North Carolina Tailored Plans – NC Medicaid’s Next Chapter

In 1965, Lyndon B. Johnson signed the Social Security Act of 1965, thus establishing the Medicare and Medicaid programs. These programs began providing healthcare coverage for low-income Americans, supporting the belief that all of us have the right to healthcare. Creating big programs takes time, so it wasn’t until 1970 that North Carolina began enrolling Medicaid beneficiaries. 

Since its first year of enrollment, NC Medicaid has experienced many changes and updates. It was expanded thrice in 1987 to cover older children, pregnant women, and infants. It expanded again in 1995 to cover older adults and Supplement Security Income (SSI) recipients. Most recently, in 2023, NC Medicaid was expanded to provide health insurance for those who fall into the “coverage gap.”

NC Medicaid has been transformed. In 2015, the NC General Assembly enacted Session Law 2015-245, which directed the Department of Health and Human Services (DHHS) to transition Medicaid and NC Health Choice from fee-for-service to Managed Care. Thus, NC Medicaid Transformation was born, and approximately 1.6 million North Carolina Medicaid beneficiaries transitioned to a model called NC Medicaid Managed Care.

The next occurrence in NC Medicaid’s history will be the launch of Medicaid Tailored plans on July 1, 2024. Approximately 160,000 NC Medicaid beneficiaries with intellectual or developmental disabilities will be transferred to new specialized Medicaid Plans called Tailored Plans. These plans are a new kind of NC Medicaid Managed Care health plan for North Carolinians with complex mental health needs such as serious mental health illness, severe substance use, intellectual or developmental disability, and traumatic brain injury. Medicaid Tailored Plans will cover the beneficiary’s physical health, mental health, and prescription drug needs all in one plan.

Some people whose NC Medicaid will be moving to a Tailored Plan began receiving notices of the change in mid-April 2024. They will be enrolled into one of four Tailored Plans that cover the North Carolina county that manages their Medicaid. The Tailored Plan companies are Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health. Unlike the Standard Plans of NC Medicaid Managed Care, each county has only one Tailored Plan Managed Care Organization.

People with serious mental health illness, severe substance use, intellectual or developmental disability, or traumatic brain injury who are currently receiving NC Medicaid should check their mail for information about a change in plans and automatic enrollment. Eligible NC Medicaid recipients who are not automatically enrolled can request a move to a Tailored Plan by completing and submitting the “Request to Move to NC Medicaid Direct or LME/MCO” form. People in need of healthcare assistance can apply for NC Medicaid. Their eligibility for Tailored Plan coverage will be reviewed, and if approved, a letter from the appropriate Plan will be sent in the mail.

NC Medicaid continues to evolve to meet the changing needs of low-income North Carolina residents. Information about NC Medicaid can be found at the NCDHHS website. You can also receive answers to questions and assistance with issues from the NC Medicaid Ombudsman.