Medicaid and Healthcare

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) is part of the federal Medicaid Act. It entitles children under age 21 who have Medicaid to all services that are medically necessary to make or keep them physically and mentally healthy. It is a powerful but poorly understood provision.

Services for Children with Complex Behavioral Health Needs explains the services and resources available to children who have been diagnosed with both an intellectual or developmental disability and a mental illness. You can get more details about our settlement agreement with the state regarding services for these children, including what services the state has promised to provide, by reading LME-MCO Community Bulletin #J231 from the NC Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.

Budget Reductions and Changes to the Innovations Waiver is a guide to the changes to the Innovations Waiver which took effect in November 2016. It explains how your Individual Budget was created, your right to request services in excess of your Base Budget, and tips on completing your Individual Support Plan.

Autism-Related Services in North Carolina offers information about autism and Medicaid, including the requirement that the state cover autism-related services for children under 21 when medically necessary. It also includes guidance on how to request autism-related services.

Resources for Appealing Denials, Terminations or Reductions of Medicaid Services

If you receive a letter that says the Medicaid-funded service or equipment you asked for is denied, terminated, suspended, or reduced, you have the right to appeal within a specific amount of time. Go to our Medicaid Appeals resource page for information to guide you through the appeals process.

NC State Agencies

The North Carolina Department of Health and Human Services

  • The NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services is responsible for implementing public mental health, developmental disability and substance abuse services.
  • The North Carolina Division of Medical Assistance (DMA) is the state agency responsible for administering the Medicaid program in North Carolina. Some of the resources on their website include:
    • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law that says Medicaid must provide all medically necessary services to Medicaid-eligible children, even if a service is not covered under the NC Medicaid State Plan. This is an important requirement to understand when advocating for Medicaid services for children.
    • NC Health Choice is a health care program for children who are not eligible for Medicaid because of family income, but meet the eligibility requirement for Health Choice.
  • NC Health Insurance Premium Payment Program is a program under NC Division of Medical Assistance that provides payment reimbursements to Medicaid eligible families for the cost of their employer-sponsored insurance.
  • The North Carolina Innovations Waiver is a home and community-based Medicaid program that provides services and supports for individuals with intellectual and/or developmental disabilities that are at risk of institutional care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IDD). The goal is to provide an array of community-based services and supports to promote choice, control, and community integration as an alternative to institutionalization.
  • NC Clinical Coverage Policies are the policies that set forth the coverage provided under the NC Medicaid program. These policies describe the services available under Medicaid, the eligibility criteria, limitations on coverage, provider qualifications, etc. If an individual is appealing a Medicaid service, understanding the policy that covers that service is key to having a successful appeal.

The NC Department of Insurance (DOI) is the state agency responsible for licensing and supervising private health care and Medicare plans in North Carolina. DOI operates two specific programs that provide direct assistance to individuals:

  • Seniors’ Health Insurance Information Program (SHIIP) counsels Medicare beneficiaries and caregivers about Medicare, Medicare supplements, Medicare Advantage, Medicare Part D, and long-term care insurance. SHIIP counselors offer free and unbiased information regarding Medicare health care products. SHIIP also provides information for retirees who have employer group health insurance plans (EGHPs) that continue beyond a person’s 65th birthday.
  • Health Insurance Smart NC (Smart NC) is an assistance program to help individuals understand their options and rights related to health insurance. Smart NC provides consumer counseling on utilization review and appeals issues and assists consumers with resolving coverage disputes with their health insurance company. Services are provided at no cost to you.

Other Resources, which is under the federal Centers for Medicare and Medicaid Services, provides extensive information on Medicaid and the Children's Health Insurance Program.

The National Health Law Program (NHeLP) is a non-profit advocacy group dedicated to “protecting and advancing the health rights of low-income and underserved individuals.”  They publish resources for other professional advocates that describe these health rights.

The Henry J. Kaiser Family Foundation (KFF) provides information about health policy and programs to advocates, health care professionals, and the public. KFF conducts presentations about current health care issues. 

The Patient Advocate Foundation is a national nonprofit that seeks to safeguard patients through effective mediation to assure access to health care by serving as liaisons between the patient and their insurer, employer, etc. For more on their work and eligibility for their services, visit their Frequently Asked Questions page. They also have resources available on a variety of healthcare related subjects.

In NC, the Exception Children’s Assistance Center’s Family-to-Family Health Information Center provides information and support to families who have children with special healthcare needs. This includes a Parent Info Line, Parent and Professional Education workshops, a lending library, and some individual assistance with healthcare issues.

Prescription Assistance

There are various prescription assistance programs, many offered directly from the pharmaceutical company that produces the drug. The following are a few prescription assistance programs:

  • The Medication Access and Review Program helps North Carolinians find free or discounted drugs.
  • Medicare Extra Help is a program that can help low-income seniors pay the costs of monthly premiums, annual deductibles, and prescription co-payments related to a Medicare prescription drug plan.
  • NC Med Assist is a nonprofit organization that provides free medications (prescription and over-the-counter) to people who are uninsured or who have exhausted their Medicare Part D benefits.
  • NeedyMeds is a national nonprofit that provides information about patient assistance programs and advocacy tips on participating in such programs. It offers a list of programs in North Carolina that provide assistance for those who want to get their medications through pharmaceutical company patient assistance programs.

Legal Services for Medicaid Issues

Legal Aid of North Carolina is a statewide, nonprofit law firm that provides free legal services in civil matters to low-income people in order to ensure equal access to justice and to remove barriers to economic opportunity. As part of their work, Legal Aid NC may take cases regarding Medicaid and other benefits. They also have resources available through

Legal Services of Southern Piedmont (LSSP) is a non-profit legal advocacy organization that provides legal assistance in civil matters to low-income persons in the Charlotte area and in west-central North Carolina. In addition, they publish information designed to educate individuals and families about health care and benefits at

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