Economic Services:
NC Health Choice For Children

Children who are under age 19 may qualify for free or low cost health insurance if they are uninsured and if the family income is higher than the Medicaid limits but less than 200% of the poverty level. There is no limit on resources. The coverage is similar to that of Medicaid. Eligible children receive a card which is valid for one year (unless they move out of state or become insured through another source).

As of October 1998, families who make too much money to qualify for Medicaid but too little to afford rising health insurance premiums are able to get free or reduced price comprehensive health care for their children. The new plan, "NC Health Choice for Children," is the same as coverage provided for the children of state employees and teachers, plus vision, hearing and dental benefits. 

When working families cannot afford health care for their children, the consequences can be dire. Babies may not get the checkups that make sure they are growing healthy and strong. Families may wait until a child is very sick before seeking medical help, sometimes getting help only in an emergency. Untreated illnesses can have long-lasting consequences, such as hearing loss caused by ear infections. 

Eligibility is determined by family income--children must be a part of a family which makes less than the following federal income standard:   
 

Eligibility determination is based on the preceeding one-month's pay stubs. Add $530 monthly for each additional family member in the household.

For those whose income is borderline for eligibilty, do not assume that you are not eligible. There are deductions for necessary child care. The amounts are $200 per month per child for children under age 2 and $175 per month per child for children two and over. These amounts are the total amounts that can be deducted per child from the family's earned income. (In other words you cannot deduct $200 from one parent and $200 from the other parent for the same child.)

There is a $90 work related expense standard. It is for each family member who works.

For the families at the higher end of this income scale there are certain out of pocket costs. Under federal law, these can never exceed 5% of the family's income. There is an enrollment fee of $50 for one child or $100 for two or more children. There are also copayments of $20 for nonemergency emergency room use, $6 per perscription drug and $5 per physician or dental visit.  

For those at 150% of poverty and below there is no out of pocket cost.
 

 For each additional family member add $398 monthly. Families at this income level are also allowed child care and business deductions. They have no copayments or enrollment fees.

This is a comprehensive health insurance plan which covers not only hospitalization but outpatient care. Preventive dental, vision and hearing benefits are available. The following is a summary of benefits: 

• Hospital Care - Semiprivate room, medications, laboratory texts, x-rays, surgeries, and professional care.
• Outpatient care - includes diagnostic services, therapies, laboratory services, X rays, and outpatient services.
• Physician and clinic services - office visits; preventive services such as four well-baby visits up to one year of age, three visits per year between one and two years of age and one visit per year between 2 and 7, and once every three years between 7 and 19. Immunizations are covered.
• Surgical services - includes standard surgical procedures, related services, surgeon’s fees, anesthesia.
• Prescription drugs
• Laboratory and radiology services
• Inpatient mental health services - requires precertification
• Outpatient mental health services - requires precertification after 26 outpatient visits per year.
• Durable medical equipment and supplies such as wheelchairs
• Vision
• Hearing
• Home health care - limited to patients who are homebound and need care that can only be provided by licensed health care professionals or in the case that a physician certifies that the patient would other wise be confined to a hospital or skilled nursing facility. Professional health care is covered, care provided by an unlicensed caregiver is not.
• Nursing care
• Dental care Dental services (Section 2110(a)(17)), Oral examinations, teeth cleaning, and scaling twice during a 12month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, fluroide applications twice during a 12-month period, sealants, simple extractions, therapeutic pulpotomies, prefabricated stainless steel crowns, and routine fillings of amalgam or other tooth colored filling material to restore diseased teeth.
• Inpatient substance abuse treatment and outpatient substance abuse treatment -is covered. See the mental health inpatient and outpatient notes above.
• Physical therapy, occupational therapy and therapy for individuals with speech, hearing and language disorders
• Hospice care
• Special needs children with chronic mental or physical conditions or illness may receive services beyond those listed above if services are medically necessary and receive precertification.

Once a child has been covered under this plan, should family economic conditions change so that the child is no longer eligible, but the family wants the child to continue in the program, the family will be allowed to purchase the plan at full premium for one year. 

Applications for this program are available at:

The Department of Social Services:
40 Coxe Avenue
Asheville NC 28802
(828) 250-5500The Health Center

or at the bottom of this page. It is a two-page application form which may be submitted to DSS in person or by mail. The form will begin the application process. Each application will first be looked at to see if the child is eligible for Medicaid and, if not, then looked at to see if the child is eligible for the new program. If the child is found to be eligible, the application will be processed and the parents will receive a health card, a benefits booklet and instructions in the mail. Once parents are notified, the child is eligible to receive care. 

Note: Unlike Medicaid, this program is limited by the amount of funds that are available. Therefore, it is open only to children on a first come, first served basis. Once the program is full, a waiting list will be taken, so it is in the best interest of the child to enroll as soon as it is possible.

Want the Federal perspective? Go to the Centers for Medicare & Medicaid Services web site on Child Health Insurance. 

• NC Health Choice for Children Information and Application English (DMA-5063) 64 KB
• NC Health Choice for Children Information and Application Spanish (DMA-5063) 64 KB

For more information regarding insurance for children please visit the Children's Insurance page.