North Carolina Medicaid Transformation: What’s the Difference Between the Medicaid Standard Plan and the Tailored Plan?

Posted by The Arc of North Carolina

This blog series will address topics related to Medicaid Transformation to help answer questions and give you the most current information.

What’s the Difference Between the Medicaid Standard Plan and the Tailored Plan?

As we continue to move forward with Medicaid Transformation in North Carolina, we want to bring you the second installment of our Medicaid Transformation Blog Series. The last post gave a general overview of Medicaid Transformation. This time, we will talk about the Standard Plan and the Tailored Plan.

The Standard Plan (SP) is a plan for how the state will manage costs for health and medical services for Medicaid recipients. Most Medicaid recipients will move into the SP when it goes live across the state on February 1, 2020.

Medicaid recipients will then choose a Health Plan from 4 or 5 options (depending on where you live), including: Healthy Blue (BCBS), AmeriHealth Caritas, WellCare, United HealthCare, and Carolina Complete Health (only available in certain counties).

Please be aware that if you are currently receiving community-based services from The Arc of North Carolina or any other organization and you choose to move to one of the health plans, you will LOSE all of your current services. This will happen because those insurance companies, or health plans, will only manage medical services, and they will NOT have funds for the community-based services you are receiving now.

As the Standard Plan begins, most people with I/DD (and severe MI and SU) will be "exempt" from the Standard Plan. This means they are exempt from the mandate to be served under the SP. They will remain in the traditional fee-for-service model for medical services while they wait for the Tailored Plan. That fee-for-service model is now called "NC Medicaid Direct."

Tailored Plan is a plan for how the state will manage costs for health and medical services for a "tailored" population with more intense needs. Most people with (I/DD), severe mental illness (MI) and severe substance use (SU) disorders will be covered under the Tailored Plan, which goes live in July 2021. This is the state's way of combining the long-term services and supports for this group with their medical services under managed care.

Most or all of the current LME/MCOs will apply to become the Tailored Plan providers.

If you have questions regarding the services you receive or how Medicaid Transformation will affect you, contact your LME/MCO . You can also contact The Arc of North Carolina at 1-800-662-8706 or info@arcnc.org.

Next Up: Medicaid Enrollment

Click here for Medicaid Transformation Resources.