What is a Tailored Plan?
Tailored Plans are a new type of NC Medicaid Managed Care health plan that went into effect on July 1, 2024. The plan covers mental health, severe substance use, intellectual/developmental disability (I/DD), or traumatic brain injury (TBI) and prescriptions.
In addition to providing the same services as Standard Plans, Tailored Plans provide additional services for people with serious mental illness and substance use disorders, I/DDs, and TBIs as well as people using State-funded services.
Which Tailored Plans are in-network/contracted with Duke?
- Alliance Tailored Care
- Vaya Health Tailored Care
Which plans are out-of-network/non-contracted with Duke?
- Partners Health Management Tailored Care
- Trillium Health Resources Tailored Care (CCH/LME)
What if I am an existing patient but I have an out-of-network/non-contracted plan?
If you are an existing patient in the out-of-network plan, you can still be seen during the 90-day grace period. The grace period ends October 1, 2024. Our team can help you transition to an in-network provider during this time.
The Tailored Plan will allow members to continue medically necessary services in an ongoing course of treatment, until the end of the episode of care for seven months or through Jan. 31, 2025, whichever occurs first. You can learn more here: NC Legislation Statutes-Continuity of Care.
What if I am a new patient with an out-of-network/non-contracted plans?
You will be redirected to an in-network provider.
How will claims and authorizations be handled?
Tailored Plans are required to relax medical prior authorization requirements and honor existing and active medical prior authorizations on file with NC Medicaid Direct for services covered by the health plan for the first 91 days after launch (until Sept. 30, 2024) or until the end of the authorization period, whichever occurs first.
For the first 91 days after launch (Sept. 30, 2024), the Tailored Plan will pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers.
What about pharmacy authorizations?
The Tailored Plan is required to relax pharmacy prior authorization requirements for the first 91 days after launch (until Sept. 30, 2024). Tailored Plans must honor existing and active pharmacy prior authorizations on file with NC Medicaid Direct through the end of the authorization period.
How will ophthalmology services be handled?
Alliance and Vaya Tailored Plans require a separate contract for all ophthalmology services (routine and non-routine). Duke is not contracted with the vision administrator Avesis at this time. Patients will be redirected to an in-network provider.
Do I have to enroll in a Tailored Plan?
You may refuse to enroll in a Tailored Plan but you could lose coverage for services. If you choose a different health plan, some services may not be covered. Here are examples of coverage:
- Child and adolescent day treatment services
- Intensive in-home services
- Multi-systemic therapy services
- Psychosocial rehabilitation
- Residential treatment facility services
- Community living and support (specific to I/DD and TBI)
- Supported employment (available to I/DD, TBI, and behavioral health)
- Respite (specific to I/DD, TBI, serious emotional disturbance and severe substance use disorder).
- State-funded behavioral health, I/DD, and TBI service.
Where can I get more information?
Read the Medicaid Tailored Plans Patient Fact Sheet. If you have questions, visit ncmedicaidombudsman.org or call 877-201-3750, 8:00 am to 5:00 pm, Monday through Friday.