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 a new kind of NC Medicaid Managed Care health plan. They start July 1, 2024.
Tailored Plans cover your physical care, prescription drugs, and services for serious mental illness, severe substance use disorders, intellectual/developmental disabilities (I/DD) and traumatic brain injury (TBI) in one health plan.
Tailored Plans will also serve people on the NC Innovations Waiver or Traumatic Brain Injury (TBI) Waiver. People will not lose their spots on the waitlist.
Tailored Plans offer more behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and state-funded services.
There are four Tailored Plans: Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health.
Alliance Health is the only Tailored Plan that currently offers TBI Waiver services.
- What is a Tailored Plan Company?
A Tailored Plan company coordinates services for Tailored Plan members. There are four Tailored Plans in North Carolina: Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health.
- How are Tailored Plans different from what the LME/MCOs do now?
LME/MCOs currently only manage behavioral health services. Once Tailored Plans launch, they will manage all Medicaid services for their members, including physical health services. Your primary care provider (PCP) must be in the Tailored Plan’s network. If they are not, you will likely have to change to a different PCP.
- How will the move to Tailored Plans happen?
NC Medicaid beneficiaries will be assessed for Tailored Plan eligibility. Eligible beneficiaries will get a letter from the NC Medicaid Enrollment Broker in mid-April. The letter will tell you if you have been auto-enrolled in a tailored Plan or if you have the choice to opt-in.
To learn more about the move to Tailored Plans, visit https://medicaid.ncdhhs.gov/tailored-plans/moving-to-a-tailored-plan
- When are Tailored Plan changes happening?
NC Medicaid will transition beneficiaries who may need certain services for a severe mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) to Tailored Plans) July 1, 2024. Until then, potential Tailored Plan beneficiaries will receive health care services the same way they do today, through NC Medicaid Direct or Standard Plans.
- How can I choose my Primary Care Provider (PCP) or Tailored Care Management provider?
To choose a PCP or Tailored Care Management (TCM) provider with your Tailored Plan, contact your Tailored Plan directly. If you are getting TCM services now, you will keep your TCM provider.
If you do not choose a PCP by May 15, 2024, one will be assigned to you.
- What if I move outside of my Tailored Plan’s service area?
If you move outside of the county that manages your Medicaid case (administrative county), you will be moved to the Tailored Plan that serves that area.
- 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 so 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 (the number of family members) that may impact the type of coverage you qualify for.
* Check your mail.
You can also learn more about Tailored Plans at medicaid.nc.gov/tailored-plans.
- 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.
You can begin scheduling rides for appointments on or after July 1, 2024, on May 16, 2024.
- 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 May 23, 2024. 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.
- What is Tailored Care Management?
TCM is a new kind of care management for eligible NC Medicaid beneficiaries. The goal of the program is to provide whole person care management to help beneficiaries meet their health goals.
Whole person care looks at all the beneficiary’s needs including:
- Physical health
- Behavioral health
- Intellectual and developmental disabilities (I/DD)
- Traumatic brain injuries (TBI)
- Pharmacy/medications
- Long term services and supports
- Unmet resource needs (or gaps in a person’s health care which make it hard to meet their health goals)
- What services are only offered by Tailored Plan?
Tailored Plans offer some behavioral health services that are not available in Standard Plans, including Innovations and TBI Waiver services and State-funded services.
To see a list of services offered by Tailored Plans, visit https://ncmedicaidplans.gov/en/tailored-plan-services.
