North Carolina Medicaid and CHIP Programs

Source: Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015.

Note: Tables below present rules in effect as of January 1, 2015.

 

Adult Income Eligibility Limits[1]^,[2]

Parents (in a family of three)		Other Adults
Section 1931 Limit	Upper Limit	0%
45%	45%

 

Income Eligibility Limits for Children’s Health Coverage as a Percent of the Federal Poverty Level (FPL)[3]^, [4],[5],[6]

Upper Income Limit	Medicaid for Infants Ages 0-1		Medicaid for Infants Ages 1-5		Medicaid for Infants Ages 6-18		Separate CHIP Ages 0-18
	Medicaid (Title XIX) Funding	CHIP (Title XXI) Funding	Medicaid (Title XIX) Funding	CHIP (Title XXI) Funding	Medicaid (Title XIX) Funding	CHIP (Title XXI) Funding
216%	199%	215%	146%	215%	112%	1385	216%

 

Waiting Period for CHIP Enrollment

Waiting Period[7]	Income-Related Groups Exempt from Waiting Period (Percent of the FPL)
None

 

Optional Medicaid and CHIP Coverage for Children[8]

Income Eligibility for Buy-In Program (Percent of the FPL)[9]	Coverage for Dependents of State Employees in CHIP[10]	Lawfully-Residing Immigrants Covered without 5-Year Wait (ICHIA Option)[11]	Medicaid Coverage of Former Foster Youth up to Age 26 Extends to Youth from Other States[12]
211%-225% FPL	Yes	Yes

 

Medicaid and CHIP Coverage for Pregnant Women

Income Eligibility Limits (Percent of the FPL)[13]			Lawfully-Residing Immigrants Covered without 5-Year Wait (ICHIA Option)[14]	Full Medicaid/CHIP Benefit Package Offered to All Pregnant Beneficiaries[15]
Medicaid (Title XIX)	CHIP (Title XXI)	Unborn Child Option (Title XXI)[16]		Medicaid	CHIP
201%			Yes	Yes	N/A

 

Online and Telephone Medicaid Applications

Medicaid Applications Can be Submitted Online at the State Level[17]	Online Application for Medicaid Allows Individuals to:		Combined Online Multi-Benefit Application for Medicaid and Non-Health Programs[18]	Medicaid Applications Can be Submitted by Telephone at the State Level[19]
	Start, Stop, and Return to an Application	Upload Documentation
Yes	Yes		Yes	Yes

 

Income Verification Procedures Used by Medicaid Agencies at Application[20]

Pre- Enrollment Verification

Yes

Reasonable Compatibility Approach[21]
If attestation is below and data are above the income standard			If attestation is above and data are below the income standard
Reasonable Compatibility Standard	If not reasonably compatible:		Reasonable Compatibility Standard	If not reasonably compatible:
	Ask for a Reasonable Explanation	Paper Documentation Required		Ask for a Reasonable Explanation	Paper Documentation Required	Transfer to Marketplace
None	Yes		None	Yes

 

Adoption of Targeted Strategies to Streamline Enrollment of Eligible Individuals

Presumptive Eligibility[22]					Express Lane Eligibility for Children at Enrollment[23]
Children’s Medicaid	Children’s CHIP	Pregnant Women	Parents	Childless Adults	Medicaid	CHIP
		Yes		N/A

 

Targeted Strategies to Streamline Renewal

12-Month Continuous Eligibility for Children		Express Lane Eligibility for Children at Renewal[24]
Medicaid	CHIP	Medicaid	CHIP
Yes	Yes

 

 

Integration between Eligibility Systems for Medicaid and Other Programs

Marketplace Type[25]	FFM Makes Assessment or Final Determination for Medicaid Eligibility[26]	MAGI-Based Medicaid Eligibility System Integrated with SBM[27]	CHIP Integrated into MAGI-Based Medicaid Eligibility System	MAGI-Based Medicaid System Integrated with Other Non-Health Programs[28]
FFM	Assessment	N/A (FFM)	Yes	Yes

 

Premium, Enrollment Fee, and Cost-Sharing Requirements for Children[29]^,[30],[31]

