Benefits Overview

• Office visits with your PCP, including regular check-ups, routine labs and tests
• Referrals to specialists
• Eye/hearing exams
• Well-baby care
• Well-child care
• Immunizations (shots) for children and adults 
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for members under age 21 
• Help with quitting smoking or other tobacco use

With a Carolina Complete Health Medicaid plan, many preventive health services are covered including the below:

• Annual check-up
• Blood pressure screening
• Blood tests
• Breast cancer mammography screening
• Cervical cancer screening
• Colorectal cancer screening
• Depression screening
• Development screening (for children)
• Diabetes (Type 2) screening
• Diet counseling
• Flu vaccine
• HIV screening
• Immunization vaccines (for children and adults)
• Lead screening for children at risk of exposure
• Obesity screening and counseling
• Osteoporosis screening
• Tobacco use screening
• Vision screening (for children)
• Well baby and well child visits

• Respiratory care services 
• Podiatry services
• Chiropractic services 
• Cardiac care services 
• Surgical services  

• Prescription drugs
• Some medicines sold without a prescription (also called “over-the-counter”), like allergy medicines
• Insulin and other diabetic supplies like syringes, test strips, lancets and pen needles
• Smoking cessation agents, including over-the-counter products
• Enteral formula (balanced nutrition designed for the tube-feeding of children)
• Emergency contraception 
• Medical and surgical supplies

• The first week visit (3 to 5 days old)
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• 2 years old (24 months)
• 2 ½ years old (30 months)
• Annually from ages 3 to 21

• Services provided by ophthalmologists and optometrists, including routine eye exams and medically necessary lenses
• Specialist referrals for eye diseases or defects

• Inpatient care
• Outpatient care
• Labs, X-rays and other tests

• Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency.
• After you have received emergency care, you may need other care to make sure you remain in stable condition.
• Depending on the need, you may be treated in the emergency department, in an inpatient hospital room or another setting.

• Pregnancy care
• Childbirth education classes 
• OB/GYN and hospital services
• One medically necessary post-partum home visit for newborn care and assessment following discharge, but no later than 60 days after delivery
• Care management services for high-risk pregnancies during pregnancy and two months after delivery

Behavioral health care includes mental health (your emotional, psychological, and social well-being) and substance (alcohol and drugs) use disorder treatment and rehabilitation services. All members have access to services to help with mental health issues like depression or anxiety, or to help with alcohol or other substance use disorders. These services include:

• Mental Health Services
  • Services to help figure out if you have a mental health need (diagnostic assessment services)
  • Individual, group and family therapy
  • Mobile crisis management services
  • Facility-based crisis programs
  • Outpatient behavioral health services
  • Outpatient behavioral health emergency room services
  • Inpatient behavioral health services
  • Research-Based Behavioral Health Treatment for Autism Spectrum Disorder
    
  • Partial hospitalization
  • Peer Support Services
    
• Substance Use Disorder Services
  • Outpatient opioid treatment
  • Ambulatory detox
  • Non-hospital medical detox
  • Alcohol and drug abuse treatment center detox crisis stabilization

If you believe you need access to more intensive behavioral health services, like psychiatric residential treatment facilities or assertive community treatment, that your plan does not provide, talk with your PCP or call Member Services at 1-833-552-3876 (TTY: 711). The following intensive behavior health services are not covered by this plan:

• State Plan Services
  • Residential treatment facility services
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
  • Child and adolescent day treatment services
  • Intensive in-home services
  • Multi-systemic therapy services
  • Psychiatric residential treatment facilities (PRTFs)
  • Community support team (CST)
  • Psychosocial rehabilitation
  • Substance abuse non-medical community residential treatment
  • Substance abuse medically monitored residential treatment
  • Substance abuse intensive outpatient program (SAIOP)
  • Substance abuse comprehensive outpatient treatment program (SACOT)
• Waiver Services
  • Innovations waiver services
  • TBI waiver services
  • 1915(b)(3) services
• State-Funded behavioral health, I/DD and TBI Services
• Other services as indicated by each LME-MCO

You can go to any provider/doctor or clinic that takes Medicaid and offers family planning services. You can also visit one of our family planning providers. You do not need a referral from your PCP for family planning services. Family planning services include:

• Birth control 
• Birth control devices such as IUDs, implantable contraceptive devices, and others that are available with a prescription 
• Emergency contraception 
• Sterilization services 
• HIV and sexually transmitted infection (STI) testing, treatment and counseling 
• Screenings for cancer and other related conditions.

