FAQs

FAQs

Understanding the Transition to Managed Care

  • Are the eligibility rules changing for NC Medicaid?

    There are no changes to who is eligible to receive NC Medicaid. If you have questions about your eligibility, contact your local Department of Social Services (DSS) office.

  • What is NC Medicaid Managed Care?

    In July 2021, most people in North Carolina with Medicaid saw a change in how they receive their health care. If you have NC Medicaid, you may have received a letter asking you to enroll in a health plan. If you didn’t pick a health plan by the deadline, the State chose one for you so that you could continue to receive care. On July 1, 2021, this health plan started managing your health care.

    NC Medicaid Managed Care helps you get the most out of your Medicaid benefits and there are many health plans to choose from. All health plans are required to have the same Medicaid services, such as office visits, blood tests and X-rays. Health plans may also offer added services such as programs to help you quit smoking, eat healthier and have a healthy pregnancy. Health plans work with different doctors and health care professionals. Each health plan has its own network of qualified doctors and health care professionals.

    You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change your health plan unless you have a special reason. Learn more about special reasons for changing your health plan. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.

  • What are Standard Plans?

    Standard plans provide integrated physical health, behavioral health, pharmacy and long-term services and support to most Medicaid beneficiaries, as well as other programs and services that address unmet health-related resource needs

  • What is NC Medicaid Direct?

    NC Medicaid Direct was formerly known as fee-for-service. Some people will remain in NC Medicaid Direct because it provides services that meet specific needs.

    NC Medicaid Direct is North Carolina’s health care program for Medicaid beneficiaries who are not enrolled in health plans. It includes care management by Community Care or North Carolina (CCNC), the primary care case management entity (PCCMe) for physical health services. Six Local Management Entity-Managed Care Organizations (LME-MCOs) coordinate services for mental health disorder, substance use disorder, intellectual/developmental (I/DD) or traumatic brain injury (TBI). Some people are enrolled in NC Medicaid Direct because it provides services that meet specific needs.

    These populations include:

    * 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

  • Who must enroll in Medicaid Managed Care?

    Most NC Medicaid beneficiaries have been enrolled in the NC Medicaid Managed Care program. Some people will stay in NC Medicaid Direct (formerly known as fee-for-service). They will not need to choose a health plan. Those who are now in managed care should have received a new Medicaid ID card and other important information from their new health plan. If you have not received information, please call the Enrollment Broker at 833-870-5500 or visit ncmedicaidplans.gov.

  • Who has the option to choose a health plan?

    Some people can change their health plan at any time. You can change your health plan at any time for these reasons:

    * You need services to address a mental health disorder, substance use disorder, intellectual/developmental (I/DD) or traumatic brain injury (TBI)

    * You are a federally recognized tribal member or qualify for services through Indian Health Services (IHS). Some people will not need to choose or are unable to choose a health plan because of the type of health services they need. Some people will be enrolled in Tailored Plans and will be auto-assigned based on their administrative county, others will remain in NC Medicaid Direct. For example, individuals who receive Innovations Waiver services, Traumatic Brain Injury (TBI) Waiver services will be auto-enrolled in Tailored Plans by administrative county. If you qualify, you can choose the EBCI Tribal Option and keep receiving waiver services.

  • What if I don’t think I should have to enroll in a new health plan?

    Some people will not need to choose a health plan because of the type of health services they need. They will stay enrolled in NC Medicaid Direct. For example, individuals who receive Innovations Waiver services, Traumatic Brain Injury (TBI) Waiver services or Community Alternatives Programs for Children or Disabled Adults (CAP/C or CAP/DA) services will stay enrolled in NC Medicaid Direct. If you qualify, you can choose the EBCI Tribal Option and keep receiving waiver services.

    If you don’t think you should have to enroll in a health plan but got a letter telling you to do so, you can request to remain in NC Medicaid Direct by filling out a form you can find at ncmedicaidplans.gov.

    If you are unsure about what type of Medicaid coverage you have, call the Enrollment Broker at 833-870-5500.

  • What is the Eastern Band of Cherokee Indians (EBCI) Tribal Option?

    The Eastern Band of Cherokee Indians (EBCI) Tribal Option is a health plan managed by the Cherokee Indian Hospital Authority (CIHA) to meet the primary care coordination needs of federally recognized Tribal members and others eligible for services through Indian Health Service (IHS). Only IHS-eligible beneficiaries associated with the EBCI can participate in this health plan. The EBCI Tribal Option will build on the Tribe’s strong medical model and deliver high quality care at the local level. The EBCI Tribal Option offers care coordination and management of Medicaid medical, behavioral health, pharmacy and support services to address the health needs of American Indian/Alaskan Native Medicaid beneficiaries. The EBCI Tribal Option is primarily offered in five counties: Cherokee, Graham, Haywood, Jackson and Swain. Eligible beneficiaries in the following surrounding counties may opt in: Buncombe, Clay, Henderson, Macon, Madison and Transylvania.