Premiums/Enrollment Fees			Cost-Sharing Requirements
Required in Medicaid	Required in CHIP	Income at Which Premiums Begin (% FPL)	Required in Medicaid	Required in CHIP	Income at Which Premiums Begin (% FPL)
	Yes	>159%		Yes	>138%

 

Premiums and Enrollment Fees for Children at Selected Income Levels[32]^,[33],[34]

Premiums/Enrollment Fees (annual payments) at:
151% FPL	201% FPL	251% FPL	301% FPL	351% FPL
$0	$50|$100	N/A	N/A	N/A

 

Cost-Sharing Amounts for Selected Services for Children at Selected Income Levels[35]^,[36]

Family Income at 151% FPL				Family Income at 201% FPL
Non-Preventive Physician Visit	ER Visit	Non-Emergency Use of ER[37]	Inpatient Hospital Visit	Non-Preventive Physician Visit	ER Visit	Non-Emergency Use of ER[38]	Inpatient Hospital Visit
$5	$0	$10	$0	$5	$0	$25	$0

 

Cost-Sharing Amounts for Prescription Drugs for Children at Selected Income Levels[39]^,[40],[41]

Family Income at 151% FPL			Family Income at 201% FPL
Generic	Preferred Brand Name	Non-Preferred Brand Name	Generic	Preferred Brand Name	Non-Preferred Brand Name
$1	$1	$3	$1	$1	$10

 

Premium and Cost-Sharing Requirements for Selected Services for Section 1931 Parents[42]^,[43]

Monthly Contributions/ Premiums Required?	Cost-Sharing Required?	Income at Which Cost-Sharing Begins (%FPL)
	Yes	0%

Cost-Sharing Amounts for Selected Services
Non-Preventive Physician Visit	Non-Emergency Use of ER	Inpatient Hospital Visit	Generic Drug	Preferred Brand Name Drug	Non-Preferred Brand Name Drug
$3	$0	$3/day	$3	$3	$3

 

 

Cost-Sharing Requirements for Selected Services for Medicaid Expansion Adults[44]^{, [45]}

North Carolina has not adopted Medicaid expansion at this time.

 

Notes:

[1] Eligibility levels are based on 2014 federal poverty levels (FPLs). The FPL for a family of three in 2014 was $19,790. The FPL for an individual in 2014 was $11,670. January 2015 income limits reflect MAGI-converted income standards, and include a disregard equal to five percentage points of the FPL applied to the highest income limit for the group. In some states, eligibility limits for Section 1931 parents are based on a dollar threshold, and values listed represent the FPL equivalents calculated from these dollar limits.

[2] This table reflects state decisions on the Medicaid expansion under the ACA. As of January 1, 2015, 27 states (AZ, AR, CA, CO, CT, DE, HI, IL, IA, KY, MA, MD, MI, MN, ND, NH, NJ, NM, NV, NY, OH, OR, PA, RI, VT, WA, and WV) and DC had adopted the Medicaid expansion. For more information, see Kaiser Family Foundation, “Status of State Action on the Medicaid Expansion Decision” available at: http://kff.org/health-reform/state-indicator/state-activityaround-expanding-medicaid-under-the-affordable-care-act/. Arkansas, Iowa, Michigan, and Pennsylvania have approved Section 1115 waivers for their Medicaid expansions.

[3] Eligibility levels are based on 2014 federal poverty levels (FPLs).

[4] Income eligibility levels listed indicate thresholds for children covered under “regular” Medicaid (Title XIX) for whom the state receives Medicaid matching payments and any children covered by Medicaid for whom the state receives the enhanced CHIP matching payments, including those covered under a CHIP-funded (Title XXI) Medicaid expansion program and older children and teens with family incomes above 100% FPL who were moved from separate CHIP programs into Medicaid as a result of the new minimum Medicaid threshold for children of 138% FPL established by the ACA. To be eligible in the infant category, a child has not yet reached his or her first birthday; to be eligible in the 1-5 category, the child is age one or older, but has not yet reached his or her sixth birthday; and to be eligible in the 6-18 category, the child is age six or older, but has not yet reached his or her 19th birthday.

[5] The states noted operate a CHIP-funded Medicaid expansion program (Title XXI).

[6] Connecticut, Florida, Maine, New York, North Carolina, and Pennsylvania allow families with incomes above the levels shown to buy into Medicaid/CHIP.

