BH/IDD Tailored Plan Eligibility and Enrollment

NC DHHS published a “Final Guidance” paper entitled, “BH/IDD Tailored Plan Eligibility and Enrollment”.  Final guidance may reference that NC DHHS will not seek any more feedback on the policy, although it is qualified that NC DHHS has the right to amend the policy in the future.  This paper accompanies the November 2017 concept paper, “BH/IDD Tailored Plan” and further specifies eligibility requirements for the BH/IDD Tailored Plan and enrollment in the BH/IDD Tailored Plan. 

NC DHHS staff have indicated that they are continuing their review of claims and encounter data for dates of service as of January 1, 2018 or later to identify Medicaid beneficiaries who meet the eligibility requirements for the BH/IDD Tailored Plan.  Those individuals will receive a letter, probably in early summer, indicating that there are impending changes to Medicaid, but also indicating that they will also continue receiving services through the LME/MCOs and their physical healthcare services will continue to be fee-for-service until the BH/IDD Tailored Plan goes live in 2021. 

At the time of the BH/IDD Tailored Plan launch, Innovations and TBI waiver and Transition to Community Living Initiative Medicaid beneficiaries must enroll in the BH/IDD Tailored Plan to receive services under the waiver.  Medicaid beneficiaries who are eligible for the Innovations waiver but are waiting for a slot are able to enroll under the Standard Plan while on the waiting list without losing their place on the list. 

Foster children up to age 21 and those who were formerly foster children up to age 26, or receiving Title IV-E Adoption Assistance, may choose between a Specialized Foster Care Plan—if available, the Standard Plan or the BH/IDD Tailored Plan. 

Nursing home residents who are eligible for the BH/IDD Tailored Plan when it begins are included.  In general, dual eligible (Medicare/Medicaid) individuals will be folded into Medicaid managed care in 2023. 

NC DHHS has stated that they do not intend to cap enrollment in the BH/IDD Tailored Plans.  Enrollment caps will remain for the Innovations and TBI waivers.  Based on a review of past data, the Department estimates that about 25,000-35,000 dual eligible beneficiaries and 80,000-100,000 Medicaid only beneficiaries will meet the eligibility criteria for enrollment in a Behavioral Health I/DD Tailored Plan.  Specific diagnoses included in their review are listed in the Appendix B of the document. 

The following Medicaid and Health Choice beneficiaries will automatically be included in the BH/IDD Tailored Plan: 

• Enrollees in the Innovations waiver and those on the waiting list as well as any beneficiaries with a qualifying I/DD diagnosis code;

• Enrollees in the TBI Waiver and those on the waiting list;

• Transition to Community Living Initiative (TCLI)-qualified beneficiaries;

• any beneficiary who has used a Medicaid service that will only be available through a Behavioral Health I/DD Tailored Plan (See Section VI for additional detail on these services);

• any individuals who has used a behavioral health, I/DD, or TBI service funded with state, local, federal or other non-Medicaid funds;

• Children with complex needs, as that term is defined in the 2016 settlement agreement between the NC DHHS and Disability Rights of North Carolina;

• any beneficiary who has a qualifying SMI or SED diagnosis code or qualifying SUD diagnosis code who used a Medicaid-covered enhanced behavioral health service during the lookback period;

• beneficiaries who have had—

• two or more psychiatric hospitalizations or readmissions within 18 months
• two or more visits to the emergency department for a psychiatric problem within 18 months
• two or more episodes using behavioral health crisis services within 18 months;

• beneficiaries who have had an admission to a State psychiatric hospital or alcohol and drug abuse treatment center (ADATC), including, but not limited to, individuals who have had one or more involuntary treatment episode in a State-owned facility;

Self-Selection for the BH/IDD Tailored Plan and Transition of Care Requests:

An individual who qualifies for Medicaid who believes they meet the eligibility and wishes to be in the BH/IDD Tailored Plan can make that request with the help of their provider.  NC DHHS has termed this,  “Raise Your Hand”.   

NC DHHS has self-imposed timelines to address transitions of care from the Standard Plan to the BH/IDD Tailored Plan to include:

• Auto enrollments will be processed within 5-7 calendar days;
  • Optional BH/IDD Tailored Plan enrollment requests made to the Enrollment Broker will be approved or denied within 5-7 calendar days;
  • Expedited transfers for urgent medical needs will be reviewed and approved or denied within 24 to 48 hours from when the beneficiary makes the request to the Enrollment Broker.