Family and Children's Medicaid MA-3255 NC HEALTH CHOICE

REVISED 04/01/11 – CHANGE NO. 01-11

I. INTRODUCTION AND OVERVIEW

Title XXI of the Social Security Act created a program to provide health coverage for uninsured low-income children from birth through age 18. In North Carolina this program is known as NC Health Choice for Children (NCHC), and is only for children ages 6 through 18. Although administered by the Division of Medical Assistance, NCHC is not a Medicaid entitlement program.

In 1996, Medicaid began to use the existing Carolina Access (CA) infrastructure to build an enhanced managed care plan, Community Care of North Carolina (CCNC) formerly known as Access II & III. CCNC developed networks of CA providers in order to deliver community directed care. Each network developed an administrative entity to plan and administer disease targeted case management services. Each network brings together key participants in the community who provide services to Medicaid and North Carolina Health Choice (NCHC) recipients. These participants include primary care providers, social service agencies, health departments, and others, depending on community resources. CCNC and CA are now combined into one program, Community Care of North Carolina, CCNC/CA.

In 2005, the General Assembly passed legislation requiring NCHC children to be linked to a CCNC/CA provider. It is preferred that each child be linked to a provider participating in CCNC.

The maximum income limit to receive NC Health Choice coverage is 200% of the federal poverty level. Countable income must be greater than the maximum MIC income level but not greater than 200% of the federal poverty level. Refer to II.A. 3, below.

To be eligible for NC Health Choice a child cannot be eligible for full Medicaid benefits or have comprehensive private health insurance. The IMC must always evaluate eligibility for full Medicaid coverage prior to exploring eligibility for NC Health Choice.

The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 requires that effective January 1, 2010, citizenship and identity be verified for each US citizen recipient of NCHC. See MA-3331, Citizenship/Identity Data Match for instructions for using the SSA Citizenship Match process to verify citizenship and identity.

With the exception of federally recognized Indian tribes and Alaskan natives, families with countable income greater than 150%, but less than 200% of the federal poverty level, must pay an annual enrollment fee of $50.00 per child, not to exceed $100 per family. The enrollment fee is retained by the county department of social services to offset administrative expenses. In addition, these families must participate in cost-sharing (a copayment) for medical services received. The total annual cost-sharing, including enrollment fees (when applicable), cannot exceed 5% of the family's annual income. SEHP will determine the maximum amount of cost-sharing per family based upon the amount of countable income transmitted from EIS.

REVISED 04/01/11 – CHANGE NO. 01-11

(I.)

Families whose countable income is less than 150% of the federal poverty level do not pay an enrollment fee. With the exception of federally recognized Indian tribes and Alaskan natives, these families must participate in cost-sharing (a copayment) for prescription drugs and non-emergency visits to hospital Emergency Rooms.