Tailored Plan (TP) Launch and PCS

Announcement

Starting July 1, 2024, NC Medicaid members with serious mental health or substance issues, an intellectual/developmental disability, or a traumatic brain injury will transition their Medicaid coverage to a Tailored Plan (TP).

In April, the NC Medicaid Enrollment Broker mailed a letter to North Carolinians who are moving to Tailored Plans about next steps and how to choose a primary care provider (PCP). People who did not pick a PCP by the May deadline were assigned one, which they can change through Jan. 31, 2025. People moving to Tailored Plans should have also received a welcome packet and new member health plan ID card from either Alliance Health, Partners Health, Trillium Health or Vaya Total Care.

Medicaid beneficiaries receiving State Plan Personal Care Services (PCS) through Medicaid Direct are eligible to enroll in a TP to have their mental health, substance use, prescription, physical health, and intellectual/developmental disability or traumatic brain injury needs managed by one entity.

If a Medicaid beneficiary your agency is serving has been determined to transition to a TP, you will receive a personal email from the NC Medicaid PCS team identifying the transitioning Medicaid beneficiary and their assigned TP. The email will also include the contact information for the assigned TP.

If the Medicaid beneficiary is currently approved to receive PCS, the services will continue as previously approved in amount, frequency, and duration. Prior approval will be sent to the assigned TP to ensure PCS does not stop throughout the 90-day transition period, providing a sense of security during the change.

On and after July 1, claims for a Medicaid beneficiary who transitions to a TP, you will no longer submit your claims to NCTracks. The assigned TP will instruct you on submitting your claim and recording any required EVV data. You can contact the assigned TP directly to inquire.

If your agency is not an already approved PCS TP provider, you must discuss becoming one with the TP. You can continue to render PCS services to your assigned beneficiary through the 90-day transition period and while you work out the details to become a TP-approved provider. You must contact the TP directly to inquire. Their contact number is listed below.

New PCS referrals for Medicaid beneficiaries who are enrolled in a TP should be sent directly to the assigned TP in the beneficiary’s county. The TP is equipped to process new PCS referrals. On and after July 1, NCLIFTSS will send new referrals directly to the assigned TP for processing.

NC Medicaid is extending the prior approval for annual PCS assessments through the 90-day transition period until Jan. 31, 2025, to ensure services are not interrupted before the TP can complete the annual assessment. The TPs are trained on how to complete PCS assessments and score them no less than Medicaid Direct.

In addition to PCS, other services available under Tailored Plans can include:

  • Home and community-based services
  • Long-term rehabilitation and treatment services, including in-home services
  • Institutional and community-based mental health treatment
  • Access to a Tailored Care Manager, who can help schedule appointments, arrange transportation, and more
  • Breaks for caregivers, including overnight and weekend care
  • And other benefits, based on the member’s eligibility (see more benefits and services)

Please utilize our comprehensive communications toolkit, which is available in English and Spanish, to ensure you have all the information you need to understand the Tailored Plan. For more information about Tailored Plans, visit medicaid.nc.gov/tailored-plans.

The contact information is listed below for each TP.

If you need assistance from NC Medicaid, use the contact information below.

  1. NC Medicaid Contact Center. Phone: 888-245-0179.
  2. Provider Ombudsman. For provider inquiries, concerns, complaints regarding health plans. Medicaid.ProviderOmbudsman@dhhs.nc.gov. Phone: 866-304-7062.
  3. NCTracks Call Center. Phone: 800-688-6696.

NC Medicaid LTSS