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Medicaid Transformation: What You Need to Know

Update, March 2021: If you are looking for more recent information about Medicaid Transformation, please visit this post.

Editor’s note: This information is current as of July 16, 2019. Please note, a variety of factors may affect the timeline or other components of the transformation plan. The NCGA, state budget, and other system or administrative issues may create change. We will update this blog if substantive change occurs.

The NC Department of Health and Human Services is in the process of implementing Medicaid transformation in North Carolina. The vision of DHHS is “Improving the health and well-being of North Carolinians through an innovative, whole-person centered and well-coordinated system of care that addresses both medical and non-medical drivers of health.” DHHS plans to implement these changes in coming years after developing policy based on feedback from a wide variety of stakeholders since 2015.

For more information about how and why this came about, please visit our older blog articles outlining the proposal and development of the plans:


Starting in late 2019, Medicaid recipients in North Carolina will have their health services managed by private insurance companies as NC Medicaid switches from a public fee-for-service system to a private managed-care model. Instead of the state of North Carolina managing the program directly, insurance companies will be paid a per-member, per-month fee to work with people on Medicaid to manage their health services, similar to how health care works for people with private health-care coverage. Our state’s plan is unique in that it plans to incorporate elements of non-medical drivers of health, such as housing, transportation, food insecurity, etc. as well.


Standard vs. Tailored Plans

During this transformation of how health services are managed, Medicaid will integrate physical health care with behavioral health care so that people will, hopefully, be healthier and have an easier time getting services regardless of the type of healthcare needs they have. This involves services and supports for physical, pharmaceutical, behavioral, and social needs. There will be two separate identified plans to provide this: Standard and Tailored.

Standard Plans will be available for those with mild to moderate behavioral health or substance use needs. Tailored Plans will be for those with more complex or lifelong needs, for example, people on the Innovations waiver. People will be enrolled in a Standard or Tailored Plan based on various eligibility factors. Four statewide Standard Plans will be offered by AmeriHealth Caritas NC, WellCare, Healthy Blue NC, and United Healthcare NC. A regional provider-led entity, Carolina Complete Care, will also operate a Standard Plan in one area. People who move to Standard Plans will choose one of these to manage their health services.

For detailed information on eligibility determination for plans, see the policy design paper.


When Is This Happening?

This switch to integrated private managed care will happen in two phases: the Standard Plan rollout, which is scheduled to occur from November 2019 through February 2020, and the Tailored Plan rollout, which is currently scheduled to begin in July 2021. (Dates may be subject to change by DHHS.)

Initially, the Standard Plans will roll out in two regions in November 2019.

  • Region 2: Alleghany, Ashe, Davidson, Davie, Forsyth, Guilford, Randolph, Rockingham, Stokes, Surry, Watauga, Wilkes, and Yadkin counties
  • Region 4: Alamance, Caswell, Chatham, Durham, Franklin, Granville, Johnston, Nash, Orange, Person, Vance, Wake, Warren, and Wilson counties

The remainder of the regions will roll out in February 2020.  The full list of regions for Standard Plans can be found here.

Most people with autism will continue to have their health services managed as they are now through NC Medicaid (also known as Medicaid Direct). Their behavioral health and IDD services will continue to be managed by LME/MCOs at this time. Based on diagnoses and services as referenced in the above eligibility link, most people with autism will not see changes to the management of their health benefits until the Tailored Plans roll out.

For general information on Medicaid as a health insurer and how to apply, see DHHS’s website.

For more information on accessing local behavioral health or IDD services, see the LME/MCO county map.

People began receiving enrollment packets from Medicaid this summer to explain the change, and if they are eligible, give them the choice to begin selecting a new health-care insurance company (Standard Plan) and primary care provider (PCP). Those who are part of the Standard Plan rollout and have not selected a company will be automatically assigned based on where they live, their eligibility, where they seek their health care, and where other members of their household are assigned.


What Do Individuals with Autism or Their Families Need to Do?

If Medicaid is your health insurer, you or your child will have the option of enrolling in a Standard or Tailored Plan based on eligibility criteria. People who have Medicaid as their health insurer and are using Medicaid b3, state funded (IPRS), or other Medicaid services (e.g. ABA through Medicaid, Research-Based Behavioral Health Treatment) and are NOT on the Innovations waiver, will get a letter indicating options to enroll in a Standard Plan or remain in the Tailored Plan based on eligibility factors. The Tailored Plan will be operated by LME/MCOs, and services should remain unchanged until 2021. You will continue to receive your primary health-care services through Medicaid as you do now if you do not enroll in a Standard Plan. You should carefully weigh your options and choices as most support services for people with ASD (like b3 respite, IPRS Developmental Therapy, Innovations waiver) are not available in Standard Plans. At this time, most services for people with Autism Spectrum Disorder remain in the Tailored Plan (LME/MCOs).

