While the North Carolina General Assembly failed – again – to expand Medicaid to the hundreds of thousands of North Carolina residents that desperately need health insurance coverage, don’t think that means that there aren’t many things happening with Medicaid in North Carolina. Medicaid Transformation is still very much in process.
To recap: We are a little more than a year into the launch of Medicaid managed care and the Advanced Medical Home Model. Earlier this year, the Healthy Opportunities initiative launched, and providers and nonprofit organizations are working together to identify and address patients’ health related resources needs to improve their wellbeing. Now, the Tailored Plans are swinging into gear, with the go-live date set for December 1, 2022.
The scheduled launch of the Tailored Plans is pretty important. North Carolina, like many other states, is experiencing a mental health crisis as it relates to the availability and access to critical behavioral health services. This is particularly acute across Medicaid Populations. Local Management Entities (LMEs) were introduced a decade ago to better coordinate and manage mental health services for Medicaid recipients with behavioral health needs. And while greater coordination and streamlined access was then (as now) a recognized deficit, it is important to recognize that a core component of LME coordination was utilizationmanagement. That means, at least in part, minimizing use of behavioral health services.
Introducing the Tailored Plans
Let’s start at the beginning: what are the Tailored Plans you ask? Tailored Plans are the Medicaid managed care plans for individuals with intellectual/developmental disabilities (I/DD), traumatic brain injury (TBI), or significant behavioral health needs. While the Tailored Plan model reflects an enhanced care management and coordination activity from previous operations, the model is built upon the existing model for management of care for Medicaid recipients with significant behavioral health needs. Namely, the 6 regional Tailored Plans were selected from among the existing LMEs (Alliance Health, Eastpointe, Partners Health Management, Sandhills Center, Trillium Health Resources, and Vaya Health). This means that the Tailored Plan entities will all be familiar to providers. While it’s the same entities, the Tailored Plans should operate differently.
There are three important characteristics that distinguish the Tailored Plans from the LME/MCO model: first, Tailored Plans are required to cover the full spectrum of services: physical health, behavioral health, pharmacy, and long-term services and supports. Second, the population eligible to enroll in Tailored Plans is significantly smaller than the enrolled population under the LME/MCOs. Total enrollment in Tailored Plans across the state is less than 200,000. This means the number of patients previously covered by an LME/MCO will be much lower. Third, the care management that enrollees should receive is expected to be different. Tailored Care Management is specialized care management designed for people with significant behavioral health needs. It is built on the Health Home model created in the Affordable Care Act. All individuals enrolled in a Tailored Plan are eligible for Tailored Care Management.
A Closer Look at Tailored Care Management
In keeping with the NC DHHS’ goal of provider-lead, community-based care management, Tailored Care Management can be provided to Tailored Plan enrollees either by:
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