  • What are my rights under NC Medicaid Managed Care?

    You have the right to:

    * Get free advice over the phone from the NC Medicaid Enrollment Broker Call Center, where someone can inform you whether you have to enroll in a health plan, and help you decide which health plan is the best choice for you and your family.

    * Get information in your preferred language for free.

    * Switch health plans for any reason within 90 days of being enrolled. After 90 days, unless you have a special reason, you must wait until your next NC Medicaid recertification date to change health plans.

    * Continue to receive the same NC Medicaid coverage and services you receive now.

    * Get care from a provider outside your health plan’s network if medically necessary services are not available in the health plan’s group of providers.

    * Receive care without interruption when transitioning between health plans or into or out of managed care.

    * Ask for an appeal from your health plan if they deny, reduce or stop coverage for health care you need.

  • When are these changes happening?

    Coverage under the NC Medicaid Managed Care program begins July 1, 2021.

    If you did not choose a health plan or request to stay in NC Medicaid Direct by May 21, 2021, you were automatically enrolled in a health plan to ensure you could continue to get care.  Most people were able to keep their same doctors. You should have received a welcome packet from your new health plan that includes a new Medicaid ID card. The card has the name of your primary care provider (PCP).

    You can learn more about the available health plans and the services they provide by visiting ncmedicaidplans.gov or calling 833-870-5500.

    You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change your health plan unless you have a special reason. Learn more about special reasons for changing your health plan. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.

  • What should I do to prepare for the change?

    Make sure your local Department of Social Services (DSS) has your current mailing address, phone number and email address so you get all important notices about this change (especially if your contact information has changed due to COVID-19).

    Visit ncmedicaidplans.gov  or call 833-870-5500 to learn more. You can also stay up-to-date by using the free NC Medicaid Managed Care mobile app, available on Google Play or in the App Store.

    You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change your health plan unless you have a special reason. Learn more about special reasons for changing your health plan. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.

  • Choosing a Health Plan

  • How and when do I choose a health plan?

    Open Enrollment ended May 21, 2021. If you did not choose a health plan by this date, you were auto-enrolled in a health plan to ensure you could continue to get care. Most people were able to keep their same doctors.

    Each health plan works with a network, or group of doctors, hospitals and other health care providers.  You should choose a health plan that will let you keep going to your doctors and other health care providers. All health plans offer the same basic benefits and services. Some may also offer added services. When choosing a health plan, you may want to ask:

    • How do I keep my current doctors, hospitals and specialists?
    • What are my choices if I change doctors?
    • What added services does each health plan have?

    You can learn more about what health plans are available to you and the services they provide by visiting ncmedicaidplans.gov or calling 833-870-5500.

    If you are new to Medicaid, you can get help in plan selection/change in one of the following ways:

    • Call 833-870-5500 (toll-free)
    • Go to ncmedicaidplans.gov
    • Complete and return a paper enrollment form by fax or mail
    • Use the NC Medicaid Managed Care mobile app

    If you want to change your health plan, you can do so for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change your health plan unless you have a special reason. Learn more about special reasons for changing your health plan. The Ombudsman can help you figure out if you can change your health plan. Call us at 877-201-3750 for help.

  • What are the health plans I can choose from/change to?

    AmeriHealth Caritas (offered statewide)
    855-375-8811 (TTY: 866-209-6421)
    24 hours a day, seven days a week
    amerihealthcaritasnc.com

    Carolina Complete Health (only available in certain regions of the state)
    833-552-3876 (TTY: 711)
    7 a.m. to 6 p.m., Monday through Saturday
    carolinacompletehealth.com

    Healthy Blue (offered statewide)
    844-594-5070 (TTY: 711)
    7 a.m. to 6 p.m., Monday through Saturday
    HealthyBlueNC.com

    UnitedHealthcare Community Plan (offered statewide)
    800-349-1855 (TTY: 711)
    7 a.m. to 6 p.m., Monday through Saturday
    uhccommunityplan.com/nc

    WellCare (offered statewide)
    866-799-5318 (TTY: 711)
    7 a.m. to 6 p.m., Monday through Saturday
    wellcare.com/NC

    The Eastern Band of Cherokee Indian (EBCI) Tribal Option
    (The EBCI Tribal Option is primarily offered in five counties: Cherokee, Graham, Haywood, Jackson and Swain. Eligible beneficiaries in the following counties may opt in: Buncombe, Clay, Henderson, Macon, Madison and Transylvania.)

    800-260-9992 (TTY: 711)
    8 a.m. to 4:30 p.m., Monday through Friday
    EBCITribalOption.com

  • Will the types of health care services I can receive change?

    The same services will continue to be covered. However, the doctors you can go to will be based on the health plan’s provider network. Your Medicaid copays will not change.

  • Do I have to change doctors?

