Tailored Plan Eligibility and Enrollment Updates for Aug. 1, 2022, Auto-Enrollment
Tailored Plan Criteria Review
In early August 2022, NC Medicaid began identifying beneficiaries eligible for enrollment in the Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan launching Dec. 1, 2022.
NC Medicaid began notifying beneficiaries of their eligibility for a Tailored Plan beginning Aug. 22, 2022. The State will conduct a monthly review to identify and send notices to additional Tailored Plan-eligible beneficiaries. This process is known as the Tailored Plan Criteria Review.
Tailored Plan Eligibility Criteria
NC Medicaid identifies Tailored Plan-eligible beneficiaries using available data, including NC Medicaid and state-funded services claims and encounters, reports from LME/MCOs and Medicaid enrollment and eligibility data.
Criteria based on service utilization, or a combination of diagnosis and service utilization (Medicaid and state-funded services) require a date of service on or after Dec. 1, 2020. Eligibility criteria based only on diagnosis has a lookback period going back to Jan. 1, 2018.
Beneficiaries will not lose NC Medicaid eligibility due to the Tailored Plan Criteria Review.
Tailored Plan Enrollment and Health Care Options
Beneficiary Enrollment Notices
Beneficiary notices will include their health care options and information about changing their health care option. To disenroll from the Tailored Plan and enroll in a Standard Plan, Tailored Plan members must contact the NC Medicaid Enrollment Broker. Members will be explained their choices and must confirm their decision to no longer receive enhanced services only provided by the Tailored Plan. Members must provide informed consent before they are moved to a Standard Plan. Members will move back to the Tailored Plan at any time if they continue to meet eligibility criteria. Coverage changes are effective the first of the month following the request.
Enrollment for Members Receiving Innovations/TBI Waiver or TCL Services
Members who are auto-enrolled in a Tailored Plan and receive Innovations or traumatic brain injury (TBI) waiver services or transition to community living (TCL) services must contact the Tailored Plan to leave the waiver or TCL before they may enroll in a different health care option. Beneficiaries must leave the Innovations/TBI waiver or stop receiving TCL services and contact the NC Medicaid Enrollment Broker. Beneficiaries will receive choice counseling to confirm they will no longer receive services only provided by the Tailored Plan.
Enrollment via Request to Move
If beneficiaries need to move to Tailored Plans to receive the behavioral health, I/DD or TBI services they need, beneficiaries or their provider may fill out the Request to Move Form. Beneficiaries’ needs will be evaluated and if criteria are met, the beneficiary will transition back into NC Medicaid Direct or Tailored Plan based on their specific needs. For beneficiaries with a current need, the provider may complete the Request to Move Provider Form and it will be expedited. If a beneficiary has already completed the Request to Move Provider Form, the provider will not need to complete the form again.
To view sample enrollment notices, visit the County Playbook for Medicaid Managed Care –Beneficiary Notices. Beneficiaries with questions or who want to learn more about their health care options should contact the NC Medicaid Enrollment Broker:
The NC Medicaid Ombudsman offers free and confidential support if beneficiaries have trouble with access to health care and connects people to resources like social services, legal aid, and other programs and resources. Beneficiaries may contact the NC Medicaid Ombudsman:
- By calling 877-201-3750
- Online at ncmedicaidombudsman.org
For questions about contracting, contact the Health Plan. Information can be found on the NC Medicaid Provider Contracting with Health Plans webpage.
For general inquiries and complaints regarding Health Plans, NC Medicaid has created a Provider Ombudsman to represent the interests of the provider community. The Ombudsman will:
- Provide resources and assist providers with issues through resolution.
- Assist providers with Health Information Exchange (HIE) inquires related to NC HealthConnex connectivity compliance and the HIE Hardship Extension process.
Provider Ombudsman inquiries, concerns or complaints can be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov, or received through the Provider Ombudsman line at 866-304-7062. The Provider Ombudsman contact information is also published in each Health Plan’s provider manual.
For questions related to your NCTracks provider information, please contact the NCTracks Call Center at 800-688-6696. To update your information, please log into the NCTracks Provider Portal to verify your information and submit a MCR or contact the NCTracks Call Center.