What Does Carolina Complete Health Cover: Services, Extras, Prior Auth

Carolina Complete Health covers the full North Carolina Medicaid Standard Plan benefit package at no cost to members: doctor visits, hospital care, prescriptions, behavioral health, maternity care, vision, long-term services and supports, and non-emergency transportation, along with a set of extra value-added services like over-the-counter and grocery allowances, a free gym membership, and cash rewards for preventive care.¹

Who the Plan Covers

Carolina Complete Health is a Standard Plan under NC Medicaid Managed Care. Eligible groups include most families and children, pregnant women (through twelve months postpartum), people who are blind or disabled and do not have Medicare, and federally recognized tribal members or others who qualify for care through the Indian Health Service.² Enrollment runs through the North Carolina Department of Health and Human Services and the NC Medicaid Enrollment Broker.³ The network covers every county in North Carolina.⁴

Doctor Visits, Hospital Care, and Preventive Services

Primary care visits, lab work, X-rays, specialist referrals, and inpatient and outpatient hospital care are all covered. Emergency room visits are covered for life-threatening situations such as severe chest pain, uncontrolled bleeding, broken bones, overdoses, and breathing difficulties, and urgent care is available for problems like sprains, ear infections, and high fevers that cannot wait for a regular appointment.⁵

Preventive care includes annual check-ups, blood pressure and diabetes screenings, immunizations, breast, cervical, and colorectal cancer screenings, HIV testing, and tobacco, obesity, and diet counseling. Children get Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services from three days old through age 21, including well-child visits, lead screenings, developmental assessments, and vision and hearing checks. Under federal EPSDT rules, members under 21 can access any medically necessary care and are not held to the plan’s standard coverage limits.⁶

Specialty coverage includes respiratory care, podiatry, chiropractic care, cardiac procedures, and surgery. Home health, skilled nursing, hospice, and private duty nursing are covered, with some services requiring prior authorization. Nursing home stays are covered for short-term rehabilitation or longer-term care up to 90 days. Durable medical equipment, prosthetics, and orthotics are covered when medically necessary.¹

Prescription Drugs

Most prescriptions and select over-the-counter drugs are covered when a plan provider writes the prescription. The plan uses the NC Medicaid Preferred Drug List, and members can look up a specific medication through an online formulary search.⁷ Insulin and diabetic supplies, smoking cessation products, emergency contraception, enteral formula, and medical and surgical supplies are included.

Non-preferred drugs usually require prior authorization. To get one approved, the prescriber generally needs to document that the member tried and failed at least two preferred alternatives, had side effects, or has a clinical reason the preferred options will not work.⁸ Maintenance medications for chronic conditions like diabetes and high blood pressure can be filled in up to a 90-day supply, and birth control prescriptions can be filled in up to a 365-day supply. All NC Medicaid-enrolled pharmacies are in network.⁷

Mental Health and Substance Use Treatment

Behavioral health services do not require a referral from a primary care provider. Mental health coverage includes diagnostic assessments, individual, group, and family therapy, mobile crisis management, facility-based crisis programs, outpatient and inpatient care, partial hospitalization, peer support, and applied behavioral analysis for autism spectrum disorder.⁶ Substance use disorder treatment includes outpatient opioid treatment, ambulatory detox, non-hospital medical detox, and alcohol and drug abuse treatment center crisis stabilization. A 24-hour behavioral health crisis line is available at 1-844-784-8906.⁹

Some intensive services are not covered through this plan. Residential treatment facilities, psychiatric residential treatment facilities, intermediate care facilities for individuals with intellectual disabilities, community support teams, psychosocial rehabilitation, and several waiver-based services fall outside the Standard Plan. Members who need those services are directed to their primary care provider or Member Services for help accessing them through other Medicaid programs, typically a Tailored Plan.¹

Vision, Hearing, and Dental

Vision coverage includes eye exams by ophthalmologists or optometrists and medically necessary lenses. For members 21 and older, a value-added benefit adds a $125 retail allowance every two years (730 days) toward frames and lenses.¹ Hearing aid products and services are covered with a doctor’s referral and prior authorization.¹⁰ Dental services are administered by the state rather than through the plan itself; the plan does provide transportation to dental appointments.¹¹

Maternity Care and Family Planning

Pregnancy benefits include prenatal and postpartum care, OB/GYN services, childbirth education, breastfeeding support, and care management for high-risk pregnancies. The Start Smart for Your Baby program pairs members with a licensed nurse or program specialist, provides personalized care plans, offers NICH care management when needed, and helps with housing, food, clothing, and transportation.¹² Parents who file a Notification of Pregnancy form can choose between a car seat, a portable crib, or a stroller, with accessories like diapers or a baby care kit.¹³

Family planning services are covered without a referral or prior authorization. That includes birth control such as IUDs and implants, sterilization, and STI and HIV testing and counseling. Birth control prescriptions can be filled in up to a full year’s supply.¹

Telehealth

Virtual visits through Teladoc are available at no cost. General telemedicine runs around the clock; behavioral health telehealth is available on weekdays from 7:00 a.m. to 9:00 p.m. Visits can be by phone or video, and providers can prescribe during a visit. Covered conditions include colds, flu, fevers, ear infections, skin conditions, sinus and allergy issues, and behavioral health concerns. Telemedicine does not cover lab work and is not a substitute for emergency care.¹⁴

Long-Term Services and Supports

Members who need ongoing help with daily living can qualify for Long-Term Services and Supports. LTSS benefits include a dedicated care manager, personal care services such as help with bathing, dressing, and meal preparation, private duty nursing in the home, home infusion therapy, hospice care, supported employment, and nursing home coverage. Eligibility is based on individual health assessments.¹⁵

