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:
- North Carolina’s Transformation to Medicaid Managed Care (overview page)
- Tailored Plan Fact Sheet (PDF from NCDHHS October 2022)
- Tailored Plan – Medicaid Information for those with Behavioral Health Intellectual and/or Developmental Disabilities I/DD (NC DHHS overview page)
- NC Medicaid Managed Care
- Tailored Plan Services – Questions and Answers
- Medicaid Page on 1915(i) Services
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 info on the plans and services are below.
- * Now – Tailored Care Management services are available for eligible Medicaid beneficiaries.
- * 7/1/2023 until now – 1915i services for eligible Medicaid beneficiaries. Eventually, those with b3 services will transition to 1915i services.
- * 10/1/2023 – Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans launch.
Stay Connected with Us –
Quick Links –
- – Medicaid Ombudsman – available to answer questions, etc. (https://ncmedicaidombudsman.org/)
- – NC Medicaid Enrollment Broker – (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 and behavioral health care 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 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 can they 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.
- – Tailored Plans will manage physical health care as well as behavioral health care, and developmental disability services and supports beginning July 1, 2024.
- – 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 screening, triage, and referral line to connect with 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, nutrition, 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).
- – Some LME/MCOs will change or be consolidated before Tailored Plans start in July. Once the LME consolidation is complete, the 4 remaining LME/MCOs will provide Tailored Plan health care coverage to people who qualify. The LME/MCO you belong to after consolidation *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)
- – People with partial Medicaid benefits including those in Family Planning, Emergency Medicaid, and special populations like those with Refugee Benefits.
- – Children with Health Choice: children and youth who are on Health Choice will be merged into Medicaid by July 1, 2023. This is a positive change since Medicaid offers additional services, like those for autism under EPSDT. For now, children in Health Choice will continue to get the same services until the merger with Medicaid at a later time.
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 (i) Services, 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 NC 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 services to people with I/DD as well as those with mental health issues and substance use disorders. 1915 services are replacing B3 services but unlike B3, 1915 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 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 as of December 1, 2022, 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’s 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.
You should have received a letter if you qualify for Tailored Care Management of who is your provider (choices above) of the service. You can change that provider by contacting your MCO.
Primary Care Providers
Tailored plans are now 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 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
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).
- 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, contact the Enrollment Broker (NC DHHS Site) for options. An enrollment Broker will help you figure out which Medicaid plan you should be enrolled in.
- Watch for the enrollment packet sent to you ithe Spring of 2024 from the Enrollment Broker. NOTE: Because of Tailored Plan delays until July 1, 2024, enrollment packets may be resent in April/May 2024.
- Check if your PCP is listed in the Tailored Plan provider network
- Go online to your Tailored Plan and check their network (links below)
- 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 don’t plan to enroll, select a new PCP by mid-May 2024.
- If you do not already have a provider of Tailored Care Management, select one at any time before the Tailored Plans launch.
- Check to see when your b(3) services are transitioning to new 1915 services like Community Living and Support, Respite, and Supported Employment. LME MCOs will provide crosswalks for b3 services. No action is required by you right now to transition to 1915 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 services you didn’t have before.
- New Tailored Plan begins July 1, 2024.
Problems? Call your Tailored Plan (see Resources below) 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
LME/MCO Tailored Plan Contact info
- Alliance or 919-651-8500 (member services)
- Eastpointe or 888-977-2160 (member services)
- Partners or 877-864-1454 (member services)
- Sandhills Center or 855-777-4652 (member services)
- Trillium or 855-250-1539 (member services)
- – Vaya or 866-990-9712 (member services)
Eastern Band of Cherokee Indians (ECBI) Tribal Option or 800-260-9992