North Carolina Medicaid provides access to a range of medical services, including dermatological care, when the treatment is determined to be medically necessary. Access to a skin specialist, or dermatologist, is a covered benefit, but coverage is subject to specific state and federal guidelines and is heavily influenced by the patient’s assigned health plan. Understanding these rules is crucial for beneficiaries seeking treatment for skin, hair, or nail conditions within the state’s Medicaid system.
General Coverage Rules for Dermatological Care
The fundamental standard determining whether a dermatological service is covered by NC Medicaid is the concept of “medical necessity.” This means the condition being treated must be a documented illness, injury, or defect requiring professional medical intervention, rather than a matter of personal preference or purely aesthetic concern. Services are covered if they are individualized, consistent with the diagnosis, and not in excess of what is required to treat the illness.
For beneficiaries under 21, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides broader access to care. EPSDT requires NC Medicaid to cover any medically necessary service needed to correct or improve a defect, physical illness, or condition, even if that service is not typically covered for adults.
The distinction between medical and cosmetic treatment is strictly maintained across all age groups and conditions. For example, a skin lesion removal is covered if a biopsy confirms it is malignant or precancerous, or if it causes functional impairment, pain, or recurrent infection. Conversely, the same procedure is generally not covered if the sole purpose is to improve appearance.
Specific Covered and Excluded Procedures
NC Medicaid provides coverage for the diagnosis and management of a wide array of chronic and acute skin diseases. Treatment for severe, widespread conditions like chronic plaque psoriasis is covered, often including advanced systemic therapies such as biologic immunomodulators. These complex medications typically require prior authorization and are covered only if the patient meets specific clinical criteria, such as a high body surface area involvement or failure of initial standard treatments. Severe acne that is unresponsive to basic topical agents is also covered, including prescription-strength topical retinoids and combination therapies listed on the Preferred Drug List.
Eczema, particularly when severe or complicated by infection, is covered, including specialized medicated oils and high-potency topical corticosteroids. Medically necessary surgical excisions are covered for conditions like skin cancer (basal cell carcinoma and melanoma) and for the removal of benign but symptomatic lesions causing pain or functional issues. Reconstructive procedures, such as those following a mastectomy or for scar revision that impedes movement or function, are also included under the medical necessity umbrella.
Procedures considered purely cosmetic are explicitly excluded from coverage, as they do not treat an underlying medical illness. This exclusion list includes:
- Elective laser hair removal.
- Injectable wrinkle fillers.
- Chemical peels performed purely for aesthetic enhancement.
- Surgical procedures like liposuction and dermabrasion.
- Removal of excess skin following weight loss if solely intended to improve physical appearance.
Even procedures to address the appearance of keloids or scars are only covered if they are causing documented pain, recurrent infection, or functional impairment.
Navigating NC Medicaid Managed Care for Access
The majority of NC Medicaid beneficiaries are enrolled in one of the state’s Managed Care Organizations (MCOs) under the Standard Plan. This model shifted the administration of care from a traditional fee-for-service system to a network-based system. The five major Standard Plan MCOs operating statewide are:
- Healthy Blue
- AmeriHealth Caritas
- UnitedHealthcare Community Plan
- WellCare
- Carolina Complete Health
To receive covered care, the patient must find a dermatologist who is in-network with their specific MCO. Using an out-of-network provider will typically result in the patient bearing the full cost of the visit and any subsequent treatment. Each MCO maintains an online provider directory that beneficiaries should use to verify that a dermatologist is accepting new patients. This network requirement is the most significant factor affecting a beneficiary’s ability to schedule an appointment with a specialist.
Prior Authorization and Referral Requirements
While finding an in-network provider is the first hurdle, administrative requirements govern access to certain specialized services. Many complex or expensive dermatological treatments, including biologic drugs for psoriasis or extensive surgical procedures, require Prior Authorization (PA) from the MCO before the service is rendered. The MCO uses this process to confirm the medical necessity of the proposed treatment, ensuring it meets the established clinical criteria.
NC Medicaid generally does not require a formal referral from a Primary Care Provider (PCP) for a beneficiary to see a specialist like a dermatologist for claims payment. However, the dermatologist’s office itself may still request a referral for scheduling or internal care coordination purposes. The patient should always confirm the need for a referral when booking the appointment. The dermatologist’s office staff is typically responsible for submitting the necessary Prior Authorization request to the patient’s MCO.