WHAT IS TCM?
Tailored Care Management (TCM) is a new care management model that began on December 1, 2022, for eligible NC Medicaid beneficiaries. TCM-elibligble beneficiaries/members have a single designated care manager supported by a multidisciplinary team to provide integrated care management to address the member’s whole-person health needs.
WHO IS ELIGIBLE?
- Innovations Waiver participants (including duals)
- TBI Waiver participants (including duals)
- Children and Adolescents with a Serious Emotional Disorder (SED)
- Adolescents with a Severe Substance Use Disorder (SUD)
- Adults with a Serious Mental Illness (SMI) or Severe SUD
- Children ages 3+ and older and adults with I/DD
- Children and adolescents in foster care with SED or SUD
- Dual-eligible adults with SMI or SUD
- Dual-eligible Children ages 3+ and older and Adults with I/DD who are NOT on the Innovations or TBI waivers
WHAT WE DO?
Tailored care managers will:
- Provide management for beneficiaries with chronic, high-risk, high-cost care management needs
- Educate on chronic health conditions and support self-health management (eating healthier; helping you join a diabetes prevention program)
- Help with medication monitoring
- Address unmet health-related resource needs
- Support transitions out of hospitals and nursing facilities
- Provide management for beneficiaries with chronic, high-risk, high-cost care management needs
- Educate on chronic health conditions and support self-health management (eating healthier; helping you join a diabetes prevention program)
- Help with medication monitoring
- Address unmet health-related resource needs
- Support transitions out of hospitals and nursing facilities
FREQUENTLY ASKED QUESTIONS
HOW DO I KNOW WHO MY BENEFICIARY’S TCM PROVIDER IS?
PCPs will be able to see the assigned TCM entity for any of their beneficiaries on their AMH NC Medicaid Direct/Managed Care PCP Enrollee Report in NCTracks following the launch of TCM Dec. 1, 2022. Other providers may be contacted by the TCM provider for coordination of care.
WHAT IS THE ROLE OF THE DSS WORKER AND PRIMARY CARE PROVIDER IN TCM?
Tailored Care Management is a model designed to foster coordination and collaboration among care team members across disciplines and settings. A child’s care manager will work collaboratively with the child/youth’s assigned DSS child welfare worker by sharing data, supporting completion of DSS-required assessments, conducting regular check-in meetings, collaborating on the development of the care plan/individual service plan (ISP), and establishing processes to manage crises.
Primary care providers (PCPs) will also have an opportunity to engage in the child/youth’s care management. PCPs will be included in the care team and have opportunity to participate in care team meetings. PCPs will also have opportunities to review and provide input on the care plan/ISP. Beginning December 1, 2022, primary care providers will be able see which of their patients are eligible for Tailored Care Management. While Tailored Care Management care managers will be responsible for initiating outreach to DSS child welfare workers, DSS will have contact information and be able to contact a child’s care manager if they need immediate assistance.
ARE CHILDREN AGES 0-3 ELIGIBLE FOR TAILORED CARE MANAGEMENT?
Only children ages zero up to age three enrolled in the NC Innovations Waiver will be eligible to receive Tailored Care Management beginning December 1, 2022. All other children ages zero up to age 3, including those in foster care, who meet Tailored Care Management eligibility will get Tailored Care Management beginning April 1, 2023. Until then, they will continue to receive care coordination/care management as they do today. For example, children in foster care who receive care management through the Care Management for At-Risk Children (CMARC) program provided by Local Health Departments will continue to receive CMARC.
WHO IS ELIGIBLE TO BECOME A CERTIFIED TAILORED CARE MANAGEMENT PROVIDER?
Advance Medical Home Plus (AMH+) AMH+s are primary care practices actively serving as AMH Tier 3 practices, whose providers have experience delivering primary care services to the Tailored Plan eligible population or can otherwise demonstrate strong competency to serve that population. To demonstrate experience and competency to serve the Tailored Plan eligible population, each AMH+ applicant must attest that it has a patient panel with at least 100 active Medicaid patients who have an SMI, SED, or severe SUD; an I/DD; or a TBI.
Care Management Agency (CMA) To be eligible to become a CMA, an organization’s primary purpose at the time of certification must be the delivery of NC Medicaid, NC Health Choice, or State-funded behavioral health, I/DD, and/or TBI services, other than care management, to the Tailored Plan eligible population in North Carolina. The “CMA” designation is new and will be unique to providers serving the Tailored Plan population. A list of current certified Tailored Care Management providers and the populations they are certified to serve can be found on the NC Medicaid Tailored Care Management webpage under Resources, then Other.