• Must be medically necessary and arranged by Carolina Complete Health
• Time-limited skilled nursing services
• Specialized therapies, including physical therapy, speech-language pathology and occupational therapy
• Home health aide services for help with activities such as bathing, dressing, preparing meals and housekeeping 
• Medical supplies

• Hospice care will be arranged by Carolina Complete Health if medically necessary.
• Hospice helps patients and their families with the special needs that come during the final stages of illness and after death.
• Hospice provides medical, supportive and palliative care to terminally ill individuals and their families or caregivers.
• You can get these services in your home, in a hospital or a nursing home.

If you have a certain health condition or disability, you may need help with day-to-day activities like eating, bathing or doing household chores. You can get help through a Carolina Complete Health benefit known as “Long-Term Services and Supports” (LTSS). LTSS includes services like home health and personal care services. You may get LTSS in your home, community or a nursing home.

• If you need LTSS, you may have a Care Manager on your care team. A Care Manager is a specially trained health professional who works with you and your providers/doctors and other providers of your choice to make sure you get the right care when and where you need it.
  
• If you are leaving a nursing home and are worried about your living situation, we can help. Our Housing Specialist can connect you to housing options. Call Member Services at 1-833-552-3876 (TTY: 711) to learn more.

If you have questions about using LTSS benefits, talk with your PCP, a member of your care team or call Member Services at 1-833-552-3876 (TTY: 711).

• Must be ordered by a physician and authorized by Carolina Complete Health.
• Includes short-term or rehabilitation stays and long-term care for up to 90 days.
• If you need nursing care for more than 90 days, you may need to enroll in a different health plan. Talk with your PCP or call Member Services at 1-833-552-3876 (TTY: 711) if you have questions.
• Covered nursing home services include medical supervision, 24-hour nursing care, assistance with daily living, physical therapy, occupational therapy and speech-language pathology. 
• Nursing home services must come from a nursing home that is in Carolina Complete Health’s provider network. If you choose a nursing home outside of Carolina Complete Health’s network, and services are available in the plans network, you may have to transfer to another plan. Call Member Services at 1-833-552-3876 (TTY: 711) for help with questions about nursing home providers and plan networks.
• Talk with your PCP or call Member Services at 1-833-552-3876 (TTY: 711) for help finding a nursing home in our network.

• Must be medically necessary and arranged by Carolina Complete Health
• Help with common activities of daily living, including eating, dressing and bathing, for individuals with disabilities and ongoing health conditions

Emergency: If you need emergency transportation (an ambulance), call 911.

Non-Emergency: Carolina Complete Health can arrange and pay for your transportation to help you get to and from your appointments for Medicaid-covered care. This service is free to you. If you need an attendant to go with you to your doctor’s appointment, or if your child (18 years old or younger) is a member of the plan, transportation is also covered for the attendant, parent or guardian. Non-emergency transportation includes personal vehicles, taxis, vans, mini-buses, mountain area transports and public transportation.

How to Get Non-Emergency Transportation: Call ModivCare, our transportation provider, at 1-855-397-3601 up to 30 days before your appointment to arrange transportation to and from your appointment. There is no limit to the number of trips during the year between medical appointments, healthcare facilities, or pharmacies.

If transportation services are denied, you have the right to appeal our decision. If you have questions about transportation, call Member Services at 1-833-552-3876 (TTY:711).

For more information on Transportation Services, please visit our Transportation Services page.

• Durable medical equipment/prosthetics/orthotics
• Hearing aid products and services 
• Telemedicine 
• Extra support to manage your health 
• Home infusion therapy
• Rural Health Clinic (RHC) services 
• Federally Qualified Health Center (FQHC) services