Questions? Go to [Link].

Or call us
toll free at 1-833-870-5500 (TTY: 711 or [Link]).
We can speak with you in other languages.

December 18, 2024

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Dear ANTINEA M CARPENTER:

Your health plan

You chose a health plan, or we chose one for you. The people listed below can start getting
services from the health plan on the start dates below. If you chose a primary care provider
(PCP), your PCP is listed below.

Health plan / Start date / Phone PCP / Address / Phone

Name / ID number number number

SOULE SMITH UnitedHealthcare Community No PCP chosen. Please

Plan choose a PCP.
947166125L
January 1, 2025
1-800-349-1855

ZAYA CARPENTER UnitedHealthcare Community No PCP chosen. Please

Plan choose a PCP.
949461691K
January 1, 2025
1-800-349-1855

Health plans have a provider network (group). It includes doctors, therapists, specialists,
hospitals and other health care facilities. They give you the health care services you need. You
will need to get care from a provider in your health plan’s provider network. For a full list of
providers, go to the Find page at [Link]. Or call us toll free at 1-833-870-5500
(TTY: 711 or [Link]).

More on back „
MEDICAID EB MAND MCM3-ENG 221027

You can get free auxiliary aids and services, including information1
in other languages or formats such as large print
or audio. Call us toll free at 1-833-870-5500.
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Health plans must have enough network hospitals and providers for you to get covered services
near you and in a timely way. To learn more, go to the Find page at [Link].

If you want to keep your health plan

You can stay in the health plan listed in this letter. You do not have to do anything.

If you want to change your health plan, choose a new health plan by
March 31, 2025
All health plans are required to have the same Medicaid services. Some health plans provide
added services like programs to help you quit smoking. To learn more about the health plans
and the services they offer:
§ Go to [Link].
§ Use the NC Medicaid Managed Care mobile app. To get the free app, search for NC
Medicaid Managed Care on Google Play or the App Store.
§ Call us toll free at 1-833-870-5500 (TTY: 711 or [Link]).
§ Read the Health Care Option Guide that came with this letter.
To change your health plan, go to [Link] or use the NC Medicaid Managed Care
mobile app. Or call us toll free at 1-833-870-5500 (TTY: 711 or [Link]). Or send the
enrollment form that came with this letter.

If you change your health plan, the new health plan will start the first
day of the next month
After you enroll, your health plan will send you information and a new ID card. You will use your
ID card to get health care services. If you have questions, call the number on your ID card.

If you don’t change your health plan by March 31, 2025

You will stay in your health plan until your Medicaid recertification date unless:
§ You are required to change health plans
§ You have a special or “with cause” reason
§ Reasons are listed on the Health Plan Change Request form. For a copy of the
form, go to [Link].

More on next page „

MEDICAID EB MAND MCM3-ENG 221027

2
[Link] | 1-833-870-5500 (TTY: 711 or [Link])
We will send you another letter telling you when you can choose a new health plan without a
special reason.

Choose your primary care provider

Your PCP is a doctor, nurse practitioner, physician assistant or other provider. They care for
your health, coordinate your needs, and refer you to specialists when you need them. Your
health care option can tell you which PCPs are in their provider network.
Your health care option will choose a PCP for you. If you want to change your PCP, call your
health care option at the number listed in this letter.
For a full list of providers, including PCPs in your health care option’s network, go to the Find
page at [Link].

If you need certain services to address needs related to a serious

mental illness, severe substance use disorder,
intellectual/developmental disability (I/DD) or traumatic brain injury
(TBI)
You may have more choices. To learn more about your choices, call us toll free at
1-833-870-5500 (TTY: 711 or [Link]).

Questions?
We can help. Go to [Link]. You can also use the “chat” tool on the website. Or
call us at 1-833-870-5500 (TTY: 711 or [Link]), 7 a.m. to 5 p.m., Monday through
Saturday. The call is toll free. You may need your Medicaid ID number when you call or go to
the website.
You can get the information at [Link] in print. To ask for a free copy, call us toll
free at 1-833-870-5500 (TTY: 711 or [Link]). Or use the "chat" tool on the website. We
will send this information within 5 business days.

More on back „
MEDICAID EB MAND MCM3-ENG 221027

3
[Link] | 1-833-870-5500 (TTY: 711 or [Link])
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NC Medicaid Ombudsman
The NC Medicaid Ombudsman can offer help if you cannot get access to health care, connect
you to other resources, and help you understand your rights and responsibilities.
Go to [Link]. Or call 1-877-201-3750, 8 a.m. to 5 p.m., Monday through
Friday. The call is toll free.

