This page provides information about the Medicaid Transformation process in North Carolina. The Autism Society of North Carolina has created this page of information and resources to support you and your family and keep the autism community informed.
North Carolina Department of Health and Human Services (NC DHHS) links:
- NC Medicaid Tailored Plan Toolkit: Info for Medicaid participants in English and Spanish
- North Carolina’s Transformation to Medicaid Managed Care (Medicaid overview page)
- Tailored Plan – Medicaid Information for those with Behavioral Health Intellectual and/or Developmental Disabilities I/DD (NC DHHS overview page)
- NC Medicaid Ombudsman FAQ on Tailored Plans
- Medicaid and Tailored Plan Services: Info on health plan benefits
- ASNC Blog on 1915(i) services for I/DD in Medicaid
Current Timeline of Events
NOTE: Medicaid Tailored Plan launch has been delayed until July 1, 2024. Some services like Tailored Care Management have already begun and will continue. More information on the plans and services is below.
- * Now: Tailored Care Management services are available for eligible Medicaid beneficiaries.
- * Now: Medicaid beneficiaries who qualify can access 1915(i) services for I/DD supports and behavioral health care if they are enrolled with a LME/MCO to be Tailored Plan.
- April 13, 2024: Tailored Plan auto-enrollment begins.
- April 17, 2024: Tailored Plan Medicaid beneficiaries get letters announcing auto enrollment in a Tailored Plan.
- May 15, 2024: Tailored Plan Beneficiaries have until May 15, 2024, to select or change their Primary Care Provider (PCP), or to change their Tailored Care Management (TCM) provider.
- May 16, 2024: Beneficiaries who have not selected a PCP will be auto assigned to one.
- May 23, 2024: Beneficiaries who do not have a TCM provider will be assigned to one.
- * July 1, 2024: 1915(i) services will replace B3 services for eligible Medicaid beneficiaries; this transition to 1915i is going on right now. For people on Standard Medicaid plans seeking these services, they are only available on Tailored Plans.
- * July 1, 2024: Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans launch.
Stay connected with us
- ASNC social media (Facebook, Twitter, Instagram)
- Email (sign up here)
Quick links
- Medicaid Ombudsman – available to answer questions, etc. (https://ncmedicaidombudsman.org/)
- NC Medicaid Enrollment Broker – enroll in a plan, learn your options (https://ncmedicaidplans.gov/)
Tailored Plans – What you need to know
North Carolina has been changing its Medicaid system for several years. The goal is to have Medicaid physical health care, behavioral health care, developmental supports, and pharmacy benefits managed together as well as introduce programs that address social issues in order to keep people healthier. “Transformation” will integrate physical, behavioral, and intellectual and/or developmental disability (I/DD) services into two types of Medicaid health care plans: Standard Plans and Tailored Plans (TP).
Tailored Plans offer more specialized services to people with I/DD who have Medicaid, as well as those with significant mental health or substance use disorder issues. People who have an Innovations Waiver or a Traumatic Brain Injury waiver will need to be in a Tailored Plan in order to get home and community-based waiver services. Those on the Registry of Unmet Needs, aka the waitlist, who have Medicaid, can qualify for new services offered under the Tailored Plans.
Tailored Plans: what do they do, and how they can help
Your Tailored Plan is the regional Managed Care Organization (MCO) also sometimes referred to as your Local Management Entity Managed Care Organization (LME/MCO).
They are like your insurance company for Medicaid.
Beginning July 1, 2024, Tailored Plans will manage physical health care, behavioral health care, and developmental disability services and supports.
They manage a network of contracted health and disability services providers.
They authorize your health care and disability services under Medicaid.
They operate a 24/7 health crisis and nurse line.
They operate a six-day-a-week member and recipient services line to understand benefits and connect with physical health, behavior health, disability services, and providers.
They may offer other programs through local providers to help address social drivers of health like non-emergency transportation, food, connects to housing, or other needs.
