Care Grant

Carolina Complete Health offers a once per lifetime care grant of up to $250 for eligible members. The Care Grant can assist members with non-medical factors that affect health outcomes. The once per lifetime up to $250 Care Grant (eligibility requirements apply per offering) can be used to support the following:

Qualified members may receive up to $250 to assist with housing, utility or moving expenses, including deposits and payments. This Value-Added Service was developed to support members who are experiencing housing instability due to an unexpected hardship (e.g., hospitalization, extended illness, loss of employment).

This benefit is available as a one-time benefit per lifetime, as part of your health plan membership. Please allow up to 4-6 weeks for processing. For urgent needs, please contact your Care Manager for additional support.

Eligibility Requirements

You must be a current Carolina Complete Health member to receive this Value-Added Service.
Member must be at least 18 years old and enrolled in Care Management.
Member must show interruption of utilities/rent impacts their health status/condition.
Member must show support is needed to sustain housing due to instability or unexpected hardship.
Member must have a physical or behavioral health condition and at least one non-medical factor that affects health outcomes.
Must verify proof of outreach to at least two community organizations and provide documented proof of exhausted community resources.

Qualified members may receive up to $250 to assist with post-hospitalization home-delivered meals (with pre-approval). This Value-Added Service was developed to support members who need assistance with meals after their hospital stay.

Eligibility Requirements

You must be a current Carolina Complete Health member to receive this Value-Added Service.
Member must be at least 18 years old and enrolled in Care Management.
Member must have a physical or behavioral health condition and at least one non-medical factor that affects health outcomes.

Eligibility Statement: Eligibility requirements apply. You must be a current Carolina Complete Health member to receive this Value-Added Service. One care grant per member per plan lifetime. Member must be at least 18 years old and enrolled in Care Management to request a Care Grant. Please allow at least 4-6 weeks for review and processing of your request.

CARE GRANT REQUEST FORM

Are you enrolled in Care Management? * Yes No

Member Name * As it appears on your Carolina Complete Health Member ID card

Member ID Number * As it appears on your Carolina Complete Health Member ID card

Member Date of Birth *

Member Address (Must match address on file with Carolina Complete Health) * Value-Added Service items cannot be sent to a Post Office (P.O.) box. Please enter a physical mailing address. Any requests submitted with a P.O. Box listed will not be processed.

City *

Zip Code *

Phone Number (Must be Parent or Legal Guardian of Member) *

Email Address (Must be Parent or Legal Guardian of Member) *

I have read the eligibility for this Value-Added Service and understand that eligibility requirements apply. * I agree If eligible, a care manager will reach out to you at the provided email address or phone number.

This form will send your message to Carolina Complete Health as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Carolina Complete Health through email, you accept the risks associated thereof. Carolina Complete Health does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at 1-833-552-3876 (TTY: 711) to speak directly to a member service representative.

If you need assistance filling out this form, please call Member Services at 1-833-552-3876 (TTY 711).

Nombre del afiliado o afiliada * Tal como aparece en su tarjeta de identificación de afiliación de Carolina Complete Health

Número de identificación de afiliación * Tal como aparece en su tarjeta de identificación de afiliación de Carolina Complete Health

Fecha de nacimiento del afiliado o afiliada *

Dirección del afiliado o afiliada (debe coincidir con la dirección en los archivos de Carolina Complete Health) * Los artículos de Servicio de Valor Añadido no se pueden enviar a un apartado postal de correos (P.O. Box). Por favor, introduzca una dirección postal física. No se procesará ninguna solicitud cuya dirección sea un apartado postal de correos.

Ciudad *

Código postal *

Número telefónico (debe ser el del padre, la madre o el tutor legal del afiliado o afiliada) *

Dirección de correo electrónico (debe ser el del padre, la madre o el tutor legal del afiliado o afiliada) *

He leído los requisitos de elegibilidad para este Servicio de Valor Añadido y entiendo que se aplican los requisitos de elegibilidad. * Estoy de acuerdo Si es elegible, un administrador de la atención se comunicará con usted a la dirección de correo electrónico o al número telefónico que proporcionó.

Este formulario enviará su mensaje a Carolina Complete Health en forma de mensaje electrónico. El mensaje electrónico no está encriptado y no se transmite en un formato seguro. Al comunicarse con Carolina Complete Health mediante un mensaje electrónico, usted acepta los riesgos asociados con el mismo. En Carolina Complete Health no aceptamos responsabilidad alguna por pérdidas o daños que surjan del uso de correo electrónico. Para asegurar la seguridad de su información de salud protegida (Protected Health Information; PHI), por favor envíenos un mensaje mediante el Portal Seguro para Afiliados o el Portal para Proveedores, o puede llamarnos al 1-833-552-3876 (TTY: 711) para hablar directamente con un representante de servicios para los afiliados.

Si at necesita ayuda para llenar este formulario, por favor llame a Servicios para los Afiliados al 1-833-552-3876 (TTY 711).