May 18, 2021

Medicaid Open Enrollment Wraps Up for Standard Plan – What Now?

Open enrollment for a Medicaid Managed Care began March 15 and ended May 14th, giving Medicaid recipients two months to choose the Pre-Paid Health Plan (PHP) they want as their insurance program under new Medicaid Standard Plan that will begin on July 1.  For those who did not proactively choose a Standard Plan, NC DHHS will use an algorithm to auto-assign Standard Plan beneficiaries with Prepaid Health Plans and primary care practices.  To assist with enrollment, a Fact Sheet was created to help enrollees understand what they should do during this period.

The Standard Plan brings together physical health care, pharmacy and unmet health needs with mild-to-moderate behavioral and substance abuse services – thus providing the consumer with a more integrated, whole person approach to their care.  Given the newness of all of this, it is possible that some may feel the need to make changes to their plans or request their plans not be changed.

Plan Change Options

For individuals moving from their LME/MCO to a Standard Plan that do not believe they should be moved, NC DHHS has created the Request to Stay in NC Medicaid Direct and LME/MCO: Beneficiary Attestation Form that should be completed to request services only available through the LME/MCO.  Medicaid beneficiaries can make this request at any time.  In addition, providers who do not think a Medicaid beneficiary they serve should be moved to the Standard Plan can also submit a Request to stay in NC Medicaid Direct (Fee for Service) and LME-MCO: Provider form.  Once a review and decision are made, the recipient will be informed through the mail.  If recipients have questions, they can contact the Enrollment Broker at and choose the chat feature or call 1- 833-830-5500 or TTY  1-833-830-5588 7 days a week.

Timeframe for Changing PHPs

If a recipient is not satisfied with their assigned Standard Plan PHP or primary care provider, here is their recourse:

Tailored Plan

Between now and July 1, 2022, individuals receiving care from their LME/MCO for MH/IDD/SUD services will not see any changes to their primary care services (they will remain in NC Medicaid Direct).  On July 1, 2022, the Tailored Plan begins.  At that time, not only will individuals receive their MH/IDD/SUD care through a BH/IDD Tailored Plan, but that Plan will also be responsible for coordination and oversight for their primary healthcare, pharmacy and unmet health needs as well.  This will be a huge shift, but the goal is to provide Medicaid beneficiaries with more intense needs a better coordinated and integrated system of care under the Tailored Plan.  Services for every individual in the Tailored Plan will be overseen and coordinated by a Care Manager.  This will be the key to providing higher quality, better coordinated physical health, and MH/IDD/SUD services, thus improving the health and wellbeing of those being served.  All individuals receiving State-funded MH/IDD/SUD services will also transition to the BH/IDD Tailored Plan on July 1, 2022.  The announcement of which LME/MCOs are awarded the BH/IDD Tailored Plans is expected in the first few weeks of June.