[7] “Waiting period” refers to the length of time a child is required to be without group coverage prior to enrolling in CHIP coverage. Waiting periods generally apply to separate CHIP programs only, as they are not permitted in Medicaid without a waiver. The ACA limits waiting periods to no more than 90 days, and states must waive the waiting period for specific good cause waivers established in federal regulations. States may adopt additional exceptions to the waiting period, which vary by state. In addition to the income exemptions shown, specific categories of children such newborns may be exempt from the waiting periods.

[8] In North Carolina, eligibility for the buy-in program is limited to those who had been previously enrolled in CHIP. A child can participate for up to 12 months.

[9] States with a buy-in program allow families with incomes over the upper limit for children’s coverage to buy in to Medicaid or CHIP for their children. Income eligibility for the buy-in program is based on 2014 federal poverty levels (FPLs). January 2015 income limits reflect MAGI-converted income standards and include a disregard equal to five percentage points of the FPL.

[10] This column indicates whether the state has adopted the option to cover otherwise eligible children of state employees in a separate CHIP program. Under the option, states may receive federal funding to extend CHIP eligibility where the state has maintained its contribution levels for health coverage for employees with dependent coverage or where it can demonstrate that the state employees’ out-of-pocket health care costs pose a financial hardship for families. Arkansas covers these children under its ARKids B waiver. Mississippi and North Carolina cover dependents of state employees and are exempt from limitations on such coverage because there is no employer contribution for dependent coverage.

[11] This column indicates whether the state has received approval through a State Plan Amendment and implemented coverage for immigrant children who have been lawfully residing in the U.S. for less than five years, otherwise known as the Immigrant Children’s Health Improvement Act (ICHIA) option.

[12] Under the ACA, all states must provide Medicaid coverage to youth up to age 26 who were in foster care as of their 18th birthday and enrolled in Medicaid. This column indicates whether the state has elected the option to also provide Medicaid coverage to former foster youth up to age 26 who were enrolled in Medicaid in another state as of their 18^th birthday.

[13] Eligibility levels are based on 2014 federal poverty levels (FPLs).

[14] This column indicates whether the state received approval through a State Plan Amendment to adopt and implemented the option to cover immigrant pregnant women who have been lawfully residing in the U.S. for less than five years, otherwise known as the ICHIA option.

[15] These columns indicate whether all pregnant beneficiaries in the state receive the full Medicaid or CHIP benefit package. N/A responses indicate that the state does not provide CHIP coverage to pregnant women.

[16] The unborn child option permits states to consider the fetus a “targeted low-income child” for purposes of CHIP coverage.

[17] This column indicates whether individuals can complete and submit an online application for Medicaid through a state-level portal. For State-based Marketplace (SBM) states, such a portal may be either exclusive to Medicaid or integrated with the Marketplace. For Federally-facilitated Marketplace (FFM) and Partnership-Marketplace states, state Medicaid agency portals are indicated.

[18] In these states a combined online multi-benefit application is available that allows applicants to apply for multiple assistance programs, such as SNAP (food stamps) or cash assistance, along with health coverage, using a single application.

[19] This column indicates whether individuals can complete MAGI-based Medicaid applications over the telephone at the state level, either through the Medicaid agency or the State-based Marketplace.

[20] States are expected to verify income through an electronic source; they can verify information prior to enrollment or enroll based on an individual’s self-attestation and conduct a post-enrollment verification. Only in cases where there is no electronic data source for a type of income are states able to accept self-attestation of income without verification.

[21] If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at, or below the applicable income standard, the state must determine the applicant eligible or ineligible for Medicaid/CHIP. In these cases, any difference does not impact eligibility. If the data are not consistent, states have the option to apply a reasonable compatibility standard by establishing a threshold (e.g., a percentage or dollar figure) in which they will still consider the data to be reasonably compatible. States have the option to set different standards based on whether the applicant’s attestation is above or below the eligibility threshold. In both cases, if the difference between the attested income and the electronic data source are within the reasonably compatible standard, the state will process eligibility based on the individual’s attestation. If the applicant reports income below the standard and the electronic source indicates income above the standard, and the difference is not reasonably compatible, the state may accept a reasonable explanation and/or request paper documentation. If the applicant reports income above the Medicaid or CHIP limit but the electronic source reflects income below, and the data are not reasonably compatible, the state may accept a reasonable explanation, request paper documentation, or determine the individual ineligible and transfer the application to the Marketplace.

