medicaid - NC Health Choice

A new program that began October 1, 1998.
Low-income families may still be able to get health insurance for their children. North Carolina's children's health insurance plan ‘NC Health Choice’ will cover children from low-income families that still earn too much to qualify for Medicaid.

Who is eligible for NC Health Choice:
The child's income must exceed the income limit for Medicaid. Health Choice covers children from age 6 until their 19th birthday. The family's income must falls below the following guidelines in order to be eligible for NC Health Choice.

Family Size:

Annual Family Income

















Some allowances are made for child care costs and other work related expenses so those individuals who make slightly more than the limit should still consider coming to Social Services and discussing Medicaid and NC Health Choice.

What it costs:
For families who make less than 150% of the federal poverty level, there will be no additional cost. For those families with an income greater than the levels listed above, there will be an annual cost of $50 for one child and $100 for two or more children. There will also be a co-payment of $5 per visit to physician, dentist, optometrist, clinic, outpatient hospital visit, etc.; $6 per prescription for drugs; and $20 for non-emergency emergency room visits. There will be no charge for anyone for Well-Child or other preventive health visits.

What is covered?
NC Health Choice is a comprehensive health insurance plan which covers not only hospitalization but also outpatient care. Preventive dental, vision and hearing benefits are available. The following is a summary of benefits:

Hospital Care – Semi-private room, medications, laboratory tests, x-rays, surgeries and professional care.
Outpatient care - includes diagnostic services, therapies, laboratory services, X-rays, and outpatient services.
Physician and clinic services - office visits; preventive services such as one well visit per year between 6 and 7, and once every three years between 7 and 19. Immunizations are covered.
Surgical services - includes standard surgical procedures, related services, surgeon's fees, and anesthesia.
Prescription drugs
Laboratory and radiology services
Inpatient mental health services - requires pre-certification
Outpatient mental health services - requires pre-certification after 26 outpatient visits per year.
Durable medical equipment and supplies such as wheelchairs
Home health care - limited to patients who are homebound and need care that can only be provided by licensed health care professionals or in the case that a physician certifies that the patient would other wise be confined to a hospital or skilled nursing facility. Professional health care is covered; care provided by an unlicensed caregiver is not.
Nursing care
Dental care includes oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X-rays once every 60 months, bitewing X-rays of the back teeth once during a 12 month period and routine fillings.
Inpatient substance abuse treatment and outpatient substance abuse treatment -is covered. See the mental health inpatient and outpatient notes above.
Physical therapy, occupational therapy and therapy for individuals with speech, hearing and language disorders
Hospice care
Special needs children with chronic mental or physical conditions or illness may receive services beyond those listed above if services are medically necessary and receive pre-certification.

Once a child has been covered under this plan, should family economic conditions change so that the child is no longer eligible, but the family wants the child to continue in the program, the family will be allowed to purchase the plan at full premium for one year.

How to apply.
A two page application form, income verification and enrollment fee (if required) are needed to approve the application. This application form is available at Social Services and at the Health Department. The application can be mailed in or taken to your county social services department. To expedite the process, come to Department of Social Services for a face to face interview. Each application will first be looked at to see if the child is eligible for Medicaid and, if not, will be looked at to see if the child is eligible for the new program. If the child is found to be eligible, the application will be processed and the parents will receive a health card, a benefits booklet and instructions in the mail. Once parents are notified, the child is eligible to receive care.

Note: Unlike Medicaid, this program is limited by the amount of funds which are available. Therefore, it is open only to children on a first come, first served basis. Once the program is full, a waiting list will be taken, so it is in the best interest of the child to enroll as soon as it is possible.

The state discourages families from dropping current health coverage in order to enroll in the new child health insurance plan.