Thank you,
NC Medicaid Team

MEDICAID EB MAND MCM3-ENG 221027

4
[Link] | 1-833-870-5500 (TTY: 711 or [Link])
 Services covered outside health
plans, drug list, and copays

Services covered outside health plans

You can get these services from a provider outside of the health plan’s network,
as long as the provider takes Medicaid:
• Dental services
• Services provided by Local Education Agencies included in your child’s:
{ Individualized Education Program (IEP)

{ Individualized Family Service Plan (IFSP)

{ Section 504 Accommodation Plan (504 Plan)

{ Individual Health Plan (IHP)

{ Behavior Intervention Plan (BIP)

• Services provided by Children’s Developmental Services Agencies (CDSAs) or

providers contracted with CDSAs that are included in your child’s Individualized
Family Service Plan
• The fabrication of eyeglasses including complete eyeglasses, eyeglass lenses and
eyeglass frames
{ A provider in the health plan’s network will fit the NC Medicaid Direct eyeglasses

and give them to you

• Services provided before Medicaid eligibility determination
Drug formulary (list)
To learn more about your prescription drug benefits under NC Medicaid, use the NC
Medicaid Preferred Drug List (PDL) on the Learn page at [Link].

Copays
Some health plan members may have a copay. A copay is a fee you pay when you
get certain health care services or prescriptions.
Medicaid copays:
Service Your copay
• Chiropractic visits $4 per visit
• Doctor visits
• Non-emergency and emergency department visits
MEDICAID EB ENROLLMENT PACKET INSERT CMS-1 ENG 230401

• Optometrist and optical visits

• Outpatient visits
• Podiatrist visits
• Generic and brand prescriptions $4 per prescription

Questions? Go to [Link]. Or call us toll free at 1-833-870-5500

(TTY: 711 or [Link]). We can speak with you in other languages.
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 There are no Medicaid copays for:
• Members under age 21
• Members who are pregnant
• Members getting hospice care
• Federally recognized tribal members
• North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
• People living in an institution getting coverage for cost of care
• Children in foster care
• Behavioral health, intellectual/developmental disability (I/DD) or traumatic brain injury
(TBI) services

You can get free auxiliary aids and services, including

information in other languages or formats such as large
MEDICAID EB ENROLLMENT PACKET INSERT CMS-1 ENG 230401

print or audio. Call us toll free at 1-833-870-5500.

ATTENTION: For free Español (Spanish) 繁體中文 (Chinese)
interpreter services, ATENCIÓN: Para servicios 注意：如需免費的口譯員服
call 1-833-870-5500 gratuitos de un intérprete, llame 務，請撥打 1-833-870-5500
(TTY: 711 or [Link]). al 1-833-870-5500 (número (TTY: 711 或 [Link])
de TTY: 711 o [Link]).

NC Medicaid complies with applicable federal civil rights laws and does not discriminate
based on race, color, national origin, age, disability or sex.
 Enrollment Form
Use this form to change a health care option and PCP for each person
listed. Or enroll online, using the mobile app, or by phone.

Change your health care option in one

 33233826EF
of these ways:
1. Go to [Link].
2. Use the free NC Medicaid Managed
ANTINEA M CARPENTER Care mobile app.
1538 1/2 BINGHAM DR
FAYETTEVILLE NC 28304 0000 3. Call us toll free at 1-833-870-5500.
(TTY: 711 or [Link])
4. Fill out this form and mail it to us
in the envelope provided. Or fax it
to 1-833-898-9655.

Person 1 SOULE SMITH, 09/29/2002 ID Number: 947166125L

⊲ Choose one health care option.
¨ WellCare ¨ HealthyBlue ¨ Carolina Complete Health
¨ UnitedHealthcare Community Plan ¨ AmeriHealth Caritas
⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)

Do you want this PCP for everyone listed on this form? ■ Yes ■ No
Person 2 ZAYA CARPENTER, 08/24/2007 ID Number: 949461691K
⊲ Choose one health care option.
¨ WellCare ¨ HealthyBlue ¨ Carolina Complete Health
¨ UnitedHealthcare Community Plan ¨ AmeriHealth Caritas
⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)
MEDICAID EB ENROLL FORM | 6 PERSON | ENG 220201

Person 3 ID Number:
⊲ Choose one health care option.

⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)

Questions? Go to [Link]. Or call us toll free at 1-833-870-5500

(TTY: 711 or [Link]). We can speak with you in other languages.

You can get free auxiliary aids and services, including information
in other languages or formats such as large print €2NtDA?_q'Bf'M+

or audio. Call us toll free at 1-833-870-5500.

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 Person 4 ID Number:
⊲ Choose one health care option.

⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)

Person 5 ID Number:
⊲ Choose one health care option.

⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)

Person 6 ID Number:
⊲ Choose one health care option.

⊲ Choose a primary care provider (PCP). Make sure the PCP is in the health care option you choose.
PCP’s first and last name or Organization name PCP’s phone number (optional)
( )
PCP’s address (street, city, state, ZIP Code)

If a Medicaid member is not listed on this Enrollment Form:

■ Call us toll free at 1-833-870-5500 (TTY: 711 or [Link]). Or
■ Write the member’s name and ID number in a blank space on this form. Then choose the
member’s health care option and primary care provider (PCP).

Sign and date

MEDICAID EB ENROLL FORM | 6 PERSON | ENG 220201

⊲ Head of household or guardian sign here Date

⊲ Authorized representative If you are an authorized representative for this household, fill out this
section and sign below.
Name of authorized representative Phone number
( )
Address (street, city, state, ZIP Code)

⊲ Authorized representative sign here Date

2
 Health Care Option Guide
All health care options are required to have the same basic Medicaid services you get now. These include:
¡ Doctor visits ¡ Hospital visits ¡ Behavioral health care ¡ Prescriptions ¡ Eye care
¡ Medical supplies ¡ Lab tests and X-rays ¡ Therapies ¡ Hospice ¡ Care management
To see the full list of NC Medicaid covered services provided by the health care options,
go to [Link]. Some health care options also have added services.
STANDARD PLAN TAILORED PLAN NC MEDICAID DIRECT EBCI TRIBAL OPTION

005-008-00002987
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A North Carolina A North Carolina Medicaid health North Carolina’s health care program for Medicaid The primary care case
Medicaid health plan. plan. It offers physical health, beneficiaries who are not enrolled in NC Medicaid management entity (PCCMe)
It offers physical pharmacy, care management and Managed Care. It includes care coordination provided by created by the Cherokee Indian
health, pharmacy, behavioral health services. It is for Community Care of North Carolina (CCNC), the primary care Hospital Authority (CIHA). It
care management and members who may have a serious case management entity (PCCMe). There are four Local includes care coordination
basic behavioral health mental illness, severe substance Management Entity/Managed Care Organizations (LME/MCOs) by Vaya Health for a serious
services for members. use disorder, intellectual/ that coordinate services for a serious mental illness, severe mental illness, severe substance
developmental disability (I/DD) or substance use disorder, intellectual/developmental disability use disorder, intellectual/
traumatic brain injury (TBI). (I/DD) or traumatic brain injury (TBI). developmental disability (I/DD)
or traumatic brain injury (TBI).
Who qualifies Who qualifies for this option? Who qualifies for this option? Who qualifies for this option?
for this option? ƒ People who may have a ƒ Children in foster care ƒ Federally recognized tribal
ƒ Most families and serious mental illness, severe ƒ Children who get adoption assistance members or others eligible
children substance use disorder, ƒ Children who get Community Alternatives Program for Children for Indian Health Service (IHS)
ƒ Pregnant women intellectual/developmental (CAP/C) services who live in the following
ƒ People who are disability (I/DD) or traumatic counties: Buncombe,
ƒ Federally recognized tribal members or others eligible for
blind or disabled brain injury (TBI) Clay, Cherokee, Graham,
Indian Health Service (IHS)
and not receiving ƒ People who get Innovations Haywood, Henderson,
ƒ People in the Health Insurance Premium Payment (HIPP) program
MEDICAID EB TP HCOG SUMMARY ENG 241021

