North Carolina was one of the most recent states to expand Medicaid under the ACA. That changes the calculus for marketplace shoppers in the state, especially lower-income adults who previously had limited options.
If you live in North Carolina, the federal marketplace at HealthCare.gov handles QHPs with premium tax credits. NC Department of Health and Human Services handles Medicaid, and the county Department of Social Services is often the on-the-ground application point.
Medicaid expansion in North Carolina
The state implemented Medicaid expansion effective December 1, 2023. Adults up to 138 percent of the federal poverty level can qualify for NC Medicaid, including:
- Adults without dependents
- Parents and caretaker relatives
- Many adults who were in the coverage gap before expansion
Previous Medicaid categories continue (pregnant women, children, people with disabilities, seniors, very low-income parents).
Existing Medicaid enrollees did not have to re-apply. New eligibility under expansion required new applications, though the state and federal marketplace coordinated automatic referrals for some marketplace enrollees.
What changed for marketplace shoppers
If you were on a subsidized marketplace plan and your income falls below 138 percent of FPL, you likely became Medicaid-eligible. Two things can happen:
The marketplace, at renewal or income update, refers you to Medicaid.
You separately apply through NC DHHS or your county DSS.
When the transition is complete, you usually move off the marketplace plan and onto Medicaid.
Medicaid coverage is broader and typically cheaper out of pocket. The trade-off is provider networks and plan choices: NC Medicaid uses managed care plans (with carriers like AmeriHealth Caritas, Carolina Complete Health, Healthy Blue, UnitedHealthcare Community Plan, WellCare).
Above the Medicaid threshold: marketplace plans
If your income is above 138 percent of FPL, you can use the marketplace with a premium tax credit.
NC carriers typically include Blue Cross Blue Shield of NC, Cigna, Ambetter from NC Health Care, Aetna CVS Health, Oscar, and others. The exact list and availability depend on your county.
Blue Cross Blue Shield of NC has historically been the dominant carrier and the largest plan choice in many counties.
NC Medicaid for Children
After Medicaid expansion, NC Health Choice (the state CHIP program) merged in 2023 into NC Medicaid for children. Kids who had been on Health Choice moved to a single Medicaid program with more comprehensive benefits.
For families on a marketplace plan with kids who qualify for Medicaid, the kids are on Medicaid and parents are on a marketplace QHP. Applications are separate but coordinated.
Common North Carolina situations
A worked example. Family of three in Charlotte, household income $32,000.
Adults likely eligible for NC Medicaid expansion (under 138 percent of FPL for a family of three).
Child likely on NC Medicaid for Children.
Apply through HealthCare.gov, which routes the application to NC Medicaid, or apply directly through NC DHHS.
Another scenario. Self-employed consultant in Raleigh, household income $62,000.
Above Medicaid threshold.
Eligible for marketplace plan with premium tax credit.
Choice between BCBSNC and other carriers depending on Wake County options.
Another scenario. Single adult in Asheville, income $18,000.
Above 138 percent of FPL for a single person (around 138 percent of FPL in current numbers).
Eligible for marketplace plan with a strong premium tax credit. Silver-CSR plan likely the best choice.
Another scenario. Same single adult, income $14,000.
Likely now eligible for NC Medicaid expansion.
Apply through HealthCare.gov or NC DHHS.
Insurer and network considerations
NC hospital systems include Atrium Health, Novant Health, Duke Health, UNC Health, Cone Health, ECU Health (formerly Vidant), WakeMed, and others. Each carrier negotiates with each system separately.
Academic medical centers (Duke, UNC) often require specific in-network plans for non-emergency care.
Open Enrollment in North Carolina
The federal Open Enrollment schedule applies (November 1 through January 15 in recent years).
NC Medicaid has no Open Enrollment. You can apply year-round if you qualify.
Special Enrollment Periods follow the standard 60-day window for qualifying life events.
Things that catch North Carolina residents
Expansion-driven transitions. Many marketplace enrollees moved to Medicaid in 2024 and 2025. If you were on a marketplace plan with a subsidy and your income did not change, double-check whether you are still on a QHP or have moved to Medicaid.
Provider continuity. Moving from a marketplace plan to a Medicaid managed care plan can change which doctors and hospitals are in network.
Medicaid renewal. Annual redetermination is standard. Keep your address current with NC DHHS and respond to any renewal notice.
Rural network choices. Western and eastern NC counties often have fewer carrier options on the marketplace.
Where to get help
HealthCare.gov Find Local Help tool.
NC Navigator Consortium and other certified assister networks across the state.
County Department of Social Services for Medicaid applications.
Community health centers. NC Community Health Center Association lists FQHCs.
What to do next
If your income is uncertain, run the HealthCare.gov estimator and consider the Medicaid threshold.
If you might qualify for Medicaid under expansion, apply through HealthCare.gov or your county DSS.
For broader context, see marketplace vs Medicaid, Open Enrollment deadlines, and premium tax credit income.
Sources
Frequently asked questions
Did North Carolina expand Medicaid?
Yes. North Carolina expanded Medicaid under the ACA effective December 2023. Adults up to 138 percent of the federal poverty level can qualify.
Where do North Carolina residents apply?
HealthCare.gov for marketplace plans. NC DHHS or your county Department of Social Services for Medicaid.
What changed for marketplace shoppers when Medicaid expanded?
Many lower-income shoppers who were on subsidized marketplace plans became eligible for Medicaid. The transition can be automatic for some, but others have to apply separately.
What was NC Health Choice?
NC Health Choice was the state CHIP program for kids. After Medicaid expansion, many children formerly in NC Health Choice moved to NC Medicaid for Children, which has more comprehensive benefits.
