Tailored Care Management

The Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Care Management (TCM) model reflects the goal of whole-person care management in NC Medicaid Managed Care. Provider-based care management promotes integrated care and offers beneficiaries choice in how they receive care management. 

Through TCM, Behavioral Health I/DD Tailored Plan beneficiaries will have a single designated care manager supported by a multidisciplinary care team to provide whole-person care management that addresses all of their needs including physical health, behavioral health, I/DD, traumatic brain injuries (TBI), pharmacy, long-term services and supports (LTSS) and unmet health-related resource needs. Tailored Care Management will:

  • Be available throughout the entire duration of a beneficiary’s enrollment in a Behavioral Health I/DD Tailored Plan
  • Be based in provider settings to the maximum extent possible, supporting integrated care and collaboration 
  • Prioritize frequent in-person interactions between community-based care managers and beneficiaries
  • Place additional emphasis on outcomes and population health management. 

Effective, integrated and well-coordinated care management depends on care team members having the ability to efficiently exchange member health information and use that information to monitor and respond to medical and nonmedical issues that could impact beneficiaries. 

The success of Tailored Care Management will depend upon Behavioral Health I/DD Tailored Plans, Advanced Medical Home Plus (AMH+) practices, Care Management Agencies (CMAs), pharmacies, and physical health, behavioral health and I/DD providers using a coordinated approach to beneficiary care. 

Updates

NC Medicaid Begins Tailored Care Management  

Local Management Entity/Managed Care Organizations (LME/MCOs) along with Tailored Care Management providers begin providing Tailored Care Management Dec. 1, 2022.

Beneficiaries receiving Tailored Care Management will have a single designated care manager supported by a multidisciplinary care team to provide whole-person care management that addresses all their needs, including physical health, behavioral health, I/DD, traumatic brain injuries (TBI), pharmacy, long-term services and supports, and unmet health-related resource needs. 

Letters were mailed beginning Nov. 14, 2022, to TCM-eligible beneficiaries and authorized representatives with the name and contact information of their TCM provider. The letter also explains Tailored Care Management services and provides information on how beneficiaries can change their Tailored Care Management provider or opt out of the service.

The Centers for Medicare & Medicaid Services (CMS) was not able to complete the request for the 1915(i) option to launch Dec. 1, 2022. 

Temporary Flexibilities and Program Changes

The Tailored Care Management program launched on December 1, 2022. Recognizing that it would take providers some time to ramp up and meet the full set of program requirements, on November 2, 2022,  the Department released a memo permitting temporary flexibilities and program changes for the period between December 1, 2023, and March 31, 2023. The majority of these flexibilities came to an end on March 31, 2023, and some will continue until June 30, 2023. This memo seeks to clarify the current status of each flexibility and outlines several additional program updates.

NOTE: Until Tailored Plan launch, the State’s local management entity/managed care organizations (LME/MCOs) will continue to operate the Tailored Care Management model. Individuals eligible for the model will still have the option to obtain Tailored Care Management from an Advanced Medical Home Plus (AMH+) practice, Care Management Agency (CMA), or plan-based care manager. Until an eligible individual engages in Tailored Care Management, their LME/MCO will be responsible for care coordination functions. In the future, Tailored Care Management will be offered by LME/MCOs in their role as both Tailored Plans and prepaid inpatient health plans (PIHPs).

To ensure beneficiaries can seamlessly receive care on day one, the North Carolina Department of Health and Human Services (NCDHHS) is delaying the implementation of the NC Medicaid Managed Care Behavioral Health and Intellectual/ Developmental Disabilities Tailored Plans (Tailored Plans) scheduled for Oct. 1, 2023, but will now go forward at a date still to be determined. Beneficiaries who will be covered by the Tailored Plans will continue to receive care as they do today. 

Resources

Webpages

Manuals

Other

Frequently Asked Questions

Additional Information

Previous Updates

Tab/Accordion Items

Temporary Flexibilities and Program Changes

Recognizing this is a time of substantial change for NC Medicaid enrollees, providers and health plans, NCDHHS will implement temporary flexibilities and program changes for the four-month period between the Dec. 1, 2022, Tailored Care Management launch and March 31, 2023, the day before the start of Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans.

These flexibilities and program changes give organizations providing Tailored Care Management (e.g., Advanced Medical Home + (AMH+s), Care Management Agencies (CMAs) and LME/MCOs) adequate time to gain experience with the model, engage as many eligible beneficiaries as possible and identify and address unexpected challenges.

Beneficiaries will continue to receive Behavioral Health Services, I/DD and traumatic brain injury (TBI) supports through their LME/MCO and physical health and pharmacy services through NC Medicaid Direct, just as they do today. Nothing changes for beneficiaries on Dec. 1, 2022, except they will have access to Tailored Care Management through AMH+s, CMAs and LME/MCOs.

For more information, please see Medicaid provider bulletin article Tailored Care Management Implements Temporary Flexibilities and Program Changes.

