Medicaid Coverage and State-Funded Services


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

iStock_000005422322LargeMedicaid for Infants and Children (MIC) 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(s) 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 (with a Medicaid deductible).

 

  • Medicaid for Pregnant Women

Medicaid for Pregnant Women covers only services related to pregnancy:

  • Prenatal care, delivery, and 60 days postpartum care (after the 60-day postpartum period, the woman can apply for Medicaid for Families with Dependent Children, if applicable)
  • Services to treat medical conditions that might complicate the pregnancy (some services require prior approval)
  • Behavioral health services including mental health and substance-use disorder services
  • Childbirth classes
  • Family planning services

 

A pregnant woman may apply for this program before or after she delivers. A woman who has experienced a recent pregnancy loss might also be eligible for this program.

 

To be eligible for this Medicaid coverage, the pregnant woman’s monthly family income cannot exceed 196% of the federal poverty level, but the program does not put a limit on resources held by the family. If a pregnant woman is covered by Medicaid on the date she delivers, her newborn child may be eligible for Medicaid up to age 1 without a separate application.

 

[For more information regarding any of the Medicaid benefits listed above, visit: http://www.ncdhhs.gov/dma/medicaid/families.htm]

 

NC Health Choice for Children

The North Carolina Health Choice (NCHC) Health Insurance Program for Children is a comprehensive health coverage program for low-income children. The goal of the NCHC Program is to reduce the number of uninsured children in the State. If the family makes too much money to qualify for Medicaid, but too little to afford private or employer-sponsored health insurance, the child or children may qualify for NCHC.

 

[For more information about NC Health Choice, visit: http://www.ncdhhs.gov/dma/healthchoice/who.htm]

 

State-Funded Substance Abuse and Mental Health Services

Each Local Management Entity-Managed Care Organization (LME-MCO) in NC receives state and federal funds to provide mental health, developmental disabilities, and substance-use disorder services to individuals who are not Medicaid eligible or do not have a third-party payer (e.g. private insurance, Tricare). To be eligible for state-funded services, individuals must meet the eligibility requirements for one or more of the State Benefit Plans.

 

One of the State Benefit Plans for substance abuse treatment specifically includes pregnant women, and considers pregnant women a priority population.

 

Benefit Plan for Adult Substance Abuse Services – Women (ASWOM):

Persons eligible for this program will meet the following criteria: Adult women 18 years and older with a primary substance-use disorder covered in the Benefit Plan Diagnosis Array* AND who would benefit from assessment, initiation, engagement, treatment, continuity of treatment services, and/or supports for relapse prevention and recovery stability, AND who are:

 

  • Currently pregnant,

 

OR

 

  • Has one or more dependent child younger than 18 years old,

 

OR

 

  • Is seeking custody of a child younger than 18 years old.

 

For more information about state-funded benefit plans and services, please contact the Local Management Entity-Managed Care Organization based on the individual’s county of residence who is in need of services. Please go to http://www.ncdhhs.gov/mhddsas/lmeonblue.htm for a list of LME-MCOs by county.

 

*The Benefit Plan Diagnosis Array may be found at: http://www.ncdhhs.gov/mhddsas/providers/nctracks/index.htm.