Who is on the NC Medicaid exclusion list?

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The NC Medicaid Exclusion List includes healthcare providers, individuals, and business entities that are barred from participating in or receiving reimbursement from federal or state healthcare programs due to program violations.

Who Appears on the List?

  • Healthcare Providers: Doctors, nurses, pharmacists, and other individual medical practitioners who violated state or federal rules.
  • Business Entities: Clinics, agencies, pharmacies, or corporate entities terminated for cause from North Carolina Medicaid.
  • Associated Identifiers: Anyone listed includes their specific National Provider Identifier (NPI) or atypical IDs tied to the violation.

Reasons for Exclusion

  • Program Violations: Fraud, abuse, or waste within Medicare, Medicaid, or NC Health Choice.
  • Criminal Convictions: Offenses related to patient neglect, patient abuse, or felony healthcare/controlled substance convictions.
  • State Actions: Direct termination or barring by the North Carolina Medicaid's Office of Compliance and Program Integrity (OCPI).

How the List Works

  • Updates: The state list is updated on a monthly basis by the North Carolina Department of Health and Human Services (NCDHHS).
  • Duration: An individual or entity remains on the list until officially removed by the state.
  • Compliance Impact: Services rendered, ordered, or referred by anyone on this list are non-payable, and employing them can result in severe financial penalties.

You can view or download the active database directly from the NC Medicaid Excluded Providers Page.

What is a Medicaid exclusion list?

A Medicaid exclusion list is an official database of healthcare providers, individuals, and businesses barred from receiving government funds for medical services.

Why People Are Excluded

  • Fraud: Billing for services not rendered or faking claims.
  • Abuse: Patient neglect, abuse, or mistreatment.
  • Criminal Acts: Felony convictions related to healthcare finance or controlled substances.
  • Licensure Issues: Losing or having a professional medical license revoked.

Federal vs. State Lists

Rules for Healthcare Employers

  • No Reimbursement: Facilities cannot bill Medicaid or Medicare for care provided by anyone on these lists.
  • Monthly Checks: Organizations must screen all employees and contractors monthly to avoid heavy fines.

What are the income limits for North Carolina Medicaid in 2026?

In North Carolina for 2026, the general income limit for adult Medicaid expansion (ages 19–64) is 138% of the Federal Poverty Level (FPL), which is approximately $1,835 per month ($22,025 per year) for a single individual.

Income limits vary by household size and specific eligibility category. You can review the official details on the NC Medicaid Eligibility Guide.

Income Limits by Category (Effective 2026)

  • ACA Expansion Adults (Ages 19–64): 138% FPL (approx. $1,835/month for a single person; $2,435 for a household of 2)
  • Children (Ages 0–18): Up to roughly 211% to 216% FPL (e.g., about $3,806/month or less for a household of 2)
  • Pregnant Individuals: Up to roughly 196% to 201% FPL (e.g., about $4,463/month or less for a household of 2, counting the unborn child)
  • Aged, Blind, and Disabled (ABD) / Long-Term Care (CAP/DA Waiver): Generally capped around 100% FPL, or about $1,305 per month for a single applicant

What is a CMS exclusion list?

A CMS exclusion list usually refers to the CMS Preclusion List, a roster of health care providers, suppliers, and prescribers who are barred from receiving payments or reimbursements under Medicare Advantage (Part C) and Medicare Part D.

People also sometimes confuse it with the OIG List of Excluded Individuals/Entities (LEIE), which is a broader federal exclusion database.

Key Details of the CMS Preclusion List

  • Purpose: It blocks bad actors from getting federal funds and protects patients. It stops payments for items, services, or prescription drugs ordered or provided by listed individuals.
  • Who is on it:
    • Providers and prescribers with an active Medicare revocation and re-enrollment bar.
    • Un-enrolled individuals or entities that engaged in behavior deemed detrimental to the Medicare program.
    • People convicted of a state or federal felony within the past 10 years that CMS finds harmful to Medicare.
  • Duration: Restrictions usually last between 1 and 10 years, matching the length of the provider's re-enrollment bar.
  • Transparency: Unlike the public OIG list, the CMS Preclusion List is not fully open to the general public; it is shared directly with Medicare Advantage plans and Part D sponsors so they can deny claims.

