Tailored Care Management
WHAT IS TAILORED CARE MANAGEMENT?
Care Management is a service to help you meet your health goals. As a member of the Sandhills Center Tailored Plan, you will be assigned to a care manager. Your care manager will coordinate your medical, social and behavioral health services. They will work with you, your family and your doctors. The care manager will help you create a plan to live a healthy life. Sandhills Center and your care manager want to help you get healthy and stay healthy.
YOUR CARE MANAGER WILL:
- Connect you to behavioral and physical health providers.
- Work with your doctors and providers to make sure you get the care that is right for you.
- Help you make and keep appointments.
- Help you with your medications.
- Connect you to resources such as housing, transportation, food, and social services.
- Help you develop a care plan that includes your medical and behavioral health, and social and family needs.
- Explain different Care Management options.
- Make sure your health services are working for you in the setting of your choice.
YOUR CARE MANAGER WILL BELONG TO ONE OF THESE GROUPS OR ORGANIZATIONS:
- Advanced Medical Homes Plus (AMH+): These are Primary Care Providers (PCPs) who have a lot of experience working with people with behavioral health conditions, intellectual/developmental disabilities (I/DD) or traumatic brain injuries (TBIs).
- Tailored Care Management Agencies. These are Sandhills Center providers who offer Tailored Care Management services.
- Sandhills Center: Your care manager may work for the Sandhills Center Tailored Plan. If you are getting NC Innovations or NC TBI Waiver services, your care manager will work with those providers to help you get those waiver services.
CAN I OPT OUT OF TAILORED CARE MANAGEMENT?
You can choose to opt out of Tailored Care Management at any time. You must complete and return this Opt-Out Form to the Sandhills Center Tailored Plan.
The form can be sent by mail, fax or email. It also can be completed over the phone or in person with your care manager. Sandhills Center will submit the form to the North Carolina Department of Health and Human Services (NCDHHS). If you have opted out of Tailored Care Management, Sandhills Center will let you opt back in for Tailored Care Management.
Call Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778)
WHAT HAPPENS IF I OPT OUT OF TAILORED CARE MANAGEMENT?
If you opt out, you will get all of your other health care services and the Sandhills Center Tailored Plan will still be your health plan. If you have the Innovations or TBI Waiver, we will still coordinate your care. With your permission, a Sandhills Center care coordinator will:
- Work with you to choose family members or caregivers to be a part of your health planning team. This team will help you set personal health goals and identify needs as part of your Individual Support Plan (ISP).
- Help you get started with a primary care provider (PCP), if you do not already have one.
- Coordinate services from providers in your community.
- Connect you to resources and social supports in your community.
- Regularly review your services to make sure you are getting the help you need.
HOW DO I CHANGE MY CARE MANAGER?
You can change care managers twice a year without cause and at any time with cause. The Sandhills Center Tailored Plan will help you change your care manager if that is your wish.
Contact Member & Recipient Services: 1-800-256-2452 (or TTY: 1-866-518-6778)
HOW CARE MANAGERS HELP DURING THE INNOVATIONS WAIVER INDIVIDUAL SUPPORT PLAN (ISP) PROCESS
Your care manager will tell you about Innovations Waiver services. They will help you create your Individual Support Plan (ISP) based on the services you choose. Your ISP is a plan for the services you will need during the year. Your care manager will make sure your ISP has the services you want and for the length of time that you want them. You must have a signed ISP to get Innovations Waiver services. Your care manager will write up the ISP based on your wishes. Your care manager will answer your questions and make changes to the plan before you or your representative signs the ISP.
You may make changes to your plan during the ISP plan year. The Sandhills Center Utilization Management (UM) department decides if the services you are asking for are medically necessary. Your care manager does not decide. A decision will be made within 14 days unless more information is needed.
You will get details in writing if any service requested in your ISP is not fully approved (for example: if it is denied or is approved for fewer hours than requested). You will get information about how to appeal the decision and how to ask for different services while your appeal is pending. Your care manager can help you fill out the forms you need to file an appeal.
Some services may be approved and some may be denied. If you choose, you can still get the services that were approved while you appeal the denied services. You also can ask for different services while you wait for an appeal decision if you choose.
Have questions about Tailored Care Management? Contact your care manager directly, or call Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778).