Tailored Care Management Quick Reference Guide for Providers

Background

Tailored Care Management (TCM) is a care management model that began Dec. 1, 2022, for eligible NC Medicaid beneficiaries. With TCM, eligible beneficiaries have a single designated care manager, supported by a multidisciplinary team, to provide integrated care management to address the beneficiary’s whole-person health needs.

Who is Eligible for TCM?

Individuals who are enrolled in NC Medicaid Direct including:

• Innovations Waiver participants (including duals)
• Traumatic brain injury (TBI) Waiver participants (including duals)
• Children and Adolescents with a Serious Emotional Disorder (SED)
• Adolescents with a Severe Substance Use Disorder (SUD)
• Adults with a Serious Mental Illness (SMI) or Severe SUD
• Children and adults with Intellectual/Developmental Disabilities (I/DD)
• Children and adolescents in foster care with SED or SUD
• Dual-eligible adults with SMI or SUD
• Dual-eligible Children and older and Adults with I/DD who are NOT on the Innovations or TBI waivers

Eligibility Exceptions

The services below are substantially similar to TCM and; therefore, beneficiaries receiving these services will not receive TCM. However, there are some instances where beneficiaries may receive both services (e.g., TCM and Assertive Community Treatment (ACT), or TCM and Care Management for At-Risk Children (CMARC)) for a limited time to ensure a smooth transition. Tailored Plans will be responsible for developing and implementing protocols to ensure beneficiaries moving between these services and the TCM model experience smooth transitions.

TCM will be available to the above beneficiaries except those in the following services:

• Beneficiaries obtaining Assertive Community Treatment (ACT) or Critical Time Intervention (CTI)
• Beneficiaries residing in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IIDs) or Skilled Nursing Facilities
• Beneficiaries participating in CMARC
• Beneficiaries participating in the High-Fidelity Wraparound (HFW) program or Child ACT
• Community Alternatives Program for Children (CAP/C)
• Community Alternatives Program for Adults with Disabilities (CAP/DA)
• Program of All-Inclusive Care for the Elderly (PACE)

What if a Beneficiary Wants to Change their TCM Provider?

Beneficiaries can change their TCM provider twice per year “without cause” and unlimited number of times "with cause” per year. Beneficiaries on the Innovations and TBI waivers can choose their current care coordinator as their TCM provider or choose a different TCM provider.

Beneficiaries can also opt out of care management if they choose, and it will not affect the other services they receive in any way.

If a beneficiary wants to change their TCM provider, they should contact their LME/MCO (contact info below) who can share information on certified TCM providers by population served, age and geography.

How do I know who my Beneficiary's TCM Provider is?

PCPs can see the assigned TCM entity for any of their beneficiaries on the NCTracks Recipient Eligibility Verification results, as well as on their Advanced Medical Home (AMH) NC Medicaid Direct/Managed Care PCP Enrollee Report in NCTracks.

Other providers may be contacted by the TCM provider for coordination of care.

How will I interact with a TCM Care Manager for Beneficiaries I serve?

A care manager may contact your office to:

• Identify the agency and the beneficiary they represent and present release of information documentation
• Explain their role in the beneficiary’s care and talk about participation in the beneficiary’s care team
• Ask questions about symptoms, medications and treatment
• Share concerns about/from the beneficiary
• Ask questions about lifestyle changes that would promote better health for the beneficiary
• Request support for referral to another provider

Who is Eligible to Become a Certified Tailored Care Management Provider?

Advanced Medical Home Plus (AMH+)

AMH+s are primary care practices actively serving as AMH Tier 3 practices, whose providers have experience delivering primary care services to the Tailored Plan eligible population or can otherwise demonstrate strong competency to serve that population. To demonstrate experience and competency to serve the Tailored Plan eligible population, each AMH+ applicant must attest that it has a patient panel with at least 100 active Medicaid patients who have an SMI, SED, or severe SUD; an I/DD; or a TBI.

Care Management Agency (CMA)

To be eligible to become a CMA, an organization’s primary purpose at the time of certification must be the delivery of NC Medicaid or State-funded behavioral health, I/DD and/or TBI services, other than care management, to the Tailored Plan eligible population in North Carolina. The CMA designation is new and will be unique to providers serving the Tailored Plan population.

For a list of certified Tailored Care Management providers please reference the Certified Provider list.

What if I want to become a Certified AMH+ or CMA TCM Provider?

The process for TCM AMH+/CMA Provider Certification is managed by the National Committee for Quality Assurance (NCQA), using their web-based Interactive Review Tool (IRT). Providers will use IRT to submit their application, complete the desk review, site review, readiness review and recertification.

Key features include the ability for providers to upload documents, complete self-assessed scoring, review documents, reconcile issues, receive feedback for improvement and review results.

What if I have questions?

For questions that are health-plan specific, please see contacts 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

Additional Resources

• Behavioral Health I/DD Tailored Plan
• LME/MCO Directory
• Tailored Care Management including Request for Applications