CMS Preclusion List vs. OIG Exclusion List

  • CMS Preclusion List: Focuses strictly on blocking reimbursement under Medicare Part C and Part D. Providers are notified directly by mail.
  • OIG LEIE List: A public database maintained by the Department of Health and Human Services. It bars individuals and entities from all federally funded health care programs (including original Medicare and Medicaid).

How to get off Medicaid exclusion list?

To get off a federal or state Medicaid exclusion list, you must formally apply for reinstatement once your mandatory or permissive exclusion period ends, as removal is not automatic.

1. Check Your Eligibility Timing

  • Federal LEIE (OIG): You can submit your written reinstatement request starting 90 days before your defined exclusion period ends. Sending an application early will result in it being ignored.
  • State Medicaid Lists: State-specific exclusions operate independently from the federal Office of Inspector General (OIG). You must clear both the federal Office of Inspector General Reinstatements and your specific state's Medicaid agency exclusion list (such as Ohio Medicaid Provider Exclusion or your local state equivalent).

2. Prepare the Application Package

  • Written Request: Include your full name, aliases, date of birth, phone number, email address, and mailing address.
  • Supporting Documentation: Provide proof that your exclusion term is complete, any underlying professional licenses have been reinstated or resolved, and any required notarized statement or authorization forms are completed.
  • Submission: Submit your request to the federal level via email at [email protected] or mail it to the HHS OIG Exclusions Branch in Washington, DC. Submit separate paperwork to your state Medicaid office if you were suspended at the state level.

3. Await Review

  • The review process takes 120 days or longer.
  • If approved, you will receive written confirmation, and your name will be removed from the database.
  • If denied, you typically must wait one full year before you can reapply.

Medicaid Right and Eligibility - Medicaid Billing in North Carolina (4/25/25)

9 related questions found

Who is on the NC Medicaid excluded provider list?

You can access the official NC Medicaid Excluded Providers list directly on the North Carolina Department of Health and Human Services website.

Overview of the NC Medicaid Excluded Provider List

  • Definition: Excluded providers are individuals or legal entities barred from Medicare, NC Medicaid, and other federal or state healthcare programs due to violations. They cannot bill or receive reimbursement.
  • Update Frequency: The North Carolina Division of Health Benefits updates the Provider Termination and Exclusion list monthly.
  • Duration: A termination or exclusion stays in effect until the provider is officially removed from the state list.
  • Compliance Requirement: Healthcare organizations must screen this state-specific list alongside federal databases like the OIG LEIE and SAM.gov, because state exclusions do not always appear on federal records.

Questions & Support

What are exclusion lists?

An exclusion list is an official register of people or organizations banned from receiving government funds, contracts, or program participation due to fraud, misconduct, or safety violations.

Key Types of Exclusion Lists

  • List of Excluded Individuals/Entities (LEIE): Maintained by the U.S. Department of Health and Human Services' Office of Inspector General (OIG), this federal healthcare database bars named providers from Medicare, Medicaid, and other federal programs.
  • SAM.gov Exclusions: Formerly the Excluded Parties List System (EPLS), this federal system tracks individuals and contractors barred from receiving general federal procurement contracts, grants, or non-healthcare financial assistance.
  • State Medicaid Lists: Individual state agencies maintain separate databases to bar specific providers or entities from state-funded health benefit programs.

Why Exclusion Lists Matter

  • Payment Ban: Federal and state programs cannot legally pay for any goods or services ordered, prescribed, or furnished by an excluded party.
  • Legal Penalties: Businesses and healthcare groups that hire or contract with anyone on an exclusion list face heavy civil monetary penalties, fines, and potential exclusion from federal programs themselves.
  • Compliance Standard: Most industries affected by these rules require initial screening at hiring and regular monthly checks of databases to verify active credentials.

What income is too high for Medicaid?

