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Tailored Plans

 

Tailored Plans are designed to provide specialized health and medical services for Medicaid members with specific needs.

  • Will launch on July 1, 2024.
  • Cater to individuals with behavioral health needs and intellectual/developmental disabilities (I/DD), and also serve other special populations, including Innovations and Traumatic Brain Injury (TBI) waiver enrollees and waitlist members. LME/MCO Coverage Map

LME/MCO Coverage Map

Medicaid contract status chart

You might be eligible for a Tailored Plan if you have NC Medicaid and health needs related to:

  • Serious mental illness (SMI)
  • Severe substance use disorders (SUD)
  • Intellectual/developmental disabilities (I/DD)
  • Traumatic brain injuries (TBI)

Tailored Plans will also serve people on the NC Innovations Waiver or Traumatic Brain Injury (TBI) Waiver. (People will not lose their spots on the waitlist.)

How to get a Tailored Plan

  1. Apply for NC Medicaid. (If you already have NC Medicaid, skip this step.)
  2. Your eligibility for the Tailored Plan will be automatically reviewed. If you are eligible, you should get a letter in the mail letting you know.
  3. You can ask to move to a Tailored Plan. You or your provider can submit the form “Request to Move to NC Medicaid Direct or LME/MCO.”

Tailored Plans start July 1, 2024. Some people on Medicaid will be automatically enrolled in a Tailored Plan. If your NC Medicaid will move to a Tailored Plan, a letter will be mailed to you in mid-April. If you got a letter about Tailored Plans, learn more about what you should do.

How to find providers in the Tailored Plan’s network

Providers are doctors or specialists.

To have your services paid for by NC Medicaid, your Medicaid providers must be in your Tailored Plan’s network (Alliance Health, Partners Health Management, Trillium Health Resources or Vaya Health).

If a provider you need is out-of-network, talk to your Tailored Plan. Some people can get exceptions, like if a doctor is the only one who offers the service you need.

3 ways to find providers:

Tailored Plan companies

Each county is served by a single Tailored Plan company. Your Tailored Plan company is assigned based on the county that administers your NC Medicaid. You can call them with questions about Tailored Plans, even if you are not a member.

Tailored Plan companies:

Don’t know which company to call? These companies are also known as Local Management Entity/Managed Care Organizations (“LME/MCO”). Find the Tailored Plan (LME/MCO) for the county that administers your NC Medicaid using this directory. Or, call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com).

Other Resources

Check out these free materials, in Spanish and English, to learn more about your Tailored Plan: Medicaid.NCDHHS.Gov/Tailored-Plans/Toolkit

These resources include:

  • How to request rides to Medicaid-covered medical appointments with a Tailored Plan (download here).
  • How to know if your doctor is participating in your plan, and what to do if they are not (download here).
  • Guide about 1915(i) home and community-based services (download here).
  • Shareable content about Tailored Plans that you can share on your social and digital channels (download here).
  • What to do if your Medicaid will move to a Tailored Plan (visit the page here).
  • What to expect and the services covered on your Tailored Plan (visit the page here).

 

Information above sourced from NC Medicaid Division of Health Benefits webpage.

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