They coordinate care and may offer care management services. (You can also get tailored care management [TCM] from outside of the LME MCO).
Four LME/MCOs will provide Tailored Plan heath care coverage to people who qualify. The LME/MCO you belong to IS the Tailored Plan for your region of the state.
Your Tailored Plan region is based on your county of record (where you applied for Medicaid), which could be where you live now or where you lived when you or your loved one started getting services.
Who is eligible for a Tailored Plan?
People with Medicaid who:
- have an Innovations Waiver;
- or have a TBI waiver;
- or are on the autism spectrum or have other intellectual and/or developmental disabilities (I/DD);
- or have a serious mental health issue, serious emotional behavioral disorder, or serious substance use disorder, including those with complex needs due to multiple diagnoses.
Who is not eligible?
- People with Medicaid who are dually eligible for Medicare and Medicaid, unless they have an Innovations or TBI waiver. (All those with waiver slots will be in a Tailored Plan, including duals with Innovations of TBI waiver.)
- People with partial Medicaid benefits, including those in Family Planning, Emergency Medicaid, and special populations like those with Refugee Benefits.
- Children or Youth in foster care will remain in their current health plan(s) until the Child and Family Specialty Plan begins operation in 2025.
- People newly eligible for Medicaid under “expansion,” aka NC Health Works, will be assigned to a Standard Plan or Tailored Plan, depending on their needs/health conditions.
How do I enroll?
- You will be automatically enrolled into your Tailored Plan if you are eligible.
- If you are no longer eligible for a Tailored Plan, an enrollment broker can help you understand your Medicaid coverage options.
Can I opt-out or pick a different Tailored Plan?
- You do not have a choice of Tailored Plan, but you CAN and should choose your Tailored Care Management and your Primary Care Provider.
- You cannot choose to stay in Medicaid Direct. Some people will still get some health care services through Medicaid Direct, like eyewear. Some populations will still get Medicaid Direct like dual eligible people who do not have a waiver slot.
- You can opt-out of Tailored Plans and go to a Standard Plan; HOWEVER, you will lose access to I/DD services such as Innovations or TBI waivers, Tailored Care Management, the new 1915(i) Services, In Lieu of Services (ILOS), and any state or locally funded services (IPRS, single stream funded).
- For those on the Registry of Unmet needs, aka the waitlist for Innovations, you can remain on the waitlist and choose to get Medicaid through one of the Standard Plans rather than the Tailored Plan, but you will not have access to the full array of services like 1915(i) services, IPRS services, and other state and local funding.
*** Eastern Band of Cherokee Indian members and others in North Carolina who are eligible for Indian Health Services, including those with I/DD, can choose to enroll in the tribal health care plan managed by the Cherokee Indian Hospital Authority (CIHA), or they may choose a Tailored or Standard Plan based on their location and service needs. Click here for more information regarding the ECBI Tribal option. ***
What’s New? NEW Services & Options
Medicaid is now offering new services called 1915(i) services to people with I/DD as well as those with mental health issues and substance use disorders. The 1915(i) services are replacing B3 services but unlike B3, 1915(i) services are an entitlement. This means that the program does not keep waiting lists and does not run out of funds to help people. These 1915(i) services include:
- Community Transition
- Respite
- Community Living and Support
- Supported Employment
- Plus other services to support those with a primary diagnosis of mental illness or substance use disorders.
Tailored Care Management is available now to those eligible for Tailored Plans. Care management includes help navigating community programs; help coordinating the supports and services you get across all of your physical, specialty, I/DD, and behavioral health providers; help with filling out paperwork, screening for benefits, advocacy within the system, and learning self-advocacy skills.
It is your choice which of these three options you get care management from:
- The LME/MCO Tailored Plan: If you have a Care Coordinator through the LME MCO that works well for you, staying with the LME MCO for care management is an option.
