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Medicaid Transformation

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The 1115 Waiver seeks to transition Medicaid services in North Carolina from fee-for-service to managed care. Services will be offered through two distinct products: Standard Plans (SP) and Behavioral Health (BH) and Intellectual/Developmental Disabilities (IDD) Tailored Plans (TP). Standard Plans will serve most Medicaid and NC Health Choice members, including all adults and children and those with mild to moderate behavioral health needs. 

BH IDD Tailored Plans will be specifically designed to serve the complex needs of individuals with significant behavioral health disorders, intellectual and developmental disabilities, substance use disorders, and traumatic brain injury, as well as foster children — populations Trillium and all other LME/MCOs have long served. We also expect the Tailored Plans will serve uninsured individuals currently receiving state-funded services, regardless of their diagnosis.

Both Standard Plans and BH IDD Tailored Plans will integrate physical health, behavioral health, and pharmacy services to best serve individual needs. To learn more, please visit the new NC Medicaid Managed Care website here or view the Frequently Asked Question below. Trillium will continue to serve members with complex needs (significant behavioral health disorders, intellectual and developmental disabilities, substance use disorders, traumatic brain injury, and foster children) once the Standard Plans go live in November 2019. Tailored Plans will not launch until 2021.

 

INFORMATION FOR MEMBERS AND FAMILIES

 

Members do not need to do anything at this time. They will be contacted by the state if the state determines they will be served by the Standard Plan. Notification letters will include instructions if they feel they should be served by the Tailored Plan.  The state has published a “County Playbook: Medicaid Managed Care” website that will post many of the letters and communications that will be developed for members. 

Members will be encouraged to “raise their hand” and request transition to the Tailored Plan if they have been placed on the Standard Plan. Members who use certain services for their developmental disability, mental illness, traumatic brain injury, or substance use disorder (for example, need access to State-funded or B3 services, are on Innovations Waiver, OR are on the Innovations waiting list) may choose to follow the directions in the letter and ask to be served through the Tailored Plan.

Standard Plans will launch in two phases:

  • Phase I – November 2019: Regions 2 and 4 will start receiving services under the Standard Plans. For Trillium, this only includes Nash County. 
  • Phase II – February 2020: Regions 1, 3, 5, and 6 will start receiving services under the Standard Plans. This will be the rest of the Trillium region.

Time line medicaid transformation picture 
Timeline copied from NC DHHS presentation on BH I/DD Tailored Plan Eligibility and Enrollment.
For full presentation, please visit here: https://medicaid.ncdhhs.gov/behavioral-health-idd-tailored-plans

FREQUENTLY ASKED QUESTIONS

N.C. Medicaid beneficiaries will begin receiving information in the mail starting the end of June 2019, about managed care, the health plan options available to them and how to enroll in the appropriate plan. Eligible beneficiaries for the Standard Plan will receive instructions with information about selecting a Prepaid Health Plan (the commercial plans that will offer the Standard Plan) prior to the open enrollment period. Notification letters will include instructions if they feel they should be served by the Tailored Plan. 

The State selected an enrollment broker, Maximus, to help members enroll in the appropriate plan. If you are enrolled in the Standard Plan and feel your needs require enrollment in the Tailored Plan, please contact the number included in the welcome packet and follow all directions. The State will allow anyone to request a review if they believe they should be in the Tailored Plan. If you are not sure which plan you should be enrolled in, please call the enrollment broker at 1-833-870-5500 (TTY: 1-833-870-5588) or visit the tip sheet  HERE.

Individuals who meet the BH IDD Tailored Plan criteria should continue to be served by Trillium until July 2021. The state will consider qualified diagnoses and relevant service utilization (e.g., what kinds of services you use) to make these decisions.

Trillium will NOT be able to move members between the Standard and Tailored Plans. While many of our members will be served by Tailored Plans, some may be assigned to the Standard Plan based on state criteria. The State selected an enrollment broker, Maximus, to help members enroll in the appropriate plan. If you are enrolled in the Standard Plan and feel your needs require enrollment in the Tailored Plan, please contact the number and follow any directions that are included in the welcome packet. The State will allow anyone to request a review and to “raise their hand” if they believe they should be in the Tailored Plan. You can also call the enrollment broker at 1-833-870-5500 (TTY: 1-833-870-5588) or your provider with any questions.

Members will be able to remain with their existing providers as long as the providers agree to contracts with the PHPs offering the Standard Plan. Providers may contract with either or both the Standard Plan or Tailored Plan. There will not be any lapse in services for any members, regardless of whether they are enrolled in the Standard or Tailored Plan.

The following are some of the behavioral health services that will be available through the Standard Plan:

  • Inpatient behavioral health services
  • Mobile crisis management services
  • Outpatient behavioral health emergency room services
  • Outpatient behavioral health services provided by direct-enrolled providers
  • Facility-based crisis services for children and adolescents
  • Non-hospital medical detoxification services, partial hospitalization
  • Diagnostic assessment services
  • Professional treatment services in a facility-based crisis program
  • Medically supervised or alcohol and drug abuse treatment center detoxification crisis stabilization
  • Outpatient opioid treatment services
  • Research-based intensive behavioral health treatment
  • Ambulatory detoxification services
  • Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)

The exact list of services offered in the Tailored Plan will not be available until the RFP is released in February 2020.

Quick and easy way to enroll
Enroll from your smartphone (Android or iPhone).
To get the app, search for NC Medicaid Managed Care on Google Play (Android) or the App Store (iPhone).

 

Google play button App Store button

Use the app to find primary care providers (PCPs) and compare health plans for you and your family.

Learn more about the free mobile app at Get answers.

NC Medicaid Managed Care Regions and Rollout Date

Timeline map

Click the map to enlarge

For more information, please visit the NC DHHS website at Medicaid Transformation or the new NC Medicaid Managed Care Website. The State has mailed letters about these changes. If you have any questions about these letters, please contact your provider. You can also reach the enrollment broker (Maximus) at:

Call 1-833-870-5500 (TTY: 1-833-870-5588)

Go to ncmedicaidplans.gov

HELP STOP FRAUD & ABUSE

You can help keep fraud, waste, abuse, unethical, or illegal activity out of our workplace. If you are uncomfortable communicating a concern in person, report it anonymously by calling the toll-free hotline number, 1.855.659.7660, or report it online at EthicsPoint and follow the instructions on the screen