Medicare Waiver services Jackson, Macon, Madison,

ƒ People in the Program for All-Inclusive Care for the Elderly (PACE) Swain, Transylvania
ƒ Federally ƒ People who get Traumatic
Brain Injury (TBI) Waiver ƒ People who are medically needy
recognized tribal
members or others services ƒ People who get Community Alternatives Program for Disabled
eligible for Indian Adults (CAP/DA) services
Health Service (IHS) ƒ People who get Family Planning Medicaid only
ƒ People who get Medicaid and Medicare
ƒ People who may have a serious mental illness, severe
substance use disorder, intellectual/developmental disability (I/
DD) or traumatic brain injury (TBI)
Questions? Go to [Link]. Or call us toll free at 1-833-870-5500 (TTY: 711 or [Link]). We can speak with you in other languages.
You can get free auxiliary aids and services, including information in
other languages or formats such as large print or audio.
Page intentionally left blank.
 Standard Plan
To read the short list of added services that each Standard Plan offers, turn the page. To see the full list of added services, go to
[Link]. Some services may only be available for members who qualify. For questions, call us toll free at 1-833-870-5500
(TTY: 711 or [Link]).

006-008-00002988
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1-866-799-5318 1-800-349-1855 1-844-594-5070 1-855-375-8811 1-833-552-3876
TTY: 711 TTY: 711 TTY: 711 TTY: 1-866-209-6421 TTY: 711
[Link] [Link]/ [Link] [Link] [Link]
northcarolina
7 a.m. to 6 p.m., 7 a.m. to 6 p.m., 24 hours a day, 7 a.m. to 6 p.m.,
Monday through Saturday 7 a.m. to 6 p.m., Monday through Saturday 7 days a week Monday through Saturday
Monday through Saturday
MEDICAID EB HCOG S2 ENG 231031

Statewide Statewide Statewide Statewide

Only available
(all 100 counties) (all 100 counties) (all 100 counties) (all 100 counties)
in the counties listed below
Carolina Complete Health is only available in these counties: Alamance, Alexander, Anson, Bladen, Brunswick, Cabarrus, Caswell, Catawba, Chatham, Cleveland,
Columbus, Cumberland, Durham, Franklin, Gaston, Granville, Harnett, Hoke, Iredell, Johnston, Lee, Lincoln, Mecklenburg, Montgomery, Moore, Nash, New Hanover,
Orange, Pender, Person, Richmond, Robeson, Rowan, Sampson, Scotland, Stanly, Union, Vance, Wake, Warren, Wilson
Please turn the page for added services 
Questions? Go to [Link]. Or call us toll free at 1-833-870-5500 (TTY: 711 or [Link]). We can speak with you in other languages.
You can get free auxiliary aids and services, including information in
other languages or formats such as large print or audio.
 Education Education Education Education Education
ƒ School supplies, ages ƒ Up to $50 in gift cards for ƒ Up to $50 per year for school ƒ Coaches, vouchers for ƒ 24 hours online tutoring math
5-18 ($50 value) students who qualify supplies after well child visit, GED, HiSET, or TASC & reading, grades K-6
ƒ Free tutoring, all school ƒ GED exam voucher and ages 6-18 ƒ School supplies, grades
subjects, ages 8-18 materials ƒ $25 gift card to Footlocker or Prenatal Pre-K-12 ($50 value)
Old Navy, grade 11 or 12 with a ƒ Free electric non-medical ƒ Digital GED exam vouchers,
Prenatal Prenatal 3.5 GPA or higher breast pump, milk ages 16 and up
ƒ Free doula care for high- ƒ Baby products, breast ƒ Up to 24 hours per year storage bags
risk pregnancies pumps, lactation support, virtual one-on-one tutoring, ƒ In-home prenatal, well- Prenatal
ƒ Baby showers and choice doula care, and rewards ages 6-18 child care visits for high- ƒ Up to $150 new parent’s
of stroller, playpen, car ($2200 value) risk pregnancies package
seat, or diapers Prenatal
Wellness ƒ 2 items from catalog (ex: Wellness Wellness
Wellness ƒ 6 months fresh produce stroller, car seat) for pregnant ƒ 6 months ƒ My Health Pays Visa®
ƒ Up to $75 dollar reward for members who qualify members who complete 1 WeightWatchers (WW®) rewards card for those who
for completing healthy ($240 value) prenatal visit ƒ Up to $75 per year complete healthy activities
activities ƒ Yearly gym memberships, ƒ Free licensed doula after rewards card for food ƒ Up to $300 asthma support
ƒ Asthma control program, $75 youth YMCA voucher 1 prenatal visit, some areas and OTC health items program with supplies, ages
with supplies up to ƒ Up to $25 each for 1st prenatal ƒ Rides to & from provider 16 and under
$1500 value Youth / postpartum care visit visits, community ƒ WeightWatchers (WW®)
ƒ Free 6-month ƒ $75 gift card for products ƒ Rides to birthing or Lamaze services weight management
WeightWatchers (WW®) that support ADHD / Autism classes
ƒ Free ASH Fitness gym diagnosis Youth Youth
ƒ Home-delivered meals Wellness ƒ Home visits for youth to ƒ $75 per year sports, activities
Other address asthma voucher, ages 6-18
ƒ 13-week WeightWatchers
Youth ƒ $100 yearly for vitamins, (WW®) voucher ƒ Free yearly Boys & Girls
massage, and acupuncture ƒ $75 for health and wellness Club membership, up to Other
ƒ Free Boy & Girl Scouts,
4H Club, or Boys & Girls ƒ Free virtual doctor visits by visits age 18 ƒ $125 per year for glasses,
Club mobile app, 24/7 contacts, vision items, ages
ƒ Smartphone with free Youth Other 21 and up
Other monthly unlimited data ƒ Up to $150 yearly for after ƒ 14 home-delivered meals ƒ Cell phone with free monthly
MEDICAID EB HCOG S2 ENG 231031

