Tailored Plans

Tailored Plans are North Carolina Medicaid 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.

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.

Prior to Tailored Plan Launch, 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.

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.

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.

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.

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. 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.

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).

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:

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

Medicaid beneficiaries will be assessed for Tailored Plan eligibility. 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.

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.

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)

To ensure beneficiaries can seamlessly receive care on day one, the North Carolina Department of Health and Human Services (NCDHHS) is delaying the implementation of the NC Medicaid Managed Care Behavioral Health and Intellectual/ Developmental Disabilities Tailored Plans (Tailored Plans) scheduled for Oct. 1, 2023, but will now go forward at a date still to be determined.

Beneficiaries who will be covered by the Tailored Plans will continue to receive behavioral health, I/DD, TBI and physical health care as they do today. North Carolina’s unique Tailored Care Management model, which launched Dec. 1, 2022, will continue to support beneficiaries by providing a care team to coordinate care across providers. Additionally, on July 1, 2023, the LME/MCOs began to provide 1915(i) services to offer an array of home and community based (HCBS) services to Medicaid beneficiaries with serious mental health diagnoses, severe substance use disorders, intellectual/developmental disabilities and traumatic brain injuries.

For more information about Tailored Plans, visit NC Medicaid’s Tailored Plan website. For more information about 1915(i) services, visit NC Medicaid’s recent provider bulletin.

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

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.

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.

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, TBI Waiver services will only be available in the following counties: Cumberland, Durham, Johnston, Mecklenburg, Orange, and Wake. Effective April 1, 2023, CMS has approved the NC TBI Waiver expansion into Orange and Mecklenburg counties. TBI Waiver services are anticipated to be available in Orange and Mecklenburg counties on or by June 1, 2023. For additional information see: https://www.alliancehealthplan.org/members/services/traumatic-brain-injury-tbi/

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.

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

Yes. Tailored Plans will begin mailing Welcome Packets including a Welcome Letter, Medicaid ID card and Member Handbook. 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.

Yes. Some beneficiaries will stay in NC Medicaid Direct:

* People who receive both Medicare and Medicaid, except for those beneficiaries receiving the Innovations Waiver or TBI Waiver.

* People who are medically needy, except for those beneficiaries receiving the Innovations Waiver or TBI Waiver.

* People in the NC Health Insurance Premium Payment (HIPP) Program, except for those beneficiaries receiving the Innovations Waiver or TBI Waiver.

* 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, except for those beneficiaries receiving the Innovations Waiver or TBI Waiver.

* Federally Recognized Tribal Members/ IHS Eligible, however they may choose to enroll in a Tailored Plan or EBCI Tribal Option.

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.

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

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.

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.