NC Medicaid is rolling out ‘tailored’ plans for complex beneficiaries. Your questions answered. (2024)

By Jaymie Baxley

Medicaid is about to change for tens of thousands of North Carolinians who have complex health care needs.

For most of the state’s 2 million-plus Medicaid beneficiaries, nothing will happen.

The state plans to move about 160,000 enrollees, many of them people with intellectual or developmental disabilities, onto specialized Medicaid plans beginning July 1. These “tailored” plans are geared toward beneficiaries who require more extensive care and support than typical Medicaid participants.

Tailored plans will differ from standard Medicaid plans in several key ways. Here’s what you need to know about the shift.

Why is the state moving people to tailored plans?

Tailored plans are part of the Medicaid “transformation” that North Carolina started in 2021.

That year, the state changed its delivery system for Medicaid services. Providers who had been reimbursed directly for services by the state now receive care paid for by commercial insurers, who are paid a fixed, per-member, per-month rate to manage the state’s Medicaid population and get them all of the care that they need.

Because of the complexity of their health needs, some Medicaid participants have continued to receive care under the state’s old fee-for-service model, where each visit, test and procedure is paid for individually. Tailored plans are designed to bring those beneficiaries into the managed care system.

Who is eligible for tailored plans?

North Carolinians who are enrolled in Medicaid and have long-term care needs stemming from an intellectual or developmental disability, severe substance use disorder, serious mental illness or traumatic brain injury

How are tailored plans different from standard Medicaid plans?

The N.C. Department of Health and Human Services promises that tailored plans will offer all the same benefits as standard plans and have “more enhanced behavioral health services.” Some of the services exclusive to tailored plans include:

• In-depth care delivered in the home.
• Multisystemic therapy, which takes place in the home and sometimes in the community, used to manage someone with severe behavioral issues.
• Psychosocial rehabilitation, which can help people with mental illness build emotional skills to manage stressful situations in their work and social lives.
• Access to psychiatric residential treatment facilities.
• Medically monitored residential treatment for substance use disorder.

Unlike standard plans, tailored plans will be administered by four state-funded behavioral health organizations covering different regions of North Carolina. These organizations, known as LME-MCOS, are Partners Health Management, Alliance Health, Vaya Health and Trillium Health Resources.

What services will not be covered by tailored plans?

The plans won’t pay for dental services or the “fabrication of eyeglasses,” according to DHHS.

Services covered through the Program of All-Inclusive Care for the Elderly — a program that provides comprehensive care and medical services for frail seniors who have Medicare and Medicaid — are also excluded.

The same goes for services provided by Children’s Developmental Services Agencies, which serve infants and children up to 3 years old who have developmental delays.

Will people on tailored plans have to find new providers?

In most cases, no. The federal Centers for Medicare and Medicaid Services is requiring the state to ensure that at least 90 percent of tailored plan participants are given the option of staying with their current care providers.

Jay Ludlam, the state’s deputy secretary for Medicaid, recently reported that the LME-MCOs had enlisted enough providers to satisfy the mandate from CMS. In April, he said about 95 percent of the nearly 90,000 tailored plan participants served by Alliance and Partners would be able to keep their primary care providers. For Vaya and Trillium, it was 91 percent.

DHHS said enrollees whose providers do not accept tailored plans will have until Jan. 31 to find an in-network alternative.

How do people enroll in tailored plans?

Some Medicaid participants will be automatically enrolled on July 1. They should receive a letter from the LME-MCO for their region notifying them of the change.

Other qualifying beneficiaries can ask to be moved to a tailored plan by submitting a form to DHHS. A separate form is available for providers who wish to submit a request on a patient’s behalf.

Will people be allowed to keep their standard Medicaid plans?

Yes. DHHS says people who are eligible for Medicaid will remain eligible even if they enroll in a tailored plan.

Can people opt out of tailored plans?

Yes, but if they do, they may lose some benefits.

Medicaid participants who live in intermediate care facilities for people with intellectual disabilities will be required to enroll in tailored plans. The plans are also mandatory for beneficiaries who receive enhanced services through the NC Innovations Waiver, Traumatic Brain Injury Waiver or Transitions to Community Living programs.