Wellcare NC Medicaid offers comprehensive healthcare coverage for eligible North Carolinians through managed care plans. As part of Centene Corporation, Wellcare delivers affordable, quality care to nearly 1.5 million members in the state.
This article explores Wellcare NC Medicaid’s benefits, eligibility, services, and updates for 2025.
Whether you’re a current member or exploring options, this guide simplifies the details.
What Is Wellcare NC Medicaid?
Wellcare NC Medicaid is a managed care program under North Carolina’s Medicaid system. It provides health coverage for low-income families, children, seniors, and individuals with disabilities. Wellcare partners with the state to deliver cost-effective care.
The program includes doctor visits, hospital care, prescriptions, and behavioral health services. It emphasizes whole-person care, addressing medical and non-medical needs. Wellcare serves members across all 100 counties in North Carolina.
Eligibility for Wellcare NC Medicaid
Eligibility for Wellcare NC Medicaid depends on factors like income, age, and health status. Adults aged 19–64 with incomes below 138% of the federal poverty level qualify under Medicaid expansion. Children, pregnant women, and people with disabilities may also be eligible.
You must be a North Carolina resident and a U.S. citizen, though some non-citizens qualify. Apply through ePASS at epass.nc.gov or your local Department of Social Services (DSS). Eligibility is verified annually to maintain coverage.
Benefits of Wellcare NC Medicaid
Wellcare NC Medicaid covers a wide range of services at little or no cost. These include doctor visits, hospital stays, emergency care, and yearly check-ups. Prescription drugs are covered through a Preferred Drug List (PDL) created by doctors and pharmacists.
The program also offers behavioral health support, dental care for kids, and vision services. Special programs like Healthy Moms and Babies support maternal health. Members receive a Wellcare ID card for accessing services.
Here are key benefits:
- Doctor visits and preventive care
- Prescription medications and vaccines
- Behavioral health and substance use treatment
- Dental and vision for children
- Maternity and newborn care
Medicaid Expansion in 2025
North Carolina’s Medicaid expansion, effective since December 2023, covers adults aged 19–64 with higher incomes. Wellcare NC Medicaid supports this by enrolling eligible individuals into managed care plans. About 600,000 new members joined through expansion.
Expansion covers incomes up to $20,000 for a single adult or $34,000 for a family of three. It includes mental health services, emergency care, and more. Wellcare ensures seamless access to these benefits across the state.
How to Apply for Wellcare NC Medicaid
Apply for Wellcare NC Medicaid online via ePASS at epass.nc.gov. You can also submit a paper application or visit your local DSS office. Applications take up to 45 days to process, longer if incomplete.
Keep your contact information updated in ePASS to receive important notices. Sign up for an enhanced ePASS account to manage your application easily. Wellcare’s Member Portal helps track your application status.
Wellcare’s Provider Network
Wellcare NC Medicaid partners with thousands of providers across North Carolina. This includes primary care doctors, specialists, hospitals, and pharmacies. The network ensures access to care in all 100 counties.
Use the “Find a Provider” tool on www.wellcarenc.com to locate in-network providers. You can search by ZIP code, provider type, or name. Wellcare notifies members if a provider leaves the network.
Pharmacy Services and Preferred Drug List
Wellcare NC Medicaid covers medications listed on its Preferred Drug List (PDL). This list, developed by doctors and pharmacists, includes generics and brand-name drugs. Tier 1 generics often have $0 copays at preferred pharmacies.
Preferred pharmacies like CVS and Walgreens offer lower costs. Express Scripts provides mail-order services for up to 100-day supplies. Check the PDL on Wellcare’s website to confirm coverage.
Healthy Opportunities Pilot Program
Wellcare NC Medicaid participates in North Carolina’s Healthy Opportunities Pilot. This program addresses non-medical needs like housing, food, and transportation. It’s available in 33 counties, including Mecklenburg and Wake.
Eligible members receive services like meal delivery or housing support. The program aims to improve health outcomes by tackling social factors. Contact Wellcare to see if you qualify.
Member Rewards: My Health Pays
Wellcare NC Medicaid’s My Health Pays program rewards healthy behaviors. Members earn points for activities like annual check-ups, flu shots, or prenatal visits. Points can be redeemed for gift cards or health-related items.
Changes to the program took effect July 1, 2025, with updated rewards. Check the Wellcare Member Portal for details. This program encourages preventive care and engagement.
Costs and Copays
Most Wellcare NC Medicaid services have no copays. Doctor visits, hospital stays, and preventive care are typically free. Prescription copays range from $0 to $4, depending on the drug tier.
Low-income members may qualify for Extra Help, reducing prescription costs further. The 2025 out-of-pocket cap ensures affordability. Always confirm costs with your plan’s Evidence of Coverage (EOC).