For most adults in states that expanded Medicaid, any household income above 138% of the Federal Poverty Level (FPL) is too high for standard adult Medicaid.

In 2026, 138% of the FPL equals about $1,481 per month (or roughly $17,773 per year) for a single individual. For a family of three, it is about $2,530 per month (or roughly $30,302 per year).

General Income Limits

  • Expanded States: Adults under 65 usually qualify if income is at or below 138% FPL.
  • Non-Expansion States: Limits are often much lower. Adults without children, disabilities, or pregnancy often do not qualify at all if they make over a few hundred dollars a month.
  • Children and Pregnant Individuals: Income limits are much higher, often ranging from 200% to over 300% of the FPL, depending on the state.
  • Long-Term Care / Seniors (65+): Gross monthly limits for nursing homes or home care are typically capped around $2,982 per month for an individual in many states, though excess income can sometimes be placed into a special trust.

What If Your Income Is Too High?

  • Marketplace Insurance: If you make too much for Medicaid, you may qualify for tax credits to buy a plan on HealthCare.gov.
  • Spend-Down Programs: Some states let you subtract high medical bills from your income to reach the eligibility limit.

What are the new Medicaid rules in NC?

New federal and state rules are reshaping North Carolina Medicaid, introducing stricter eligibility for noncitizens, mandatory work requirements, and more frequent renewals.

Noncitizen Eligibility Changes (Effective October 1, 2026)

  • Narrowed Coverage: Most lawfully present noncitizens without a green card (such as refugees, asylees, and people with humanitarian visas) lose full NC Medicaid eligibility.
  • Key Exemptions: Green card holders, lawfully residing children under 19, pregnant or postpartum individuals, Cuban/Haitian entrants, and Freely Associated States citizens still qualify.
  • Emergency Care: Undocumented immigrants and those losing full coverage can still access Emergency Medicaid for acute medical emergencies.

Work and Community Engagement Requirements (Effective January 1, 2027)

  • Mandatory Hours/Earnings: Expansion adults ages 19 through 64 must complete at least 80 hours per month of work, school, or volunteering, or earn a minimum of $580 monthly per household.
  • Exemptions: Rules do not apply to individuals determined to have a disability, pregnant women (and those who were pregnant in the past 12 months), or primary caretakers of a child under age 14 or a disabled person.
  • Stricter Reapplication: If coverage is lost, individuals must meet the work requirement for three consecutive months before reapplying.

Renewals and Retroactive Coverage (Effective January 1, 2027)

  • Frequent Renewals: Eligibility redeterminations for expansion adults change to every 6 months instead of annually.
  • Shorter Retroactive Period: Retroactive coverage for medical bills before application is reduced to 1 month for working-age adults (2 months for elderly, disabled, and children).

You can track updates and official guidance directly through the NC Medicaid Changes Portal.

How often does Medicaid check your bank account?

Medicaid does not check your bank account on a continuous or daily schedule, but rather reviews your finances at specific key milestones.

When Medicaid Checks Your Bank Account

  • Initial Application: Your accounts are checked when you first apply to verify that your resources meet the state's financial eligibility rules.
  • Annual Renewals: Most beneficiaries must renew their eligibility once a year, prompting a yearly review of updated financial information or asset data.
  • Life and Financial Changes: If you report a major change—such as an inheritance, property sale, or increase in income—the agency may re-evaluate your accounts.
  • Discrepancies: If automated electronic systems flag an inconsistency, a manual review or request for bank statements can happen at any time.

How the Check Works

  • Asset Verification System (AVS): For programs that require an asset test (such as for seniors, individuals with disabilities, or long-term care), states use an electronic Asset Verification System to query financial institutions for account balances. AVS shows balances and active accounts, not full daily transaction histories unless requested.
  • The 60-Month Look-Back: For nursing home care or long-term services, Medicaid applies a 5-year (60-month) look-back period to review past asset transfers and large financial gifts.
  • MAGI Groups: If you apply under expansion rules (such as adults aged 19–64, parents, or pregnant individuals based on Modified Adjusted Gross Income), states generally do not check bank balances or enforce an asset limit—they only look at income.