ƒ Up to $250 per year for ƒ HEPA Filter Vacuum, school activities, ages 6-18 after hospital stay 250 minutes, calls, and texts
rent deposits / utilities hypoallergenic pillowcase / ƒ Extra pair of glasses, with providers
ƒ Rides to provider and mattress covers Other eye exam every 2 years,
classes ƒ 14 home-delivered meals ƒ Choice of asthma kit for ages 21-64
after hospital stay adults or children
 Help in Other Languages
ATTENTION: If you do not speak English, you can get free language services, such as written
translation and oral interpretation. You can also get free auxiliary aids and services or ask to
get information in other formats, such as large print or audio. Call us toll free at
1-833-870-5500 (TTY: 711 or [Link]).
SPANISH Español ATENCIÓN: Si no habla inglés, puede obtener servicios gratuitos de idiomas,
como traducción escrita e interpretación oral. También puede pedir ayuda y servicios
auxiliares gratuitos, incluida información en otros formatos como letra grande o audio.
Llámenos gratis al 1-833-870-5500 (número de TTY: 711 o [Link]).
SIMPLIFIED CHINESE 简体中文 | 注意：如果您不会说英语，您可以获得免费的语言服务，
例如笔译和口译。您还可以获得免费的辅助工具和服务，或要求获取其他格式的信息，
例如大字体或音频。请给我们打电话（免费），电话号码： 1-833-870-5500
（TTY 用户：711 或 [Link]）。
VIETNAMESE TIẾNG VIỆT LƯU Ý: Nếu bạn không nói được tiếng Anh, bạn có thể nhận được
dịch vụ hỗ trợ về ngôn ngữ miễn phí, như dịch vụ biên dịch và phiên dịch. Bạn cũng có thể
nhận được các thiết bị và dịch vụ hỗ trợ thính giác miễn phí hoặc yêu cầu nhận thông tin bằng
các định dạng khác, ví dụ như các bảng chữ in lớn hoặc bản ghi audio. Gọi miễn phí số
1-833-870-5500 (TTY: 711 hoặc [Link])
KOREAN 한국어 주의: 영어로 의사소통이 힘든 경우, 무료 언어 서비스(예: 서면 번역
및 구두 통역)를 요청하실 수 있습니다. 또한 무료 보조 지원과 서비스를 받거나, 다른
형식(예: 큰 활자체나 오디오)으로 정보를 요청하실 수 있습니다. 수신자 부담 전화
1-833-870-5500 (TTY: 711 또는 [Link]) 번으로 문의하시기 바랍니다.
FRENCH FRANÇAIS ATTENTION : si vous ne parlez pas anglais, des services d’aide linguistique
vous sont proposés gratuitement, comme une traduction écrite et une interprétation orale.
Une assistance et des services complémentaires vous sont également proposés et vous pouvez
demander d’obtenir des informations dans d’autres formats, comme en gros caractères ou en
audio. Appelez-nous gratuitement au 1-833-870-5500 (TTY : 711 ou [Link]).

