Member Benefit Plans | Service Definitions


Please Note: 

Physical health and pharmacy services and some other services will not be available until July 1, 2024.

Trillium coordinates services for Medicaid members in NC Medicaid Direct, and state-funded recipients. Services listed here will be either for members, recipients, or both as noted.

Trillium coordinates the following plans:

  • State-funded Recipients: for those who do not have insurance.
  • NC Medicaid Direct: for those who are on Medicaid but are not in the Tailored Plan. NC Medicaid will issue your Medicaid ID card.

Intellectual Developmental Disability (I/DD) and Traumatic Brain Injury (TBI) Benefits

Trillium covers special services for individuals with intellectual and developmental disabilities that include Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) and Innovations waiver services for people, enrolled in the NC Innovations Waiver.

NC Innovations Waiver services support individuals with intellectual and developmental disabilities to live the life they choose. Individuals get services in their homes or community.

The services covered by Trillium include:

  • I/DD Services
  • Home & Community-Based 1915(i) Services (started July 1, 2023)
  • Traumatic Brain Injury (TBI): until the TBI Waiver is available at all Tailored Plans, certain services will be available for those diagnosed with a TBI including some state-funded and 1915i services.

Mental Health/Substance Use (MH/SU) Benefit Plan

Behavioral health care includes mental health (your emotional, psychological and social well-being) and substance (alcohol and other drugs) use disorder treatment and rehabilitation services. All members have access to services to help with mental health issues like depression or anxiety or to help if they are abusing drugs.

The services covered by Trillium include:

Medicaid In Lieu of Services (ILOS)

Please note: The new ILOS services are not available until the Tailored Plan launch.

Trillium's Current ILOS services are available until Tailored Plan launch.

Tailored Plan Medicaid Member Pharmacy Benefits

Medicaid Member Pharmacy Benefits - Prescription drugs, over-the-counter medicines, and other supplies covered for Medicaid members.

Services for Medicaid–Eligible Children: Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Services for Medicaid–Eligible Children: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) - Trillium covers services, products, or procedures for a Medicaid member under age 21 if the service is medically necessary to correct a defect, physical or mental illness, or a condition or health problem identified through a screening examination.

Prior Authorization Services

Please use this tool to determine if prior authorization is required for specific services and codes. However, using this tool does NOT guarantee payment. Member eligibility, benefit plans, codes in provider contracts, and other details may impact payment. Please refer to the provider manual or call the Provider Support Service Line at 1-855-250-1539 for more information.

Prior Authorization Services

Service Definitions

Utilization Management

Trillium's Utilization Management (UM) Department reviews all treatment authorization requests for members or recipients in our region.

UM decisions are made by qualified health professionals. Trillium’s licensed clinicians and behavioral healthcare professionals gather only relevant and necessary clinical information to make decisions about the medical necessity of requests. “Medical necessity” means necessary for the treatment or diagnosis of a health condition.

For more information on our Clinical Review Criteria and Utilization Management Program Policy.

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