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tailored care management

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What is Tailored Care Management?

The Autism Society of North Carolina (ASNC) is now a provider of Tailored Care Management (TCM), a Medicaid program that officially launched across the State of North Carolina in December of 2022. 

 

Tailored Care Management (TCM) is a new Medicaid service that seeks to integrate care for individuals covered by Medicaid services managed by LME/MCOs (If you are unsure what a LME/MCO is click here). In the Tailored Care Management model, a single person (called a Care Manager) is assigned to each Medicaid recipient. Care Managers help lead a care team to ensure each Medicaid recipient can access all available services, supports, resources, and information to best meet all their needs.  

An team of different health care professionals meeting to discuss care planning

In this way, Tailored Care Management aims to help coordinate whole-person care. Through this model, the full care team should also include all doctors, specialists, or therapists who provide vital care. This might include a pediatrician or primary care doctor, a psychiatrist, a psychologist, a pharmacist or pharmacy office, a social worker or therapist, speech/occupational/physical therapists, ABA therapy teams, direct care staff, medical specialists like neurologists and gastroenterologists, teachers, faith communities, and anyone else the individual or family feels is very important to their overall health and well-being.  

For those who have received case management or care coordination in the past, the service may feel similar, but it’s important to know the scope of Care Management is intended to be broader to ensure that all a person’s needs (social, psychiatric, emotional, developmental, medical, educational, occupational, etc.) are acknowledged and supported. 

For many families, this may be the first time someone has been assigned to help their family. As providers within the publicly funded healthcare space, we are so excited this day has come, and we hope it means more and more people and families across North Carolina will get the support and assistance they need! 

Who is eligible?  

Tailored Care Management is available to North Carolina Medicaid recipients who have an intellectual or developmental disability, severe and persistent mental illness, substance use disorder, or a TBI (Traumatic Brain Injury).

When you are found eligible for NC Medicaid, you are assigned to one of two Medicaid Plans: The Standard Plan or what will be called the Tailored Plan (our current LME/MCO system). In basic terms, what “plan” you are in tells us which company is in charge of overseeing your care, your authorized services, and determining your eligibility for various programs. 

The Standard Plan provides coverage for medical needs, pharmacy services, and basic behavioral health supports (like outpatient therapy and medication management). Standard Plan providers include:

  1. AmeriHealth Caritas North Carolina
  2. Healthy Blue of North Carolina
  3. UnitedHealthcare of North Carolina
  4. WellCare of North Carolina
  5. Carolina Complete Health.  

The LMEs/MCOs (future Tailored Plan) provide coverage for all services included in the Standard Plan, plus coverage of enhanced behavioral health services (like the NC Innovations and TBI Waivers and waitlists for them, B3 services [which are in the process of transitioning to 1915i services], Intensive In-Home, and ACTT). LME/MCOs have contracted with community-based providers to ensure each covered recipient receives Care Management support. LME/MCOs include:

  1. Alliance Health
  2. Partners
  3. Trillium (which now includes the former Sandhills and Eastpointe LME/MCOs)
  4. Vaya Health

*If you aren’t sure if you are in the Standard Plan or will be included in the Tailored Plan, please call the LME/MCO in charge of managing your county’s Medicaid-funded services. They can look up your information and let you know which plan you are in, as well as what to do if you feel you’re not in the correct plan. 

What should you expect?  

Once you, your child, or another person in your family is found eligible, you will be assigned to a Tailored Care Management (TCM) agency. You should receive a letter from the LME/MCO you’re assigned to notify you of this assignment.  

The assigned agency will contact you by phone to tell you more about Care Management and to ensure it is something you are interested in. They may also attempt to contact you via text, email, or by traveling to the home address on file for Medicaid. It’s important to know you can decline the service for any reason – to decline, you need to speak to someone at the agency or call the LME/MCO to indicate you “opt-out” of the program.  

If you say “yes” to Care Management, your provider agency will help you identify where in your life you need support and how to best be supported. Some examples include providing information about activities to do in the community, providing support during meetings with teachers or other school staff, completing referrals for therapeutic programs (ABA, counseling, speech therapy, occupational therapy, etc.), locating community resources to help pay for housing and utility costs, helping you understand diagnoses and behavior, and helping you communicate with medical providers about your questions and concerns. Last but certainly not least, the goal of Care Management is to put clients and families at the center of the work being done – families and individuals can decide how frequently they’d like to talk with their Care Manager, through what method they’d like to talk with their Care Manager (phone, text, email, telehealth platform), and what goals or objectives their Care Manager helps them work toward.  

Within the first three months, Care Managers must complete an assessment that helps paint a fuller picture of what you need. The assessment is used to create a Plan of Care that helps the entire care team know who on the team is responsible for completing which tasks or goals, and when they will be completed. If your needs change or a crisis occurs, your Care Manager is responsible for changing the plan and supporting you through the changes. 

If you have not heard from your Care Manager, you can call the MCO assigned to manage care for the county you live in. When you call, you can say, “I’m calling to find out who my assigned Tailored Care Management agency is.” They should be able to tell you via phone and help get you connected as soon as possible. 

The last very important piece to expect is that if you are interested in receiving Medicaid 1915(i) services, a Care Manager is required to complete an assessment with you to detail your needs – this is required to determine if you are eligible for the 1915(i) services. If you have opted out of Tailored Care Management, a Care Coordinator assigned by the LME/MCO will complete this for you.   

How is ASNC’s model of Care Management different?  

Currently, ASNC’s Tailored Care Management program is being piloted in the Alliance LME/MCO region (and only in Durham, Orange, and Wake counties) to children (under age 22) who are not receiving Innovations and who have a diagnosis of autism. While we aren’t currently accepting additional families into the program, as an agency we want to help families understand the program, what to expect, and what their rights are.  

ASNC Care Management has partnered with Duke Health to ensure clients’ needs are met, as they pertain to any higher medical or psychiatric needs and understanding medication management. This partnership helps ASNC ensure high-quality care management is provided to all families assigned to our program.  

Please visit ASNC’s Tailored Care Management webpage for more information and updates as our program continues. If our program expands to include additional areas and populations or is open to new families, you will find that information there.  

What are your rights? 

As a recipient of Tailored Care Management, you have the right to: 

  • Ask questions about Tailored Care Management and the specific agency you are assigned to before providing verbal consent. 
  • Change your provider of Tailored Care Management. To change your provider, contact the LME/MCO that manages the county in which you live and tell them, “I want to change my Tailored Care Management provider.” They should assist you via phone and confirm for you that the change was submitted in the system. There can be a limit to the number of times you can change your Care Management provider, but the LME/MCO can help you understand your options. 
  • Opt out of the Tailored Care Management program. This service is offered to you but is not mandatory. If you do not feel it is something your family would benefit from, you have the right to “opt-out” of the program. 
  • Voice what you prefer when it comes to meetings. Who would you like to invite to them? Do you want them to be done in person at your home, in the community, via a telehealth platform, or by phone?  
  • Voice what you prefer when it comes to frequency of contact. While the State has outlined recommendations for how frequently your Care Manager should contact you both via phone and in person, they have stressed that families should be able to voice preferences.  
  • Have copies of all assessments and plans created for you by your Care Manager. 

Where can I get more information about Tailored Care Management? 

There are websites with more detailed information about Tailored Care Management and overall Medicaid Transformation. 

 

 

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