Tailored Plans

Tailored Plans are for NC Medicaid beneficiaries who need enhanced services for a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI).

Tailored Plans include coverage for physical health services, pharmacy services, care coordination and care management, behavioral health services, and added services, such as wellness programs.

Below are the answers to frequently asked questions about Tailored Plans. We are here to help.

Tailored Plans

  • What are Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans (Tailored Plans)?

    Tailored Plans are North Carolina Medicaid and NC Health Choice health plans. They provide physical health, pharmacy, care management and behavioral health services for beneficiaries who may have significant mental health needs, severe substance use disorders, intellectual/developmental disabilities (I/DD) or traumatic brain injury (TBI).  Tailored Plans offer enhanced behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and State-funded services. There are six Tailored Plans: Alliance Health, Eastpointe, Partners Health Management, Sandhills Center, Trillium Health Resources, and Vaya Health.

    Alliance Health is the only Tailored Plan that currently offers TBI Waiver services.

  • Who is eligible for Tailored Plans?

    Tailored Plan eligibility can be based on either diagnosis or what services the person is receiving. Generally, an eligible member has a significant mental health disorder, substance use disorder, intellectual/developmental disability, or traumatic brain injury.

  • How do I get behavioral health, intellectual and developmental disability (I/DD) or traumatic brain injury services prior to Tailored Plan launch?

    Prior to Tailored Plan Launch December 2022, you can continue to receive your health services through NC Medicaid Direct and LME/MCO. If you are currently enrolled in NC Medicaid Direct, call 888-245-0179. In NC Medicaid Direct, you may be able to get services from a Local Management Entity/Managed Care Organization (LME/MCO). For a list of NC Medicaid Direct behavioral health, I/DD and TBI services, go to NC Medicaid Direct services.

    If you are currently enrolled in a Standard Plan and need to access behavioral health, I/DD, or substance use disorder services, you may submit a request to move to NC Medicaid Direct, including your LME/MCO. Use the Request to Move to NC Medicaid Direct and LME-MCO: Beneficiary form. (link coming soon)

    If you are a provider, you may ask for a person to move to NC Medicaid Direct. Use the Request to Move to NC Medicaid Direct (Fee for Service) and LME-MCO: Provider form. (link coming soon)

    You can use this website to submit your form. It is the fastest and best way to submit a form. To learn more, go to Submit forms online.

    If you enroll in a Standard Plan, you may not be able to get certain NC Medicaid Direct services.

  • What is a Local Management Entity-Managed Care Organization (LME-MCO)?

    An LME-MCO coordinates services for mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) for NC Medicaid Direct beneficiaries and EBCI Tribal Option members. There are six LME-MCOs in North Carolina: Alliance Health, Eastpointe, Partners Health Management, Sandhills Center, Trillium Health Resources, and Vaya Health.

  • How are Tailored Plans different from what the LMEs do now?

    LME-MCOs currently only manage behavioral health services. Beginning December 1, 2022, Tailored Plans will manage all Medicaid services for their members, including physical health services. In most cases, your physical health providers must be in the Tailored Plan’s network. If they are not, you will likely have to change to a different physical health provider.

  • Can I change my Tailored Plan?

    No. Tailored Plan members will not have the option to change their Tailored Plan. Only one Tailored Plan serves each county in North Carolina. Tailored Plan enrollment is based on the county that manages your Medicaid case (administrative county).

  • Do all health plans offer the same services?

    All health plans offer the same basic benefits and services. Some health plans also offer added services. Standard Plans offer integrated physical health, pharmacy, care coordination and basic behavioral health for most people receiving NC Medicaid. Tailored Plans provide the same services as Standard Plans and provide additional services not available in Standard Plans. These include enhanced behavioral health services, services for a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI). Tailored Plans are responsible for managing two of the State’s Medicaid Section 1915(c) Home and Community-Based Services (HCBS) waivers: the North Carolina Innovations Waiver for individuals with I/DD and the TBI Waiver for individuals with a TBI:

    * Tailored Plan Information for Providers

    * Tailored Plan Information for Beneficiaries

    Alliance Health is the only Tailored Plan that currently offers TBI Waiver services.

