Are you or your sibling living in North Carolina with:

  • the Innovations Waiver for adults with intellectual/developmental disabilities (I/DD) or
  • the TBI Waiver for adults with traumatic brain injury (TBI)?

Then, you’re likely to be a part of the upcoming Medicaid Transformation into the “Tailored Plans,” which are set to launch in December 2022.

AKALAKA is here to help you, the best we can, to feel less lost and less alone in navigating this wilderness of disability services. This article is the first in AKALAKA’s series on the “Behavioral Health I/DD Tailored Plan” for our North Carolina members.

Use this article to figure out 1) where to start, 2) who to connect with, 3) what to expect next.

Note: As much as we’d love for this process to be accessible completely over the Internet, you or your sibling may need to make some phone calls. Each new agent you connect with may ask you for the same information, so be prepared to share the member’s: date of birth, administrative address, Medicaid recipient identification number, call-back phone number, primary care physician’s practice name and address. Of course, be cautious if someone calls you out-of-the-blue and requests this private information. Unless you specifically requested a call-back, consider asking the caller for a reference ID, hanging up, and calling the phone number you obtain on your own from the official agency site to be safe.

1) Start with Medicaid

Do you have a copy of the annual Medicaid identification card from the NC Department of Health & Human Services Division of Health Benefits?

  • Yes: find the “LME MCO” named: Alliance Health, Eastpointe, Partners Health Management, Sandhills, Trillium Health Resources, or Vaya Health.
  • No: contact your county’s Department of Social Services (DSS) to inquire about your current Medicaid information. Click here for their contact information.

Unless your county changes, the “LME MCO” effectively would become your “Tailored Plan.”

If your current Medicaid expires before December 1, 2022, your DSS case worker may request additional documentation from you to ensure re-enrollment in Medicaid/Special Assistance to be eligible for the Tailored Plan.

2) Connect with your Tailored Plan

What county do you or your sibling live in?

  • Cumberland, Durham, Johnston, Mecklenburg, Orange, or Wake county
  • Duplin, Edgecombe, Greene, Lenoir, Robeson, Sampson, Scotland, Wayne, Warren, or Wilson county:
    • Your Tailored Plan is: Eastpointe
    • Call this number: 1-800-913-6109
  • Burke, Cabarrus, Catawba, Cleveland, Davie, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Stanly, Surry, Union, or Yadkin county:
  • Anson, Davidson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, Richmond, Rockingham county:
    • Your Tailored Plan is: Sandhills
    • Call this number: 1-800-256-2452
  • Beaufort, Bertie, Bladen, Brunswick, Camden, Carteret, Chowan, Columbus, Craven, Currituck, Dare, Gates, Halifax, Hertford, Hyde, Jones, Martin, Nash, New Hanover, Northampton, Onslow, Pamlico, Pasquotank, Pender, Perquimans, Pitt, Tyrrell, or Washington county:
  • Alamance, Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Caswell, Chatham, Cherokee, Clay, Franklin, Graham, Granville, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Person, Polk, Rowan, Stokes, Swain, Transylvania, Vance, Watauga, Wilkes, or Yancey county:
    • Your Tailored Plan is: Vaya Health
    • Call this number: 1-800-962-9003

Ask your Tailored Plan office to:

  • Document your preferred primary care physician (PCP) in your Tailored Care file starting December 1, 2022
  • Provide you with a list of care management agency (CMA) options

3) Expect delays

In the world of care, we hope for the best but prepare for the worst! Each Tailored Plan has a different pace in building their PCP and CMA provider network, so they may not have either available for you yet. If your PCP is not already in their database, ask them for specific instructions that you can provide to your PCP’s office to ensure they become in-network. And ask your Tailored Plan for the date you can call back to get a list of CMA options. You may decide to maintain care management with the LME MCO if that is your only/best option, but it can be empowering to know your options. NC DHHS’ current deadline for members to choose their PCP and CMA is October 14, 2022, so stay tuned for more from AKALAKA to feel less lost and alone in navigating this wilderness of disability services.

Join our interest list for our upcoming AKALAKA Innovations & TBI Waiver 101 classes where we’ll learn how to better navigate this wilderness with peers who can relate.