‫ﯾﻣﻛﻧك اﻟﺣﺻول ﻋﻠﻰ ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ ﻣﺛل‬، ‫إذا ﻛﻧت ﻻ ﺗﺗﺣدث اﻟﻠﻐﺔ اﻹﻧﺟﻠﯾزﯾﺔ‬: ‫ ﺗﻧﺑﯾﮫ‬ARABIC
‫ ﻛﻣﺎ ﯾﻣﻛﻧك اﻟﺣﺻول ﻋﻠﻰ وﺳﺎﺋل وﺧدﻣﺎت ﻣﺳﺎﻋدة أو طﻠب ﻣﻌﻠوﻣﺎت‬.‫ﺑﺎﻟﻣﺟﺎن‬، ‫اﻟﺗرﺟﻣﺔ اﻟﻣﻛﺗوﺑﺔ أو اﻟﺷﻔﺎھﯾﺔ‬
1-833-870-5500 ‫اﺗﺻل ﻋﻠﻰ اﻟرﻗم اﻟﻣﺟﺎﻧﻲ‬. ‫ﺑﺄﺷﻛﺎل أﺧرى ﻛﺎﻟﻛﺗﺎﺑﺔ ﺑﺧط ﻛﺑﯾر أو اﻟﺗﺳﺟﯾل اﻟﺻوﺗﻲ‬
([Link] ‫أو ﻋﺑر اﻟﻣوﻗﻊ‬: 711 ‫)ﻟﺿﻌﺎف اﻟﺳﻣﻊ‬
HMONG HMOOB NCO NTSOOV: Yog koj tsis hais lus Askiv, yuav muab kev pab txhais lus pub
dawb rau koj, xws li txhais ntawv thiab txhais lus. Koj tseem tuaj yeem tau txais kev pab cuam
MEDICAID EB NON DISCRIM ENG 210924

thiab kev pab los sis thov cov txheej xwm ua lwm hom ntawv, xws li luam ua tus ntawv loj los
sis ua suab. Hu rau peb tus xov tooj hu dawb ntawm 1-833-870-5500 (TTY: 711 los sis
[Link]).

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 RUSSIAN РУССКИЙ ВНИМАНИЕ: Если вы говорите на русском языке, вам доступны
бесплатные языковые услуги, такие как письменный и устный перевод. Вы также можете
получить бесплатные вспомогательные средства и услуги или попросить предоставить
информацию в других форматах, например, крупным шрифтом или в аудиозаписи.
Позвоните нам по бесплатному телефону 1-833-870-5500 (TTY: 711 или [Link]).
TAGALOG ATENSYON ng Tagalog: Kung hindi ka nagsasalita ng Ingles, makakakuha ka ng mga
libreng serbisyo sa wika, tulad ng nakasulat na pagsasaling-wika at oral na interpretasyon.
Maaari ka ring makakuha ng mga libreng auxiliary aid at mga serbisyo o humingi ng
impormasyon sa mga ibang anyo, tulad ng malaking print o audio. Tawagan kami nang toll free
sa 1-833-870-5500 (TTY: 711 o [Link]).
GUJARATI !ુજરાતીઓ )યાન આપો: જો તમે !ુજરાતી બોલો છો અને અં6ે7 બોલતા નથી, તો તમે લેiખત અ;ુવાદ અને
મૌiખક અથ@ઘટન જે વી મફત ભાષકFય સેવાઓ મેળવી શકો છો. તમે મફત સહાયક મદદ અને સેવાઓ પણ મેળવી શકો છો
અથવા iવMNૃત iQRટ અથવા ઓiડયો જે વા અRય MવUપમાં માiહતી મેળવવા માટે કહF શકો છો,. અમને ટોલ VF નંબર
1-833-870-5500 (TTY: 711 અથવા [Link])પર કોલ કરો.

CAMBODIAN !"ែខ% រ (បយ័ត- ៖ េប0អ- កមិនេចះនិ8យ!"អង់េគ< ស អ- ក>ចទទួ លBនេសC!"

េDយឥតគិតៃថ< ដូ ចJKរបកែ(បJអកLរ និងKរបកែ(បMNល់Oត់។ អ- កក៏>ចទទួ លជំនួយ និងេសCកម%
េDយឥតគិតៃថ< ផងែដរ ឬ>ចេស- 0សុំព័ត៌OនJទ(មង់េផLងេទYត ដូ ចJអកLរពុមZ ធំ ឬJសេម< ង។
េ\ទូ រសពN មកKន់េយ0ង]មេលខ 1-833-870-5500 (TTY: 711 ឬ [Link])។

GERMAN Deutsch ACHTUNG: Wenn Sie kein Englisch sprechen, können Sie kostenfreie
Sprachdienste wie schriftliche Übersetzung und mündliches Dolmetschen erhalten. Sie können
außerdem kostenfreie Hilfsmittel und Services erhalten oder Informationen in anderen
Formaten (z. B. Großdruck oder Audio) anfordern. Rufen Sie uns kostenfrei an unter
1-833-870-5500 (TTY: 711 oder [Link]).