    Each health plan has its own set of doctors and health care providers, who make up its network. Most people were able to keep their same doctors when moving to managed care. The NC Medicaid Managed Care website also features a provider search tool that will tell you which health plans your providers have joined, but ask your doctor’s office to be sure.

  • When can I switch health plans?

    You can change your health plan for up to 90 days after the start date shown on your health plan enrollment letter. After 90 days, you must wait until your next recertification date to change health plans unless you have a special reason. You can change your health plan at any time for these reasons:

    • You moved out of your health plan’s area.
    • You need a service that your health plan does not cover for moral or religious reasons.
    • Your health plan says you need multiple services they cannot provide and your PCP says you need services right away.
    • You need services that meet specific needs, such as developmental disability, behavioral health, traumatic brain injury or substance use disorder.
    • You are a federally recognized Tribal member or qualify for Indian Health Services (IHS).
    • Every year at your recertification, you will be given a 90-day period to change your health plan.

    You can find more information about what this means by clicking here or by calling the NC Medicaid Enrollment Broker at 833-870-5500. The call is toll-free.

  • What if I need Non-Emergency Medical Transportation (NEMT)?

    Under Medicaid Managed Care, the new health plans must provide non-emergency medical transportation (NEMT) services for all Medicaid eligible individuals who need and request assistance with transportation. Health plans may use transportation brokers to arrange and provide transportation or contract directly with transportation providers. For beneficiaries in NC Medicaid Direct and the Eastern Band of Cherokee Indians (EBCI) Tribal Option, local Departments of Social Services (DSS) will continue to arrange NEMT services.

    Beneficiaries will receive the same transportation service from the health plans that they are used to receiving from DSS, and these services will continue to be provided for free. If you have problems getting the transportation you need and are unable to resolve by working with your health plan or broker, call the NC Medicaid Ombudsman at 877-201-3750.

  • Information & Assistance

  • What problems can the NC Medicaid Ombudsman help address?

    The Ombudsman can help with these issues and more if you have been unable to resolve them by working with your health plan or the Enrollment Broker:

    Enrolling in a health plan, if:

    • You think you should not have to enroll in a health plan
    • You have trouble enrolling in a health plan
    • You can’t find any health plan that includes the doctors you need to see
    • The State has denied your request not to enroll in a health plan

    Accessing care, if:

    • You can’t continue getting the services you are getting now
    • Your health plan denies care that you need
    • Your health plan won’t cover services from a provider who is not in your health plan’s network, when the service is not otherwise available
    • It takes too long before you can get the care you need
    • Your plan says you have to travel too far to get the care you need
    • You have trouble getting transportation to your doctor appointments
    • You need services for behavioral health or an intellectual/developmental disability your health plan won’t cover

    Changing care, if:

    • You have problems changing to a different health plan
    • You have problems changing to a different primary care provider

    Experience barriers to care and coverage, if:

    • You can’t access material or information in your preferred language
    • You feel a health plan, provider or enrollment representative has discriminated against you

    The NC Medicaid Ombudsman can also help you understand information you receive, explain your rights, and connect to the right people at health plans and the Enrollment Broker.

  • What information will the NC Medicaid Ombudsman ask me?

    We will start by asking your name, how to reach you, what county you live in and what health plan you are enrolled in (or trying to enroll in). We will ask you if you have attempted to resolve your issue directly with the entity at issue. We will then ask you for other information about your concerns or questions. If you have received any paperwork, please have it in front of you when you call. If you don’t, please call us anyway.

  • Can the NC Medicaid Ombudsman help me appeal if I am denied care?

    The NC Medicaid Ombudsman cannot provide legal advice or represent you in your appeal. However, if you have already talked with your health plan and were not able to resolve your issue, we can contact your health plan to try to resolve your issue informally. For example, we can give your health plan new information, and ask your health plan to change their decision or find another solution to the problem. We can help you understand how to file your own appeal with the health plan, and what things you can do to get the health plan to change its decision.

    If our assistance doesn’t resolve your issue or you want legal representation instead of informal assistance, we can refer you to your local legal services office who may be able to handle your appeal for free.

  • Does the NC Medicaid Ombudsman work for the government or health plans?

    The NC Medicaid Ombudsman is contracted by the State of North Carolina but operates as an independent organization serving as a resource to Medicaid beneficiaries.

  • What is the best way to reach the NC Medicaid Ombudsman?

    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.

  • 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)

  • Other Resources

    NC Medicaid Enrollment Broker

    833-870-5500
    ncmedicaidplans.gov
    You can learn more about what health plans are available to you and the services they provide. You can also use the website’s provider search tool to find out which health plans your providers have joined to make sure you choose a health plan that allows you to continue seeing your doctors.

    NC Medicaid Contact Center

    888-245-0179
    This video from the North Carolina Department of Health and Human Services (NCDHHS) also explains the change to NC Medicaid Managed Care and what you should do to prepare.

    NC Medicaid Managed Care Auto-Enrollment Fact Sheet