Medicaid Transformation

MEDICAID TRANSFORMATION: TRANSITION TO MEDICAID MANAGED CARE IN NORTH CAROLINA

Most people in North Carolina who get Medicaid services get them directly from the State, or they got behavioral health or intellectual/developmental disabilities (I/DD) coverage from a Local Management Entity-Managed Care Organization (LME-MCO), like Sandhills Center.

All of that is changing through Medicaid Transformation.

Because Medicaid Transformation may seem complex, this information can help guide you.  

HOW IS MY HEALTH CARE AFFECTED?

North Carolina is changing the way it manages care for most people who get Medicaid. The state is switching to a managed care model, rather than the fee-for-service model.

Eligibility for North Carolina Medicaid does not change. The services you use will still be covered by Medicaid. However, by October 1, 2023, most Medicaid members and State-Funded services recipients will have all of their physical and behavioral health needs covered by one plan – either a Standard Plan or a Tailored Plan.  

WHAT IS A STANDARD PLAN?

The Standard Plan, which went into effect on July 1, 2021, is a prepaid plan that covers physical and behavioral health services. Sandhills Center members who have switched to the Standard Plan chose a plan from one of the following companies:

• Blue Cross Blue Shield
• AmeriHealth Caritas North Carolina
• United Healthcare
• WellCare
• Carolina Complete Health  

WHAT IS A TAILORED PLAN?

The Tailored Plan also covers physical and behavioral health services. Under the Tailored Plan, coverage is for people who have intellectual/developmental disabilities (I/DD) or significant needs. The Tailored Plan helps Sandhills Center members and recipients get better health care that is “tailored,” or customized, to fit their unique needs. Under the Tailored Plan, some Sandhills Center members and recipients may be able to keep the plan they already have. Tailored Plans go into effect on October 1, 2023.

HOW ARE THE STANDARD AND TAILORED PLANS SIMILAR?

Both plans cover:

• Physical health.
• Mental health and substance use disorder (behavioral health) services.
• Pharmacy (medication) services.  

HOW ARE THE STANDARD AND TAILORED PLANS DIFFERENT? 

• The Tailored Plan has services for people with intellectual/developmental disabilities or those with complex and long-term behavioral health care needs.
• The Standard Plan is offered by one of five insurance companies in North Carolina.
• Tailored Plans will be managed, starting Dec. 1, 2022, by organizations that are transitioning from being Local Management Entities-Managed Care Organizations (LME-MCOs), such as Sandhills Center, and are located within specific regions of the state.  

WHAT HAPPENS WHILE I AM CHANGING TO MY NEW PLAN?

The North Carolina Department of Health and Human Services (NCDHHS) wants to make sure there are no problems or gaps in your services when you change to the new plans. Sandhills Center is working with NCDHHS so that your providers know what services are approved (known as authorizations) so you can keep getting services during the change to your new plan. We will talk with Medicaid members and State-Funded services recipients, their families, and providers so that issues are addressed right away.  

MEDICAID TRANSFORMATION TIMELINE 

• Early 2021 – Individuals were mailed information about whether they will stay with Medicaid Direct (the Tailored Plan) or switch to the Standard Plan.
• March 1, 2021 – Open enrollment began. This is when members were to choose their new health plan under the Standard Plan.
• May 21, 2021 – Open enrollment ended. Members who did not choose a new health plan were automatically assigned to one.
• July 1, 2021 – The new Standard Plan health coverage started. Individuals had 90 days to decide if their plan was a good fit for them. After September 1, 2021, individuals were not able to change their health care plans unless they had a special reason.
• December 1, 2022 – The new Tailored Plans go into effect.  

WHAT IF I HAVE CONCERNS OR QUESTIONS?

• Call Sandhills Center Member & Recipient Services, toll-free anytime: 1-800-256-2452 (TTY: 1-866- 518-6778). ·      
• Visit the NCDHHS Medicaid Transformation website
• Call the NC Medicaid Enrollment Broker at 1-888-870-5500. You may also visit:ncmedicaidplans.gov if you have a Medicaid enrollment question.
• Call the NC Health Choice Contact Center: 1-888-245-0179 (8 a.m. to 5 p.m. Monday through Friday.
• For questions about claims and billing, contact the NC Tracks Contact Center -- 1-800-688-6696. 
• Additional questions can be answered by sending an email message to: Medicaid.Transformation@dhhs.nc.gov