Behavioral Health and Intellectual/​Developmental Disabilities Tailored Plan

Tailored Plans are a new kind of NC Medicaid Managed Care health plan.

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Tailored Plans started July 1, 2024. 

• Guide: What to do if your NC Medicaid will move to a Tailored Plan
• Toolkit: Free materials to share with your community

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 are the only Medicaid health plan that offer the NC Innovations Waiver or Traumatic Brain Injury (TBI) Waiver. You must have a Tailored Plan to access these waiver services.

A Medicaid health plan for more complex health needs

Tailored Plans cover doctor visits, prescription drugs and services for serious mental health, severe substance use, I/DD and TBI all in one plan.

They are “tailored” for people who have more complex health needs and who need long-term rehabilitation and care, either in a treatment facility or at home.

Services available with Tailored Plans can include*:

• Home and community-based services
• Long-term rehabilitation and treatment services, including in-home services
• Support for recovering from substance use disorders
• Support for members with traumatic brain injury and support for those with intellectual and developmental disabilities
• Institutional and community-based mental health treatment
• Access to a Tailored Care Manager, who can help schedule appointments, arrange transportation and more (Tailored Care Management)
• Help moving out of a treatment facility and into your own home
• Breaks for caregivers
• Coaching to help you find and keep a job that’s right for you
• See more benefits and services

*This is not a complete list. Services depend on your eligibility. Talk to your Tailored Plan or Tailored Care Manager for details.

If you are on one of these programs, you must be on a Tailored Plan:

• NC Innovations Waiver
• TBI Waiver
• Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID)
• Transitions to Community Living (TCL)
• State-Funded (non-Medicaid) services

Like other Medicaid health plans, Tailored Plans offer free, accessible transportation to and from Medicaid appointments (called Non-Emergency Medical Transportation or NEMT). To schedule rides, call your Tailored Plan.

For more information on services, contact your Tailored Plan.

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 automatically be reviewed. Letters are sent in the mail from your Tailored Plan (Vaya Total Care, Alliance Health, Partners Health Management and Trillium Health) letting you know if you are eligible.
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 started July 1, 2024. Some people on Medicaid were automatically enrolled in a Tailored Plan. 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 Total Care). Providers who do not accept Tailored Plans are considered “out-of-network.”

3 ways to find providers:

• Call your Tailored Plan
  • Alliance Health, 1-800-510-9132, TTY: 711 or 1-800-735-2962
  • Partners Health Management, 1-888-235-4673, TTY: 711
  • Trillium Health Resources, 1-877-685-2415, TTY: 711
  • Vaya Total Care, 1-800-962-9003, TTY: 711
• Ask your Tailored Care Manager, if you have one
• Use this directory to find a provider near you

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

Moving to a Medicaid Tailored Plan?

• Providers that don’t accept Tailored Plans are considered “out-of-network.” You can keep seeing them until January 31, 2025.
• Talk to your Tailored Plan if you would like to continue to see them after January 31, 2025.

Learn more about the move to Tailored Plans and what you need to do.

Who manages Tailored Plans?

Each county is served by an organization to manage Tailored Plans. Your Tailored Plan 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 Plans:

• Alliance Health, 1-800-510-9132, TTY: 711 or 1-800-735-2962
• Partners Health Management, 1-888-235-4673, TTY: 711
• Trillium Health Resources, 1-877-685-2415, TTY: 711
• Vaya Total Care, 1-800-962-9003, TTY: 711

Don’t know who to call? These organizations 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).

Updates

• Tailored Plans started July 1, 2024. Some people on Medicaid were be automatically enrolled in a Tailored Plan. If your NC Medicaid will move to a Tailored Plan, a letter was mailed to you in mid-April. Learn more about the move to Tailored Plans and what you need to do.
• NCDHHS Consolidates Local Management Entity/Managed Care Organizations Ahead of Tailored Plan Launch (Feb. 1, 2024)

Need help?

Questions about eligibility: Contact the NC Medicaid Enrollment Broker at 1-833-870-5500. Hours of operation: 7 a.m. to 5 p.m., Monday through Saturday.

Questions about Tailored Plans:  Call your Tailored Plan.

• Alliance Health, 1-800-510-9132, TTY: 711 or 1-800-735-2962
• Partners Health Management, 1-888-235-4673, TTY: 711
• Trillium Health Resources, 1-877-685-2415, TTY: 711
• Vaya Health, 1-800-962-9003, TTY: 711

Your Tailored Plan is assigned based on the county that administers your NC Medicaid. Find your Tailored Plan (also known as “LME/MCO”) by using this directory. Or, call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com). 

If you are an independent provider and interested in the TBI Waiver and its processes, please contact the Tailored Plan in your area.  

Other related services

• Tailored Care Management
• Behavioral Health and Intellectual/Developmental Disabilities Services

Information for Providers

• Provider Playbook: NC Medicaid Managed Care