[22] Presumptive eligibility (PE) allows authorized qualified entities such as hospitals, community health centers, and schools to make presumptive eligibility determinations for Medicaid and/or CHIP and extend coverage to individuals temporarily until a full eligibility determination is made. This table does not reflect state implementation of ACA required hospital presumptive eligibility, which allows hospitals to conduct presumptive eligibility determinations to expedite access to Medicaid coverage, regardless of whether a state has otherwise adopted presumptive eligibility.

[23] The Express Lane Eligibility (ELE) option allows states to use data and eligibility findings from other public benefit programs to determine children eligible for Medicaid and CHIP at application or renewal. States are designated as having ELE if they have an approved and implemented State Plan Amendment from CMS.

[24] The Express Lane Eligibility (ELE) option allows states to use data and eligibility findings from other public benefit programs to determine children eligible for Medicaid and CHIP at enrollment or renewal. States are designated as having ELE at renewal if they have an approved and implemented State Plan Amendment from CMS.

[25] This column indicates whether a state has elected to establish and operate its own State-based Marketplace (SBM), establish a State-based Marketplace with federal support, use the Federally-facilitated Marketplace (FFM), or establish a Marketplace in partnership with the federal government (Partnership). States running an SBM are responsible for performing all Marketplace functions, except for three SBM states (NV, NM, OR) that rely on the FFM information technology (IT) platform for eligibility determinations. In a Federally-facilitated Marketplace (FFM), the

US Department of Health and Human Services (HHS) conducts all Marketplace functions. States with a Partnership Marketplace may administer plan management functions, in-person consumer assistance functions, or both, and HHS is responsible for the remaining Marketplace functions.

[26] This column indicates whether states using the FFM IT platform for eligibility determinations (including FFM, Partnership, and Federally-supported SBM states) have elected to allow the FFM to make assessments or determinations of Medicaid/CHIP eligibility for MAGI-based groups. In assessment states, applicants’ accounts must be transferred to the state Medicaid/CHIP agency for a final determination. In determination states, the FFM makes a final Medicaid/CHIP eligibility determination and transfers the account to the state Medicaid/CHIP agency for enrollment. States marked as N/A operate a full SBM.

[27] This column indicates whether the state operates a single integrated eligibility determination system for MAGI-based Medicaid and Marketplace coverage.

[28] This column indicates whether the MAGI-based Medicaid eligibility determination system is used to determine eligibility for at least one other non-health benefit program such as the Supplemental Nutrition Assistance Program (SNAP), cash assistance, or child care subsidies.

[29] Eligibility levels are based on 2014 federal poverty levels (FPLs).

[30] States have flexibility to impose premiums and cost-sharing in Medicaid, with the maximum allowable amounts varying by income and group. Medicaid enrollees, including children, pregnant women, parents and the adult expansion group, with incomes below 150% of the federal poverty level (FPL) may not be charged premiums without a waiver. Cost-sharing generally is not allowed for children with incomes below 133% FPL. Medicaid enrollees with incomes above 150% FPL can be charged premiums and relatively higher cost-sharing compared to those at lower incomes. Cost-sharing cannot be charged for preventive services for children or emergency, family planning, and pregnancy-related services in Medicaid. Overall premium and cost-sharing amounts for all family members enrolled in Medicaid may not exceed 5% of household income. States have somewhat greater flexibility to charge premiums and cost-sharing for children covered by CHIP, although there remain federal limits on the amounts that can be charged, including the overall 5% of household income cap.

[31] Income eligibility limits at which premiums and cost-sharing begin include the five percentage point of FPL disregard only for states where the lowest level for premiums and/or cost-sharing coincides with the upper income limit for Medicaid and lower threshold for CHIP eligibility.

