Tailored Care Management Questions and Answers

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Tailored Care Management (TCM) is a free NC Medicaid service that pairs you with an expert who knows the system and is here to help you, a Tailored Care Manager. They support your health and wellbeing by partnering with you to develop a care plan to achieve your goals. They can even help with basic needs like food, transportation and housing.

You can get Tailored Care Management from your Medicaid health plan or from another certified TCM provider.

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Tailored Care Management (TCM) provides you with a dedicated Tailored Care Manager and a care team. Assistance includes:

  • A full review of your health needs
  • A full review of your basic needs (such as housing, food, transportation, personal safety, employment)
  • Connecting you and your family to local programs and community resources to help with your needs
  • Follow-up with doctors or specialists about your care needs
  • And much more!

A Tailored Care Manager will create a care plan with you. This care plan will list your specific goals and ways to meet them.

After making the care plan, your Tailored Care Manager will organize applicable services for physical health, behavioral health, long term services and supports, intellectual/developmental disabilities (I/DD), medicine, traumatic brain injury (TBI) and more.

You must have NC Medicaid, and specifically be on the Tailored Plan or in NC Medicaid Direct.

If you are eligible, you automatically have Tailored Care Management. You should have gotten a letter letting you know, and a Tailored Care Manager may call you to help you start getting services.

Those eligible for Tailored Care Management include:

  • Adults with serious mental illness (SMI)
  • Adolescents and adults with severe substance use disorder (SUD)
  • Children and adults with intellectual/developmental disabilities (I/DD)
  • Children and adolescents with serious emotional disturbance (SED)
  • Children and adolescents in foster care with SED or SUD
  • Innovations Waiver recipients, including those who are dual-eligible (which means they get both Medicaid and Medicare)
  • TBI Waiver recipients, including those who are dual-eligible
  • Dual-eligible adults with SMI or SUD
  • Dual-eligible children and adults with I/DD

Some people were automatically enrolled in a Tailored Plan on July 1, 2024. Most people moving to a Tailored Plan may get Tailored Care Management services at any time. If you are already getting Tailored Care Management services, nothing should change for you.

If you did not get a letter, or are not sure if you are eligible: Call your Medicaid health plan and ask about Tailored Care Management. Your plan is printed on your Medicaid health plan ID card. If you are not sure which plan to call, call the NC Medicaid Contact Center at 1-888-245-0179, and they will help.

People with a Medicaid Standard Plan (AmeriHealth Caritas, Carolina Complete Health, Healthy Blue, UnitedHealthcare Community Plan, or WellCare) are not eligible for Tailored Care Management (TCM).

Those with the Eastern Band of Cherokee Indians (EBCI) Tribal Option are also not eligible for TCM.

People receiving the following services are not eligible for TCM:

  • ACT or Critical Time Intervention (CTI)
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IIDs) or Skilled Nursing Facilities
  • Certain people participating in Care Management for at Risk Children (CMARC)
  • 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)

Even if you do not qualify for TCM right now, there may still be resources available to help you manage your health. Talk to your Medicaid health plan or support team.

Call your Medicaid health plan and ask about Tailored Care Management. Your plan is printed on your Medicaid health plan ID card. If you are not sure which plan to call, call the NC Medicaid Contact Center at 1-888-245-0179, and they will help.

No. Tailored Care Management is free and included in your Medicaid benefits, if you are eligible.

Your Medicaid health plan may have already assigned you to a Tailored Care Manager. Your Tailored Care Manager will guide you through the process of getting started.

If you are not sure if you are eligible, or do not know who your Tailored Care Manager is, call your health plan to find out:

If you are not sure which plan to call: Call the number printed on your Medicaid health plan ID card or call the NC Medicaid Contact Center at 1-888-245-0179 and they will help.

Tailored Care Managers

Your Tailored Care Manager is an expert who knows the system. They help you navigate the health care system and manage your health and wellbeing. They can even help with basic needs like food, transportation and housing.

Tailored Care Managers can come from your Medicaid health plan or from a certified TCM provider. Certified TCM providers are agencies that have met program requirements and been approved by the state of North Carolina.

All Tailored Care Managers have the same role and responsibilities, whether they come from your health plan or from a certified TCM provider. The choice is yours, and you can change your mind later.

In some cases, a Tailored Care Manager may be assigned to you. You may change this if you wish.

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Your Medicaid health plan may have already assigned you to a Tailored Care Manager.

In some cases, a Tailored Care Manager is assigned to you based on your care needs. Claims history, diagnoses, historical relationships with providers and where you live are also used to pair you with a Tailored Care Manager.

If you are on the Innovations Wavier or TBI Waiver, you may have a “care coordinator.” This person can become your Tailored Care Manager, or you can choose a different TCM provider.

You may change your Tailored Care Manager or TCM provider twice per year “without cause” (for any reason at all) and an unlimited number of times "with cause” (for an approved reason) per year.

If you want to change your Tailored Care Manager or TCM provider, contact your Medicaid health plan. They can share information on certified TCM providers near you, and help you find a good match based on your age, where you live and your health issues.

Opting Out of Tailored Care Management

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You can opt out of Tailored Care Management (choose not to get TCM) at any time. Doing so will not affect the other services you get in any way.

Contact your Medicaid health plan to submit an “opt-out” form. Forms may be mailed, completed online, filled out in person with your Care Manager or filled out over the telephone.

You can return to Tailored Care Management later if you wish.

Some people on Medicaid have a service called “care coordination.”

Tailored Care Management is more comprehensive than care coordination.

Tailored Care Managers make a detailed assessment and develop a care plan that addresses all your needs. Tailored Care Management also includes:

  • gathering your care teams, including you and your doctors and specialists
  • helping you understand your treatment and your options
  • coordinating and monitoring when you move between services or settings
  • coordinating your benefits
  • assessing and linking to basic needs, like food, transportation and housing

Care coordination is more narrowly focused on linking people to needed services and is more reactive and short term than Tailored Care Management.

NC Innovations Waiver: if you are part of the Medicaid program called the “NC Innovations Waiver,” talk to your Medicaid health plan about whether Tailored Care Management is right for you.

If you are on the waitlist to get the Innovations Waiver, using Tailored Care Management will not affect your place in line.

More Information

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If you have a Tailored Care Manager, call them first.

If you don’t have one or don’t know who they are, call your Medicaid health plan:

If you are not sure which plan to call: call the number printed on your Medicaid health plan ID card or call the NC Medicaid Contact Center at 1-888-245-0179 and they will help.

If you have a complaint or concern, or need help with understanding your rights and responsibilities: call the NC Medicaid Ombudsman at 1-877-201-3750. They are an outside group that can advocate on your behalf.

Primary care providers can see the assigned TCM provider by using the NCTracks Recipient Eligibility Verification results, as well as on their AMH NC Medicaid Direct/Managed Care PCP Enrollee Report in NCTracks.

Other providers/clinicians may be contacted by the TCM provider for coordination of care and can also contact the LME/MCO (Tailored Plan) for member assignment information.