This form to be used for NC Medicaid and or Health - Value Options 2025

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Health plan types Standard Plan. Tailored Plan. Eastern Band of Cherokee Indians (EBCI) Tribal Option. NC Medicaid Direct. Children and Families Specialty Plan.
An adult ages 19-64 may be eligible if the family income is $1,732/month or less. An adult ages 65+ may be eligible for full Medicaid if the family income is $1,255/month or less, and for other Medicaid programs if the family income is $1,695/month or less. Additional requirements apply.
Proof of citizenship or immigration status. Proof of income, like paystubs or W-2s. A verification of what other government benefits you receive. Information about an insurance plan your employer has offered you or an insurance plan you currently have.
Prepare the following documents below for each person applying to help complete your application: Full legal name. Date of birth. Social Security number (or immigration documents) North Carolina residency. Income information (from paystubs, W-2 forms, tax returns or business records)
Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity. Prior approval is for medical approval only and must be obtained before rendering a service, product or procedure that requires prior approval.
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