Transportation

Non-emergency medical transportation is covered at no cost for medical, dental, vision, and behavioral health appointments and for prescription pickups. Trips are managed by MTM and should be scheduled at least two business days in advance, though urgent trips for sick visits or hospital discharges can be arranged on shorter notice. There is no annual trip limit.¹⁶ Trips over 75 miles one way, out-of-state travel more than 40 miles over the border, and anything requiring air travel or hotel stays need prior authorization. Members who use a wheelchair or need other accommodations submit a Level of Need form from their physician. As an extra, eligible members get up to two supplemental round trips per plan year for community events like baby showers and support groups, limited to 20 miles each way.¹⁷

Value-Added Extras

These benefits sit on top of standard Medicaid coverage, with eligibility rules that vary by service. Member Services at 1-833-552-3876 can confirm what applies to a given member.

OTC and Grocery Allowances

Members get a $120 annual over-the-counter allowance at CVS, loaded as $30 per quarter. Eligible products include vitamins, first aid supplies, pain relievers, cold and cough remedies, oral hygiene products, baby care items, digestive health products, and reading glasses.¹⁸ Members 18 or older with a Care Needs Screening on file identifying food insecurity can receive a $150 annual grocery allowance, loaded onto a prepaid Mastercard at $50 across three months. The card works at retailers including Walmart, Food Lion, Publix, Harris Teeter, Costco, and CVS, but not for alcohol, tobacco, or firearms. Funds expire at the end of the plan year (March 31).¹⁹

Fitness and Wellness

Members 18 or older who complete two My Health Pays healthy activities can enroll in Active&Fit Enterprise for a free gym membership through the ASH Fitness network or a home fitness kit with workout videos. Going inactive for more than two consecutive months cancels the gym benefit for the rest of the plan year.²⁰ Other wellness offerings include 10 weeks of digital WeightWatchers, the YMCA Diabetes Prevention Program, a YMCA blood pressure self-monitoring program, the Quit for Life tobacco cessation program, up to $150 in asthma support supplies, and sensory and Alzheimer’s support kits.¹⁰

Rewards for Preventive Care

The My Health Pays program pays up to $75 per year on a Visa Prepaid Card for completing preventive activities. Each qualifying activity earns $25: a Care Needs Screening, flu shot, annual wellness exam, child wellness visit, lead screening, mammogram, colonoscopy, cervical cancer screening, HPV vaccine, or comprehensive diabetes care. Pregnant members can earn rewards for filing a Notification of Pregnancy, attending a prenatal visit, and completing a postpartum visit. Funds can go to utilities, rent, transportation, childcare, education, and everyday retail, but not alcohol, tobacco, or firearms. Rewards expire 365 days after being earned or 90 days after coverage ends, whichever comes first.²¹ Native American members can earn $100 in My Health Pays rewards for completing two Tribal Talking Circles sessions.²²

Education and Youth

Children and young adults can get up to 12 hours of online math and reading tutoring for grades K through 6, a school supplies benefit for grades Pre-K through 12, a youth program voucher for ages 4 to 18, and GED exam assistance for members 16 and older. GEDWorks provides free tests, study materials, and a personal advisor for members 18 and older who have been enrolled for at least 90 days.²²

Other Extras

A one-time lifetime Care Grant of up to $250 is available for eligible members and can be applied to housing, post-hospitalization meal delivery, or natural healing services. Up to 10 home-delivered meals are available after a hospital stay for qualifying members.²² Other benefits include a pre-programmed cellphone with 250 minutes per month for members who do not qualify for the federal program, a $175 Mastercard Rewards Card for expungement certification assistance for non-violent misdemeanor offenses, and a Welcome Home Kit for members in care management who are setting up a new residence.¹

When Prior Authorization Is Needed

Some services need approval before the plan will cover them: inpatient hospital admissions, hospice care, out-of-network services, complex imaging like MRIs and CT scans, cardiac and surgical procedures, genetic testing, home infusion therapy, durable medical equipment, and some behavioral health services. Emergency room and urgent care visits do not require prior authorization, and neither do family planning or STI and tuberculosis services at local health departments.¹¹

Out-of-Network Care

Members are expected to use in-network providers. Out-of-network care is covered for emergencies and where law otherwise requires it. Any other out-of-network service needs prior authorization; without it, the member may be responsible for the cost. The Find a Provider tool on the plan’s website lists in-network doctors, specialists, and facilities.⁴

1
Carolina Complete Health. Benefits Overview
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NC DHHS. Medicaid Health Plans and Programs
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Carolina Complete Health. Provider Manual
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Carolina Complete Health. Provider Directory
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Carolina Complete Health. Benefits and Forms Book
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Carolina Complete Health. Member Handbook
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Carolina Complete Health. Pharmacy Benefits
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Carolina Complete Health. Pharmacy Prior Authorization Standard Drug Request Form
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Carolina Complete Health. Behavioral Health Services
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Carolina Complete Health. Value-Added Services
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Carolina Complete Health. Medicaid Pre-Auth
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Carolina Complete Health. Start Smart for Your Baby Resources
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Carolina Complete Health. New Mothers Value-Added Services
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Carolina Complete Health. Telemedicine Services
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Carolina Complete Health. Long Term Services and Supports
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Carolina Complete Health. Transportation Services
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Carolina Complete Health. Supplemental Transportation
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Carolina Complete Health. OTC Item Catalog
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Carolina Complete Health. Household Grocery Allowance
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Carolina Complete Health. Gym Membership
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Carolina Complete Health. Healthy Rewards Program
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Carolina Complete Health. VAS Master List