  • How will the transition to Tailored Plans occur?

    Medicaid beneficiaries will be assessed for Tailored Plan eligibility in August 2022. Some beneficiaries will be auto-enrolled in a Tailored Plan. Some will be able to opt-in to a Tailored Plan. In both cases, beneficiaries will receive a notice from the NC Medicaid Enrollment Broker letting them know about Tailored Plans.

    Tailored Plan members will be able to choose their primary care provider (PCP) and Tailored Care Management provider beginning August 15, 2022. If a Tailored Plan member does not choose a PCP or Tailored Care Management provider before October 14, 2022, they will be automatically assigned one. On December 1, 2022, Tailored Plan members will begin to receive health services from their Tailored Plan.

  • What if I disagree with the decision to enroll me or not to enroll me in a Tailored Plan?

    You or your provider can contact the NC Medicaid Enrollment Broker at 833-870-5500 or ncmedicaidplans.gov to learn more about your health care options.

  • How do I access enhanced services only offered by Tailored Plans if I am required to enroll in a Standard Plan after Tailored Plans launch December 2022?

    If you are currently enrolled in a Standard Plan and need to access behavioral health, I/DD, or substance use disorder services, you may submit a Request to Move to The Tailored Plan. Use the Request to Move to The Tailored Plan: Beneficiary form. (link coming soon)

    If you are a provider, you may ask for a person to move to The Tailored Plan. Use the Request to Move to The Tailored Plan: Provider form. (link coming soon)

  • When are these changes happening?

    * August 1, 2022: Tailored Plan Criteria

    * August 15, 2022: Tailored Plan Auto-Enrollment (NC Medicaid Enrollment Broker begins mailing Enrollment Packets to potential Tailored Plan members)

    * August 15, 2022 through October 14, 2022: Choice Period (Beneficiaries can choose a primary care provider (PCP) and Tailored Care Management provider with their Tailored Plan or choose a different health plan, if applicable)

    * October 15, 2022: PCP and Tailored Care Management Auto-Assignment (Tailored Plans will begin mailing Welcome Packets and ID Cards with PCP and Tailored Care Management provider assignment on October 22, 2022.)

    * December 1, 2022 – Tailored Plan Launch (Tailored Plan members will begin receiving health care services from their Tailored Plan)

  • How can I choose my PCP or Tailored Care Management provider?

    To choose a PCP or Tailored Care Management provider with the Tailored Plan, contact your Tailored Plan directly.

  • What if I move outside of my Tailored Plan’s service area?

    If you move outside of your Tailored Plan’s service area, you will continue to receive services from your Tailored Plan. If the county that manages your Medicaid case (administrative county) changes, you may be moved to a different Tailored Plan.

  • Will Tailored Plans provide non-emergency medical transportation (NEMT)?

    Tailored Plans will provide NEMT for all Medicaid-covered services, including carved out services. This means you will need to call your Tailored Plan, not your local Department of Social Services (DSS), when you need to schedule a ride to a doctor, pharmacy, or other health provider.

    Tailored Plans will start accepting trips on October 17, 2022, for appointments on or after December 1, 2022.

  • What is the Traumatic Brain Injury (TBI) Waiver?

    The Traumatic Brain Injury (TBI) Waiver is a special federal program that provides long-term services and supports for people who experienced a traumatic brain injury (TBI). Alliance Health is the only Tailored Plan that currently offers TBI Waiver services. At Tailored Plan launch on December 1, 2022, TBI Waiver services will only be available in the following counties: Cumberland, Durham, Johnston, and Wake. The TBI Waiver may be expanded to additional counties at a later date.

  • What should I do to prepare for Tailored Plan launch?