- A Tailored Care Management organization: Provider organizations with experience delivering behavioral health, I/DD, and/or TBI services to the Tailored Plan-eligible population, will also hold the primary responsibility for providing integrated, whole-person care management. This may be similar to case management offered in the past by provider organizations.
- An Advanced Medical Home Plus: Health providers who have experience delivering primary care services to the Tailored Plan-eligible population or can otherwise demonstrate strong competency to serve that population can be designated as an Advanced Medical Home Plus (AMH+). These AMH+ are offering care management and other integrative services, so if you are part of an AMH+ you can get your care management from that practice.
If you qualify for Tailored Care Management, you should have received a letter about who is your provider (choices above) of the service. You can change that provider by contacting your LME MCO.
Primary Care Providers
Tailored Plans will now be managing physical health care including visits to your primary care provider (PCP) / your doctor.
- Check if your primary care provider (PCP) is enrolled in your Tailored Plan’s provider network. They might also be enrolled in a Standard Plan provider network that has contracted with a Tailored Plan to offer a network of health providers.
- Look on your Tailored Plan website to see if your PCP is in their provider network. (See Tailored Plan links in the Resource section.)
- Ask your PCP or other medical specialists if they are enrolled in the Tailored Plan and if not, ask your PCP/doctor to get enrolled. Here is a sample letter you can provide to your PCP about enrolling in a Tailored Plan.
- Or, if your doctor does not plan to enroll in the Tailored Plan network, select a new PCP/doctor that is in your Tailored Plan network.
Medicaid Ombudsman
The NC Medicaid Ombudsman is an independent advocate for NC Medicaid beneficiaries. They can help you learn more about Tailored Plans and anything else related to NC Medicaid Managed Care. If you need assistance, visit their website or call them at 877-201-3750, 8 a.m.- 5 p.m., Monday through Friday (except on State holidays).
Your checklist:
Find out who is providing your Tailored Plan. (Who is your current LME-MCO?)
Review your letter from Medicaid explaining any change and qualification for Tailored Plan (a sample can be seen here).
If not qualified, see the NC DHHS Site for enrollment information and options. An Enrollment Broker can help you figure out which Medicaid plan you should be enrolled in.
Watch for the enrollment packet sent to you from the Enrollment Broker in mid-April of 2024.
Check if your Primary Care Provider (PCP), aka your doctor, is listed in the Tailored Plan provider network.
If you have other health care providers, go online to your Tailored Plan and check their provider network (links below) for other health specialists.
Ask your doctor/Primary Care Provider (PCP) if they are enrolled in the LME/MCO Tailored Plan for your region. If not, encourage them to get enrolled. An easy script to follow with your PCP is: “I/my child will be in a Medicaid Tailored Plan starting July 1, 2024. My/Their Tailored Plan is [insert name of LME MCO]. Are you enrolled in the [insert name of LME MCO/Tailored Plan] network?”
You can also use this sample letter for your provider. It may be helpful to customize it to your specific situation.
If they do not plan to enroll, select a new PCP by May 15, 2024.
If you do not already have a provider of Tailored Care Management (TCM), select one at any time before the Tailored Plans launch.
Check to see when your B(3) services are transitioning to new 1915(i) services like Community Living and Support, Respite, and Supported Employment. LME MCOs will provide crosswalks for B(3) services. No action is required by you right now to transition to 1915(i) services, but you should be aware that this will happen.
Choose/Confirm how you want to receive your Tailored Care Management (from Tailored Plan, Community Care Management Agency, or your Advanced Medical Home+).
Get your Tailored Plan welcome packet in the mail in April/May 2024 from your Tailored Plan.
Check with the Tailored Plan and/or your care manager to see if you qualify for other 1915(i) services you didn’t have before.
New Tailored Plan begins July 1, 2024.
Resources
- Problems? Call your Tailored Plan and/or the Medicaid Ombudsman program (877-201-3750)
- Find your Tailored Plan by contacting your Local Management Entity Managed Care Organization (LME/MCO) – Map link
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LME/MCO Tailored Plan contact information
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