Here’s a table of sample copays:
| Service Type | Copay Range | Notes |
|---|---|---|
| Doctor Visits | $0 | Free for most members |
| Prescriptions (Tier 1) | $0–$1 | $0 at preferred pharmacies |
| Emergency Care | $0 | No cost for emergencies |
| Specialist Visits | $0–$3 | Varies by plan type |
Behavioral Health Services
Wellcare NC Medicaid covers behavioral health, including mental health and substance use treatment. Services include therapy, counseling, and inpatient care. These are available to children and adults.
Members can access care through in-network providers or telehealth. The Twill by Dario platform offers 24/7 behavioral health support. Contact Wellcare to find a provider or learn about coverage.
Dental and Vision Benefits
Children under 21 receive comprehensive dental and vision care through Wellcare NC Medicaid. This includes cleanings, exams, glasses, and orthodontics if medically necessary. Adults may have limited dental coverage, like emergency extractions.
Vision benefits for adults cover exams and glasses in some cases. Use the “Find a Provider” tool to locate dentists and optometrists. Check your EOC for specific coverage details.
Maternity and Newborn Care
Wellcare NC Medicaid’s Healthy Moms and Babies program supports pregnant women and newborns. It covers prenatal visits, ultrasounds, delivery, and postpartum care. Newborns receive well-child visits and vaccinations.
The program offers education and support for healthy pregnancies. Members can access doulas or lactation consultants in some areas. Contact Wellcare to enroll in maternity programs.
Updates for 2025
In 2025, Wellcare NC Medicaid aligns with NC Medicaid’s Standard Plan enhancements. These focus on timely care access, whole-person care, and reduced provider burden. Public feedback shaped these changes, with comments accepted until May 7, 2025.
The My Health Pays program updated its rewards structure. Wellcare also revised clinical policies, like those for neonatal care and sleep studies. Check www.wellcarenc.com for policy updates.
Managing Your Benefits
The Wellcare Member Portal and Wellcare+ app help manage your benefits. View your ID card, check claims, or find providers online. The portal supports English, Spanish, and other languages.
The Healthy Benefits+ app tracks rewards and pharmacy benefits. Call Member Services at 1-855-256-4620 (TTY 711) for help. Keep your ePASS account updated to avoid coverage issues.
Community and Support Programs
Wellcare NC Medicaid supports communities through events and partnerships. The Member Advisory Committee (MAC) gathers feedback to improve services. Members can join to share their experiences.
The NC Integrated Care for Kids (InCK) program supports children’s health in select counties. Wellcare hosts back-to-school events and wellness fairs. These efforts strengthen community health.
Challenges and Considerations
Some members face challenges with Wellcare NC Medicaid, like provider network changes or prior authorization delays. The 2025 exit from six states for Medicare Advantage doesn’t affect NC Medicaid. Customer service wait times can be long.
Use the Wellcare+ app to resolve issues quickly. Contact your DSS office for eligibility disputes. Wellcare is improving IT systems to enhance service reliability.
Why Choose Wellcare NC Medicaid?
Wellcare NC Medicaid offers comprehensive coverage with no or low copays. Its focus on whole-person care includes medical, behavioral, and social services. The program’s 3.5 CMS star rating reflects strong quality.
With nearly 1.5 million members in North Carolina, Wellcare’s network is robust. Tools like the Member Portal and My Health Pays make it user-friendly. It’s a reliable choice for affordable care.
Summary
Wellcare NC Medicaid provides affordable, comprehensive healthcare for nearly 1.5 million North Carolinians in 2025. Covering doctor visits, prescriptions, behavioral health, and more, it supports families, children, and seniors. Benefits like the My Health Pays program and Healthy Opportunities Pilot enhance care. Use the Wellcare Member Portal or call 1-855-256-4620 to manage your benefits. With Medicaid expansion and a strong provider network, Wellcare NC Medicaid is a valuable option for eligible residents.
FAQ: Frequently Asked Questions
What is Wellcare NC Medicaid?
Wellcare NC Medicaid is a managed care program covering low-income families, children, and seniors. It includes doctor visits, prescriptions, and behavioral health services. Apply via ePASS at epass.nc.gov.
Who qualifies for Wellcare NC Medicaid?
Residents aged 19–64 with incomes below 138% of the federal poverty level qualify. Children, pregnant women, and people with disabilities are also eligible. Verify eligibility through your local DSS.
What services are covered?
Coverage includes doctor visits, hospital care, prescriptions, and dental/vision for kids. Behavioral health and maternity care are also covered. Check your EOC for details.
How do I find a provider?
Use the “Find a Provider” tool on www.wellcarenc.com or the Wellcare+ app. Search by ZIP code or provider type. Call 1-855-256-4620 for assistance.
What are the costs?
Most services have $0 copays; prescriptions may cost $0–$4. Extra Help reduces costs for low-income members. The 2025 out-of-pocket cap ensures affordability.