    Make sure your local Department of Social Services (DSS) has your current mailing address, phone number and email address to ensure you receive all important information. You can find your local county DSS at dhhs.gov/localdss.

    * Report all changes, including your address and any changes such as income or a change in household that may impact the type of coverage you qualify for.

    * Check your mail.

    You can also learn more about Tailored Plans at ncmedicaidplans.gov.

  • How will potential Tailored Plan members receive health care services before Tailored Plan launch on December 1, 2022?

    Potential Tailored Plan members will continue to receive health care services the same way they do today.

  • Will I receive a new Medicaid ID card?

    Yes. Tailored Plans will begin mailing Welcome Packets including a Welcome Letter, Medicaid ID card and Member Handbook to their members beginning October 22, 2022. Make sure your local DSS has your current mailing address, phone number and email address to ensure you get all important information from your Tailored Plan.

  • Will any beneficiaries stay in NC Medicaid Direct?

    Yes. Some beneficiaries will stay in NC Medicaid Direct because they need certain services:

    * People who receive both Medicare and Medicaid

    * People who are medically needy

    * People in the NC Health Insurance Premium Payment (HIPP) Program

    * Children who receive Community Alternatives Program for Children (CAP/C) services

    * People who receive Community Alternatives Program for Disabled Adults (CAP/DA) services

    * Children and youth in foster care

  • What is Tailored Care Management?

    Tailored Care Management is a service for Tailored Plan members. Tailored Plan members will have a single designated care manager, supported by a multidisciplinary care team, to provide whole-person care to address physical health, behavioral health, intellectual/developmental disability (I/DD), traumatic brain injury (TBI), pharmacy, long-term service and supports (LTSS) and unmet health-related resource needs.

  • What is the Tailored Plan Criteria Review?

    Beginning August 1, 2022, NC Medicaid beneficiaries will be assessed for the Tailored Plan with a lookback period of 24 months. Assessment for Tailored Plan will be based on the following criteria, but not limited to:

    * Enrolled in the Innovations or TBI Waivers, or on the waiting lists

    * Enrolled in the Transition to Community Living (TCL) program

    * Have used a Medicaid service that will only be available through the Tailored Plan

    * Have used a mental health, substance use, I/DD or TBI service funded with state, local, federal or other non-Medicaid funds

    * Children with complex needs

    * Have a qualifying I/DD diagnosis code

    * Have a qualifying mental illness or SUD diagnosis code, and used a Medicaid-covered enhanced behavioral health service during the lookback period*

    * Have a diagnosis of a psychotic disorder (primary or secondary to a mood disorder), use of clozapine or a long-acting injectable antipsychotic medication, or receive electroconvulsive therapy (ECT) during the lookback period**

    * Have had an admission to a state psychiatric hospital or Alcohol and Drug Abuse Treatment Center (ADATC), including but not limited to, individuals who have had one or more involuntary treatment episodes in a State-owned facility

    * Have had two or more visits to the emergency department for a psychiatric problem; two or more psychiatric hospitalizations; or two or more episodes using behavioral health crisis services during the lookback period**

    * * The look back period is 24 months

  • What enhanced services are only offered by Tailored Plan?

    Tailored Plans are health plans that offer integrated physical health, pharmacy, care coordination and behavioral health services for members who may have significant mental health needs, intellectual/developmental disabilities (I/DDs), traumatic brain injuries (TBIs) or severe substance use disorders. Standard Plans offer some basic behavioral health services. Tailored Plans offer enhanced behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and State-funded services. Additional information is available here.

  • Who do I call if I am having trouble keeping my providers or getting the services I need?

    You can call us at 877-201-3750 from 8 a.m. to 5 p.m., Monday through Friday except for State holidays. We do our best to answer every call, but if we are unable to answer, please leave a message with your name and phone number. We’ll call you back by the next business day. You can also send us a message using our online Contact Form. (link coming soon)