As always, it is important for people to get on the waitlist and ensure their information is up to date with DSS and LME/MCOs for services. Individuals who are on the Innovations waiver, CAP/DA, CAP Child or dually enrolled with Medicaid and Medicare will not move into standard plans. There are other exceptions to eligibility criteria. For children receiving Research Based Behavioral Health Treatment, those services should be available in both Tailored and Standard Plans in addition to regular health services.

If you are eligible for the Standard Plan, more information and contacts for who can help you choose a plan and provider can be found on the Enrollment Broker’s website, found here. It’s important to know that if you do choose a Standard Plan, and your needs change for services not available in the Standard Plan, you can seek to move back to a Tailored Plan. We will publish more information on this in the future as details are worked out. It is also important to note that individuals who are on the waitlist for Innovations waiver services will also be automatically enrolled into the Tailored Plan, unless they choose to opt out and into a Standard Plan. They can maintain their place on the Innovations waiver waitlist if they are eligible to and choose to enroll in a Standard Plan.

Here are the behavioral health and IDD services available in each plan from DHHS:


Covered by Both Standard Plans and Behavioral Health IDD Tailored Plans

State Plan Behavioral Health and IDD Services

  • Inpatient behavioral health services
  • Outpatient behavioral health emergency room services
  • Outpatient behavioral health services provided by direct enrolled providers
  • Partial hospitalization
  • Mobile crisis management
  • Facility-based crisis services for children and adolescents
  • Professional treatment services in facility-based crisis program peer supports
  • Outpatient opioid treatment
  • Ambulatory detoxification
  • Substance abuse comprehensive outpatient treatment program (SACOT)
  • Substance abuse intensive outpatient program (SAIOP) pending legislative change
  • Clinically managed residential withdrawal (social setting detox)
  • Research-based intensive behavioral health treatment
  • Diagnostic assessment
  • Non-hospital medical detoxification
  • Medically supervised or ADATC detoxification crisis stabilization


Covered Exclusively by Behavioral Health IDD Tailored Plans (or LME-MCOs Prior To Launch)

State Plan Behavioral Health and IDD Services

  • Residential treatment facility services for children and adolescents
  • Child and adolescent day treatment services
  • Intensive in-home services
  • Multi-systemic therapy services
  • Psychiatric residential treatment facilities
  • Assertive community treatment
  • Community support team
  • Psychosocial rehabilitation
  • Substance abuse non-medical community residential treatment
  • Substance abuse medically monitored residential treatment
  • Clinically managed low-intensity residential treatment services
  • Clinically managed population-specific high-intensity residential programs
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)

Waiver Services

  • Innovations waiver services
  • TBI waiver services
  • 1915(b)(3) services

State-Funded BH and I/DD Services

State-Funded TBI Services


What Benefits Are There to Transformation?

The benefits of transformation include having choice, access to care management, and coordinated approaches to physical, behavioral, and social needs. People should be able to compare the benefits of each plan and choose the one that best supports themselves and their family. Both Standard and Tailored (2021) Plans will provide access to care management, which should serve as a central hub to all needs in the Medicaid system. Care management, as defined in transformation, will include “the involvement of a multidisciplinary care team and the development of a written care plan.”

As mentioned at the beginning of this article, one of the goals of transformation is to integrate physical and behavioral health care. Plans must work to address not just direct health care, but also non-medical drivers of health, such as nutrition and food insecurity, obesity, lack of exercise, smoking, access to transportation, and employment. will benefit all North Carolinians, including the autism community.


Where Can I Learn More?

DHHS has a wealth of information online at www.ncdhhs.gov/assistance/medicaid-transformation. Find FAQ documents here.

You may also contact us at 800-442-2762 (press 2) for additional information. We know this is a complex issue to navigate.


This is the largest change to North Carolina’s Medicaid system in 40 years. We applaud the hard work and vision of DHHS to move North Carolina to a healthier population overall. We will continue to inform, advocate, and translate what this means for people with autism in the future.


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