What to do if your NC Medicaid will move to a Tailored Plan

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Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans (or “Tailored Plans”) are a new kind of NC Medicaid Managed Care health plan. Tailored Plans cover your doctor visits, prescription drugs, and services for mental health, substance use, intellectual/developmental disabilities, and traumatic brain injury in one plan. They start July 1, 2024.

If your NC Medicaid will move to a Tailored Plan, you should receive a welcome packet and new health plan ID from Alliance, Partners, Trillium or Vaya Total Care.

Didn’t get a welcome packet? If you think you should be in a Tailored Plan, call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com). You may also need to update your address.

 

What you should do

If your Medicaid is moving to a Tailored Plan, follow the steps below. Click each headline for more details.

Tab/Accordion Items

One of these companies will provide your Tailored Plan:

You should have received a welcome packet and new health plan ID from one of these companies.

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

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).

Check to see if your providers accept your Tailored plan – not just “Medicaid.”

3 ways to check or find providers:

Providers that don’t accept Tailored Plans are considered “out-of-network.” You can keep seeing them until January 31, 2025. Learn more about out-of-network providers.

A primary care provider (PCP) is the doctor you see when you feel sick, need a check-up or need management of chronic conditions like diabetes.

If you did not choose a PCP by May 15, one was assigned to you. This is the doctor listed on your health plan ID card, included with your Welcome Packet. Your assigned PCP must be in your Tailored Plan’s network (group).

Note: A provider that is “in-network” means they accept your Tailored Plan as health insurance. The provider’s county or physical location does not matter.

To change your PCP, call your Tailored Plan:

You can keep seeing the PCP you see now until January 31, 2025, even if they’re not listed on your health plan ID card. Learn more about seeing doctors who don’t accept Tailored Plans.

Tailored Care Managers (or “Care Managers”) are available to everyone on a Tailored Plan. They can help schedule your medical appointments, arrange transportation, help locate child care and more.

Call your Tailored Plan and ask who your Tailored Care Manager is, or how to get one:

If you already have a Tailored Care Manager, they will still be your Tailored Care Manager when you move to a Tailored Plan.

Your address needs to be correct so you can get important information.

If you moved recently, or will move soon, call your local Department of Social Services (DSS) to update your address. Use this directory to find your DSS, or call the NC Medicaid Contact Center 1-888-245-0179 (TTY: 711 or RelayNC.com).

If you have an ePASS account, you can update your address online.

Get printable posters and flyers, PowerPoint presentations, and other materials in our Tailored Plan Transition Toolkit.

 

If a provider is not in your Tailored Plan’s network

Your providers need to accept your Tailored Plan to be covered. Providers that don’t accept Tailored Plans are considered “out-of-network.”

There are rules in place to help make this move easier for you. The goal is to avoid disrupting your care as much as possible.

  1. You may keep seeing the Medicaid providers you see now until January 31, 2025 – even if they’re not listed on your health plan ID card. (If you see a new provider for the first time, they must accept your Tailored Plan.)
  2. Your coverage for the medicine you take also stays the same until January 31, 2025.
  3. You can keep seeing the dental providers you see now. Your dental coverage will not change.
  4. You can change your primary care provider (PCP) for any reason until January 31, 2025.

If you would like to continue to see an out-of-network provider after January 31, 2025, talk to your Tailored Plan:

 

Do I have to move to a Tailored Plan?

For most people, if you got a letter that said your NC Medicaid is moving to a Tailored Plan:

  • Moving to a Tailored Plan lets you keep your current coverage of services. Tailored Plans cover the same services you get now through NC Medicaid Direct and your LME/MCO.
  • You can refuse to enroll in a Tailored Plan, but you could lose coverage for certain services. If you are currently in NC Medicaid Direct and choose to stay instead of moving to the Tailored Plan, you could lose coverage for certain services.
  • You must be on a Tailored Plan to use certain programs, like the NC Innovations or TBI Waiver.

Changing Tailored Plan companies: There is only one Tailored Plan company (LME/MCO) per county. You cannot change your Tailored Plan company unless you move.

Need help? The NC Medicaid Enrollment Broker can help you understand your eligibility for health plans and provide counseling for picking a health plan. Call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com).

 

What the move to a Tailored Plan means for you

If your Medicaid is moving to a Tailored Plan:

 

Timeline for the move to Tailored Plans

If your NC Medicaid is moving to a Tailored Plan, here are important dates:

Mid-April 2024

Letters were mailed to those moving to a Tailored Plan. Some people may get a letter saying they have the choice to move to a Tailored Plan. The letter gives instructions on how to pick a primary care provider. You should check to see if your providers are in your Tailored Plan’s network.

May 15, 2024

This is the last day to pick a primary care provider (PCP). If you do not pick a PCP, one will be assigned to you. You can still change your PCP.

May 16, 2024

You can start scheduling non-emergency medical transportation (NEMT) for appointments on or after July 1, 2024. Call your Tailored Plan to schedule rides.

Late May 2024

Tailored Plans begin mailing a welcome packet and new member health plan ID card. Your primary care provider (PCP)’s information will be included.

July 1, 2024

Tailored Plans begin! Start seeing providers (doctors and specialists) in your Tailored Plan’s network.

January 31, 2025

If you would like to continue to see an out-of-network provider after this date, talk to your Tailored Plan.

 

Need help?

Questions about Tailored Plans: Call your Tailored Plan.

You can find the Tailored Plan 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).

Questions about your health plan options: Call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com). Hours of operation: 7 a.m. to 5 p.m., Monday through Saturday.

 

Other related services

Information for Providers

Provider Playbook: NC Medicaid Managed Care