Benefit Types and Services

Benefits you can get from AmeriHealth Caritas North Carolina or a Medicaid provider

You can choose where to get care for some services. You can get these services from providers in the AmeriHealth Caritas North Carolina network or from another Medicaid provider. You do not need a referral from your primary care provider (PCP) to get the following services. If you have any questions, talk to your PCP or call Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

Human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening

You can get HIV and STI testing and treatment, and counseling service any time from your PCP or AmeriHealth Caritas North Carolina health care providers. When you get this service as part of a family planning visit, you can go to any health care provider or clinic that takes Medicaid and offers family planning services. You do not need a referral when you get this service as part of a family planning visit.

You can choose to go either to your PCP or to the local health department for diagnosis or treatment. You do not need a referral to go to the local health department.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): the Medicaid health benefit for members under 21 years old

Members under 21 years old have a broad menu of health care benefits. Medicaid calls this benefit EPSDT.

Learn more about EPSDT benefits and services.

Benefits you can get only from a Medicaid provider

There are some services AmeriHealth Caritas North Carolina does not provide. You can get these services from a provider outside of our health plan's provider network who takes Medicaid:

  • Dental services
  • Services provided through the Program of All-Inclusive Care for the Elderly (PACE). Learn more about PACE.
  • Services provided by Local Education Agencies
  • Services provided by Children's Developmental Agencies that are included in your child's Individualized Family Service Plan
  • Fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses and ophthalmic frames

If you have questions or need help with accessing benefits you can only get through Medicaid, talk with your PCP or call Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

Services not covered

Below are some examples of the services that are not available from AmeriHealth Caritas North Carolina or Medicaid. If you get any of these services, you may have to pay the bill:

  • Cosmetic surgery if not medically necessary
  • Personal comfort items such as cosmetics, novelties, tobacco or beauty aids
  • Routine foot care, except for beneficiaries with diabetes or a vascular disease
  • Routine newborn circumcision
  • Experimental drugs, procedures or diagnostic tests
  • Infertility treatments
  • Sterilization reversal
  • Sterilization under age 21
  • Medical photography
  • Biofeedback
  • Hypnosis
  • Blood tests to determine paternity (contact your local child support enforcement agency)
  • Chiropractic treatment unrelated to the treatment of an incomplete or partial dislocation of a joint in the spine
  • Erectile dysfunction drugs
  • Weight loss or weight gain drugs
  • Liposuction
  • Tummy tuck
  • Ultrasound to determine sex of child
  • Hearing aids for beneficiaries age 21 and older
  • Services from a provider who is not part of AmeriHealth Caritas North Carolina, unless it is a provider you are allowed to see as described in the member handbook or AmeriHealth Caritas North Carolina or your PCP sent you to that provider
  • Services for which you need a referral (approval) in advance and you did not get it
  • Services for which you need prior authorization in advance and you did not get it
  • Medical services provided out of the United States
  • Tattoo removal
  • Payment for copies of medical records

This list does not include all services that are not covered. To determine if a service is not covered, call Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

A provider who agrees to accept Medicaid generally cannot bill you. You may have to pay for any service that your PCP or AmeriHealth Caritas North Carolina does not approve or cover. Or, if before you get a service, you agree to be a "private pay" or "self-pay" patient, you will have to pay for the service. This includes:

  • Services not covered (including those listed above)
  • Unauthorized services
  • Services provided by providers who are not part of AmeriHealth Caritas North Carolina
Members