Application Period for Round 3 Tailored Care Management Certification is Open

The end-to-end process for Tailored Care Management AMH+/CMA Provider Certification is managed by 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.

To start the process of participating in Round 3 certification, providers must submit a statement of intent form by November 10, 2022. NCQA will create an IRT license for each provider that meets the eligibility criteria for a Tailored Care Management (TCM) provider and email them when their license has been created.

Utilize the linked Application as a template or reference to prepare for completion of the Application in the IRT. The linked Application previews each question that you should prepare to answer in the IRT. Please review of the Interactive Review Tool User Guide to plan for completing your application within the web-based portal.

Care Management for High-Risk Pregnancies in Tailored Plans (Sept. 30, 2022)

All pregnant women enrolled in managed care through Tailored Plans will continue to receive a coordinated set of high-quality clinical maternity services through the Pregnancy Medical Program (PMP). This program will be administered as a partnership between Tailored Plans and local maternity care service providers (defined as any provider of perinatal services). A key feature of the program will be the continued use of the standardized screening tool to identify and refer women at risk for an adverse birth outcome to Care Management for High-Risk Pregnancies (CMHRP) program, a more intense set of care management services that will be coordinated and provided by Local Health Departments (LHDs). Together, these two programs will work to improve the overall health of women and newborns across the state.

The Department has published the Program Guide for CMHRP program. More information about the CMHRP program and additional programmatic guidance are available on the CMHRP webpage.

Certified Tailored Care Management Providers Completed Readiness (Sept. 28, 2022)

Certified Care Management Agencies (CMAs) and Advanced Medical Home + (AMH+) providers from rounds one and two of the certification process have completed their readiness review and will begin providing Tailored Care Management on Dec. 1, 2022, are listed here. The list will be updated as additional providers complete readiness and is found below under "Resources" and "Other." For more information, please see Medicaid bulletin Tailored Care Management Updates – Sept. 28, 2022.

Application Period Open for Round 3 Tailored Care Management Certification (Sept. 26, 2022)

A key area of focus in Medicaid Transformation is building robust and effective models for supporting beneficiaries’ whole person care needs through local care management. Provider-based care management will support whole-person care, foster high-functioning integrated care teams, address medical and non-medical drivers of health and promote better health outcomes.

To assist providers in understanding the process and requirements, the Department will host a webinar Thursday, Sept. 29, 2022, at 3:30 p.m. to provide more information and respond to providers’ questions. Please register on the Mountain Area Health Education Center (MAHEC) website. To participate, providers must complete a statement of intent form by Nov. 10, 2022. More information is available in the Medicaid bulletin Application Period Open for Round 3 Tailored Care Management Certification.

Tailored Care Management Frequently Asked Questions Posted (Sept. 26, 2022)

As we progress towards Tailored Plan launch, the Department has published frequently asked questions and answers, and provided clarity on some items in the Tailored Care Management Provider Manual. This covers changes and added flexibilities that have been added to the manual.  

Tailored Care Management Updates (Aug. 29, 2022)

NC Medicaid has released Tailored Care Management updates in the Medicaid provider bulletin article Tailored Care Management Updates - Aug. 29, 2022. 

Updates include new guidance on Care Manager and Care Manager Supervisor qualifications and Care Manager Extenders. It also provides updates on:

  • Provider Manual Updates
  • Phased Assignment Approach for Tailored Care Management Providers
  • Twenty-Four-Hour Coverage for Tailored Care Management Providers
  • Data and Security
  • Security Documentation Required by Clinically Integrated Networks or Other Partners
     

Verifying Provider Information (NPI+Location Code) in NCTracks (May 16, 2022)

Prior to submitting an application for Advanced Medical Home/Care Management Agency (AMH+/CMA) Certification with the State of North Carolina, please download and utilize the Provider Directory Listing Report (not the NCTracks Provider Portal) to locate the NPI, Location Code and Practice Site Address for each of the locations that you would like to have certified. 

If you are an NC Medicaid enrolled provider and you are unable to find your practice’s information in the Provider Directory Listing Report, or if your practice’s information is outdated, please submit a Manage Change Request (MCR) to update the applicable NCTracks provider record. Visit the NCTracks Provider webpage or contact NCTracks Call Center for additional assistance. 

Tailored Care Management Updated Guidance (April 21, 2022)

NC Medicaid has published updated guidance, including Capacity Building Program Frequently Asked Questions, updates to the Use of Care Manager Extenders, revised Standard Terms and Conditions (STCs), updates to the Tailored Care Management Provider Manual and a summary of changes to the Provider Manual. 

Tailored Care Management Technical Support Educational Series Presentations Available

The Department conducted a Tailored Care Management Technical Support Educational Series on March 10, 2022, and March 17, 2022, to provide additional clarification on Tailored Care Management Data Flow. The presentations are available:

Tailored Care Management Updated Guidance (Jan. 28, 2022)

NC Medicaid has published updated guidance on Tailored Care Management, including updates to the Tailored Care Management Provider Manual, the use of Care Manager extenders, Tailored CM 101 Frequently asked Questions and updated guidance on rates. For more information, please see Medicaid bulletin article Tailored Care Management Updates – Jan. 28, 2022.

