Post Author
Emily Blevins
Communications Director
Public policy has a meaningful impact on the way we live our lives—and when it comes to things like Medicaid, the impact is all that more profound, especially for children. That’s why I sat down with NC Child Health Policy Manager Hannah Preston to talk about changes to Medicaid, the summer rollout of tailored plans, and what these changes mean for children and families across North Carolina.
EMILY: Hi Hannah! So, tailored plans rolled out on July 1st. What are tailored plans and who is eligible?
HANNAH: Hi Emily! Tailored plans are a new kind of NC Medicaid managed care health plan. Tailored plans are designed to help people who have more complex health needs, such as those with more serious mental health disorders, severe substance use disorders, those with intellectual and developmental disabilities, and individuals with traumatic brain injuries. Tailored Plans will cover the same services that beneficiaries received through NC Medicaid Direct, while also offering specialized services for mental health, substance use, intellectual/developmental disabilities, and traumatic brain injury in one plan. A full list of services can be found here. The difference is that you must be on a Tailored plan to use certain programs like the NC Innovations or TBI waivers. A really good explainer on tailored plan eligibility can be found here.
People who met the eligibility requirements should have already received a welcome packet and a new health plan ID their assigned plan (Alliance, Partners, Trillium or Vaya Total Care) the beneficiary will be enrolled in.
Now, if a current Medicaid beneficiary is reading this and thinks that they may be eligible for a tailored plan but didn’t receive any communication about being enrolled, call the NC Medicaid Enrollment Broker at 1-833-870-5500 (TTY: 711 or RelayNC.com). Not hearing back could be for 1 of 2 reasons; eligibility or outdated information. If you have moved recently, contact your local Department of Social Services to update your address. If you are not currently a Medicaid beneficiary, but you think you would be eligible for a Tailored Plan, Apply for Medicaid here.
EMILY: So, it sounds like tailored plans are helping to serve people who make up what I’d say are pretty medically vulnerable populations. I know that sometimes getting new health coverage comes with the task of figuring out which of your health care providers are in-network and finding replacements for those who are out-of-network. I’d imagine that if someone has complex health needs, this process can be even more burdensome and could lead to some possible disruptions of care. For individuals who have been enrolled in tailored plans, what does this process look like for them?
HANNAH: The good news is that all Tailored plan eligible beneficiaries will be able to continue to see their providers that they currently see even if they’re out of network and not listed on their health ID card through the end of January 31st, 2025. The beneficiary’s coverage for medicine also stays the same until January 2025. Another flexibility here is that members can change their primary care for any reason until January 31st, 2025. These extensions won’t guarantee that the transition will be seamless for everyone, but they are designed to take some of the pressure off what can undoubtedly be a stressful experience.
If someone is looking for a new provider now, there are three pathways to doing so: Call your tailored plan, ask your Tailored Care Manager (if applicable), or use this directory to find a provider near you.
I want to flag that there are a few resources that are available for individuals who are transitioning into tailored plans. Specifically, there is an ombudsman separate from the North Carolina Medicaid Program and staffed by a member of Legal Aid of North Carolina. This ombudsman can help Medicaid members resolve issues with their health plan and escalate the issue to a member ombudsman with NC Medicaid and work towards an immediate resolution. They take calls Monday through Friday from 8am to 5pm. You can find out more about this on the NC Medicaid Ombudsman website.
At NC Child, we also recently had a virtual lunch and learn that dives more into tailored plans and what other resources, flexibilities, and information is out there to help folks better understand these changes. You can watch the recording here.
EMILY: How does the rollout of tailored plans affect children and families in North Carolina?
HANNAH: That is a good question, but there is no one-size-fits-all answer. Broadly speaking, if families have members who have behavioral health needs or Intellectual Developmental Disabilities, they will have a one-stop-shop to address their health needs on one plan. This means that all mental and physical health needs, as well as any specialty services, like substance use or brain injury treatment services, are all under one plan. I highly suggest using the Tailored Care Management Services to navigate the Tailored plan specific to your family’s needs. This free service and made for North Carolinians eligible for Tailored Plans. You will get paired with an advocate who is an expert in Tailored Plans that can help you manage the transition and the health care system at large. They even help with transportation, food, and housing!
At the end of the day, tailored plans are designed to help individuals—children and adults alike—who have a certain range of special health care needs. For children and the adults in their lives who are being enrolled in tailored plans, the impact is centralized around the goal of making accessing needed health care more seamless.
EMILY: This is a lot of really great information—but is there information out there about tailored plans and about Medicaid more broadly in languages other than English?
HANNAH: Absolutely. It’s a federal requirement that information on programs like Medicaid be offered in multiple languages. With North Carolina Medicaid, because Spanish is the second most widely spoken language in the state, all Medicaid materials are available in Spanish. For languages other than English and Spanish, there are translation services available for all services through your newly assigned Tailored Plan. Each Tailored Plan is required to provide translation services for their patients. Those services can be found on each specific Tailored Plans website.
EMILY: Is there anything about tailored plans that I haven’t asked you that you think would be helpful for parents and caregivers to know?
HANNAH: Absolutely! Firstly, I think context is important here. Are tailored plans going to help children and families in North Carolina? 100%. But we also must acknowledge the elephant is in the room. The Medicaid Innovations waiver supports North Carolinians with I/DD to receive long-term care services in their home. North Carolinians on this waiver are automatically enrolled in the Tailored Plans. There are currently 15,000 people on the waitlist of this waiver, with an average wait of 9 years. This means there are 15,000 eligible for Tailored Plan services that will not receive the benefits.
But for those who are eligible for tailored plans, there are services offered in addition to the one discussed already. I want to make sure that I highlight a few of them. Each Tailored Plan has their own Behavioral Health Crisis Hotline. Basically, the Tailored Plan equivalent to the statewide 988 crisis hotline. If you are a Tailored Plan beneficiary, please save the number below in your phone. This hotline is available to you 24 hours a day, seven days a week and will connect you to a licensed professional. The hotline is designated for beneficiaries that are thinking of hurting themselves, seeing things that others are not, and or feeling at risk from withdrawals of substances.
Trillium: 1-888-302-0738
Vaya: 1-800-849-6127
Alliance: 1-877-223-4617
Partners: 1-833-353-2093
Transportation is crucial for people to be able to attend their appointments, especially for our North Carolinians that live in Rural parts of the state. Each tailored plan offers rides to and from appointments, and for picking up prescriptions. If you need transportation for an upcoming appointment, contact your Tailored plan and ask about Non-Emergency Medical Transportation (NEMT). It is important to note that you must call 2 days in advance to schedule a ride and no more than 3 days before your appointment. For more information on NEMT services, click here.