HINDI !हंद% 'यान द+ : य!द आप !हंद% बोलते ह4, तो आप म8

ु त भाषा सेवाएं >ा?त कर सकते
ह4, जैसे DलEखत अनुवाद और मौEखक JयाKया। आप मु8त सहायक सहायता और सेवाएं भी
>ा?त कर सकते ह4 या अNय >ाOपP, जैसे Qक बड़े S>ंट या ऑVडयो म+ जानकार% >ा?त करने के
Dलए कह सकते ह4। हम+ टोल XY 1-833-870-5500 (TTY: 711 या [Link]) पर कॉल कर+ ।

LAOTIAN: ຖ ້ າທ ່ ານເວ ົ ້ າພາສາອັງກ ິ ດບ ່ໍ ເປ ັ ນ, ທ ່ ານສາມາດໄດ ້ ຮັບການບ ໍ ິ ລການຟຣ

ີ ດ
້ ານພາສາ,
່ເຊັ ນການແປເປ ັ ນລາຍລັກອັກສອນແລະການແປພາສາໂດຍການເວ ້
ົ າ.
ທ ່ ານຍັງສາມາດໄດ ້ ຮັບເຄ ່ ື ອງຊ ່ ວຍເຫ
ື ຼ ອແລະການບ ໍ ິ ລການເສ
ີ ມຟຣ ີ
ືຫ
ຼ ຖາມເພ ່ື ອໄດ ້ ຮັບຂ ໍ້ ມ ູ ນໃນຮ ູ ບແບບອ ່ື ນໆ, ເຊ
່ ັ ນການພ ິ ມໃຫຍ ່ ືຫ
ຼ ສຽງ.
ໂທຫາພວກເຮ ົ າໄດ ້ ຟຣ ີ ່ີທເບ ີ ໂທ 1-833-870-5500 (TTY: 711 ືຫ ຼ ່ີທ [Link])
MEDICAID EB NON DISCRIM ENG 210924

JAPANESE 日本語 注意事項：英語を話さない方には、書面による翻訳や口頭での通訳

などの言語支援を無料で提供しています。また、補助器具や支援サービスを無料で受
けることもでき、大きな文字サイズや音声など様々なフォーマットの情報提供も可能
です。無料番号 1-833-870-5500 (TTY: 711 または [Link]) までお電話にてご連絡く
ださい。
 Notice of Non-Discrimination
NC Medicaid complies with applicable federal civil rights laws and does not discriminate
based on race, color, national origin, age, disability, creed, religious affiliation, ancestry,
sex, gender identity or expression, or sexual orientation. NC Medicaid does not exclude
people or treat them differently because of race, color, national origin, age, disability, creed,
religious affiliation, ancestry, sex, gender, gender identity or expression, or sexual orientation.
NC Medicaid provides free aids and services to people with disabilities to communicate
effectively with us, such as:
§ Qualified sign language interpreters
§ Written information in other formats (large print, audio, accessible electronic formats,
other formats)
NC Medicaid provides free language services to people whose primary language is not
English, such as:
§ Qualified interpreters
§ Information written in other languages
If you need these services, contact NC Medicaid toll free at 1-833-870-5500
(TTY: 711 or [Link]). If you believe that NC Medicaid has failed to provide these
services or discriminated in another way based on race, color, national origin, age,
disability, or sex, you can file a grievance with:
DHHS ADA/RA Complaints
Office of Legal Affairs
2001 Mail Service Center
Raleigh, NC 27699-2001
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, the Office of Legal Affairs is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights:
§ electronically through the Office for Civil Rights Complaint Portal, available at
[Link]/ocr/portal/[Link]
§ by mail at:
U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building
MEDICAID EB NON DISCRIM ENG 210924

Washington, DC 20201; or
§ by phone at 1-800–368–1019 (TDD: 1-800–537–7697)
Complaint forms are available at [Link]/ocr/office/file/[Link].

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