AMH+/CMA Certification Round Two Desk Reviews Completed (Jan. 28, 2022)

The Department has completed desk reviews of the Round Two Advanced Medical Home Plus (AMH+) practices/Care Management Agencies (CMAs) provider certification applications and has advanced 32 providers to the site review stage of the certification process. For more information, please see Medicaid bulletin article Tailored Care Management Update: AMH+/CMA Certification Round Two Desk Reviews Completed.

Tailored Care Management Technical Advisory Group (TAG) 

The Tailored CM TAG will serve as the primary venue for advisory conversations among these stakeholders and the Department, ahead of and after Tailored CM launch. The Department expects that members will take issues raised in the Tailored CM TAG back to their organizations and networks to promote dialogue and communication between the Tailored CM TAG and a broader group of stakeholders. Go to the Tailored CM TAG page. 

Tailored Care Management 101 Webinar Series

The Tailored Care Management 101 webinar series was designed to help develop a shared understanding of the model across the North Carolina provider community (including advanced medical homes and behavioral health, I/DD and TBI providers) and anyone interested. The webinar series will run from October through mid-December, on Fridays from noon to 1 p.m.

Register for the webinar series.

The topic schedule and previous trainings are available on the TCM Training page.

Tailored CM Data Specifications Guidance 

Effective, integrated and well-coordinated care management depends on care team members having the ability to efficiently exchange timely and actionable member health information and use that information to monitor and respond to medical and nonmedical events that could impact a member’s well-being. The success of Tailored Care Management will depend on Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans, Advanced Medical Home Plus (AMH+) practices, and Care Management Agencies (CMAs) having the technological capabilities to collect, use and share data in support of an integrated and coordinated approach to care. The Department is utilizing this page to ensure that all Tailored Care Management Providers have the most current guidance.

Tailored CM Data Specifications Guidance page.

Round 2 Application Period for Tailored Care Management Certification Closes Sept. 30, 2021 (Aug. 3, 2021)

The Round 2 application period for Tailored Care Management Certification is open. For providers looking to obtain certification prior to Behavioral Health and I/DD Tailored Plan launch in July 2022, the certification process will take place in two rounds. Interested providers should review the updated Provider Manual and application questions and may submit applications through Sept. 30, 2021, to Medicaid.TailoredCareMgmt@dhhs.nc.gov. 

Data on Medicaid and NC Health Choice Beneficiary Eligibility for Behavioral Health I/DD Tailored Plans and Tailored Care Management (May 24, 2021)

In response to stakeholder requests and feedback, the Department of Health and Human Services (the Department) is releasing data on the number of Medicaid and NC Health Choice beneficiaries, as of April 2021, who currently meet the eligibility criteria to enroll in Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans and receive Tailored Care Management scheduled to launch in July 2022.

The table included shows this information in aggregate, and broken down by county and condition. For more information, please see Data on Medicaid and NC Health Choice Beneficiary Eligibility for Behavioral Health I/DD Tailored Plans and Tailored Care Management.

Updated Guidance (May 14, 2021)

NC Medicaid has published updated guidance on Tailored Care Management, including updates on AMH+/CMA Certification, capacity building and rates.

Tailored Care Management Certification Desk Review Guide and Scoring Tool Available (April 16, 2021)

DHHS is releasing the draft Tailored Care Management Desk Review Guide and Scoring Tool to support providers applying for AMH+ or Care Management Agency (CMA) certification. The Department is making this document publicly available to give applicants more guidance on what reviewers will be looking for when assessing an application. 

Application Period for Tailored Care Management Certification Closes June 1, 2021 

The application period for Tailored Care Management Certification is open. For providers looking to obtain certification prior to Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plan launch in July 2022, the certification process will take place in three rounds. Interested providers should review the updated Provider Manual and application questions and may submit applications to Medicaid.TailoredCareMgmt@dhhs.nc.gov. 

Webinar: Transition to Tailored Care Management for Children/Youth Served by the Child Welfare System:
A Resource for County DSS and Other Stakeholders - Nov. 29, 2022

Tailored Care Management Technical Support Educational Series 

 
Tailored Care Management Certification Webinar – Thursday, Dec. 17, 2020
 
This webinar walks through the certification process for AMH+ practices and CMAs looking to deliver services through the Tailored Care Management model.

Tailored Care Management: What Providers Need to Know - Dec. 18, 2019

Care Management under the Behavioral Health I/DD Tailored Plan - August 30, 2019

Behavioral Health I/DD Tailored Plan Care Management - August 20, 2019

Behavioral Health I/DD Tailored Plan Care Management - May 30, 2019

Integration of Behavioral and Physical Health Care in Tailored Plan - Jan. 24, 2019

This page was last modified on 08/31/2023