[32] States have flexibility to impose premiums and cost-sharing in Medicaid, with the maximum allowable amounts varying by income and group. Medicaid enrollees, including children, pregnant women, parents and the adult expansion group, with incomes below 150% of the federal poverty level (FPL) may not be charged premiums without a waiver. Medicaid enrollees with incomes above 150% FPL can be charged premiums and relatively higher cost-sharing compared to those at lower incomes. Overall premium and cost-sharing amounts for all family members enrolled in Medicaid may not exceed 5% of household income. States have somewhat greater flexibility to charge premiums and cost-sharing for children covered by CHIP, although there remain federal limits on the amounts that can be charged, including the overall 5% of household income cap. N/A indicates that coverage is not available at the specified income level. If a state does not charge premiums at all, it is noted as “- -“.

[33] Enrollment fees are charged annually and families are typically not allowed to enroll in coverage without paying the fee

[34] In Arizona, Connecticut, Indiana, Iowa, Colorado, and North Carolina, the values before the vertical line represent premiums or enrollment fees for one child. Those after the line represent premiums for two or more children.

[35] States have flexibility to impose premiums and cost-sharing in Medicaid and CHIP, with the maximum allowable amounts varying by income and group. Cost-sharing generally is not allowed for children with incomes below 133% FPL, though charges may be imposed for non-emergent use of the emergency room and non-preferred drugs. Medicaid enrollees with incomes above 150% FPL can be charged premiums and relatively higher cost-sharing compared to those at lower incomes. Cost-sharing cannot be charged for preventive services for children or emergency, family planning, and pregnancy-related services in Medicaid. Overall premium and cost-sharing amounts for all family members enrolled in Medicaid or CHIP may not exceed 5% of household income.

[36] If a state charges cost-sharing for selected services or drugs shown in “Cost-Sharing Amounts for Selected Services for Children at Selected Income Levels” and “Cost-Sharing Amounts for Prescription Drugs for Children at Selected Income Levels”, but either does not charge them at the income level shown or for the specific service, it is recorded as $0; if a state does not provide coverage at a particular income level, it is noted as “N/A;” if a state does not charge copayments at all, it is noted as “- -“. Some states require 18-year-olds to meet the copayments of adults in Medicaid. These data are not shown.

[37] In California, Louisiana, Oregon, Pennsylvania, Tennessee, West Virginia, and Wyoming, the emergency room copayment is waived if the child is admitted. In New Mexico, the emergency room copayment is waived if the child is admitted, but the inpatient copayment is still applied.

[38] Ibid

[39] Cost-sharing is allowed, with some restrictions for children with family incomes up to 150% of the FPL. In general, states cannot adopt cost-sharing or premium policies that impose costs that exceed 5% of family income or that favor higher-income families over lower-income families. They also are prohibited from imposing cost sharing for well-baby and well-child care, including immunizations.

[40] If a state charges cost-sharing, but either does not charge at the income level shown or for the specific service, it is recorded as $0; if a state does not provide coverage at a particular income level it is noted as “N/A;” if a state does not charge copayments at all, it is noted as “- -“; if a state does not cover a type of drug, it is noted as “N/C”. Some states require 18-year-olds to meet the copayments of adults in Medicaid. These data are not shown.

[41] In North Carolina, the copayment for brand-name drugs only applies if a generic version is available.

[42] States have flexibility to impose premiums and cost-sharing in Medicaid, with the maximum allowable amounts varying by income and group. Medicaid enrollees with incomes below 150 percent of the federal poverty level (FPL) may not be charged premiums without a waiver. Adults enrolled in Medicaid may be charged cost-sharing, but charges for those below 100 % FPL are limited to nominal amounts.

[43] If a state charges cost-sharing, but does not charge for the specific service, it is recorded as $0; if a state does not charge cost-sharing at all, it is noted as “- -“; if a state does not cover a type of drug, it is noted as “N/C”.

[44] Data in the table represent premium (or other monthly contribution) and cost-sharing requirements for adults covered through the ACA Medicaid expansion to adults with incomes up to 138% of the federal poverty level (FPL).

This group includes parents above Section 1931 limits and childless adults.

[45] States have flexibility to impose premiums and cost-sharing in Medicaid, with the maximum allowable amounts varying by income and group. Medicaid enrollees with incomes below 150% FPL may not be charged premiums without a waiver. Adults enrolled in Medicaid may be charged cost-sharing, but charges for those below 100% FPL are limited to nominal amounts. If a state charges cost-sharing, but does not charge for the specific service or drug, it is recorded as $0; if a state does not charge cost-sharing at all, it is noted as “- -.”