While the North Carolina General Assembly failed – again – to expand Medicaid to the hundreds of thousands of North Carolina residents that desperately need health insurance coverage, don’t think that means that there aren’t many things happening with Medicaid in North Carolina. Medicaid Transformation is still very much in process. 
 
To recap: We are a little more than a year into the launch of Medicaid managed care and the Advanced Medical Home Model. Earlier this year, the Healthy Opportunities initiative launched, and providers and nonprofit organizations are working together to identify and address patients’ health related resources needs to improve their wellbeing. Now, the Tailored Plans are swinging into gear, with the go-live date set for December 1, 2022. 
 
The scheduled launch of the Tailored Plans is pretty important. North Carolina, like many other states, is experiencing a mental health crisis as it relates to the availability and access to critical behavioral health services. This is particularly acute across Medicaid Populations. Local Management Entities (LMEs) were introduced a decade ago to better coordinate and manage mental health services for Medicaid recipients with behavioral health needs. And while greater coordination and streamlined access was then (as now) a recognized deficit, it is important to recognize that a core component of LME coordination was utilizationmanagement. That means, at least in part, minimizing use of behavioral health services. 
 
Introducing the Tailored Plans
Let’s start at the beginning: what are the Tailored Plans you ask? Tailored Plans are the Medicaid managed care plans for individuals with intellectual/developmental disabilities (I/DD), traumatic brain injury (TBI), or significant behavioral health needs. While the Tailored Plan model reflects an enhanced care management and coordination activity from previous operations, the model is built upon the existing model for management of care for Medicaid recipients with significant behavioral health needs. Namely, the 6 regional Tailored Plans were selected from among the existing LMEs (Alliance Health, Eastpointe, Partners Health Management, Sandhills Center, Trillium Health Resources, and Vaya Health). This means that the Tailored Plan entities will all be familiar to providers. While it’s the same entities, the Tailored Plans should operate differently. 
 
There are three important characteristics that distinguish the Tailored Plans from the LME/MCO model: first, Tailored Plans are required to cover the full spectrum of services: physical health, behavioral health, pharmacy, and long-term services and supports. Second, the population eligible to enroll in Tailored Plans is significantly smaller than the enrolled population under the LME/MCOs. Total enrollment in Tailored Plans across the state is less than 200,000. This means the number of patients previously covered by an LME/MCO will be much lower. Third, the care management that enrollees should receive is expected to be different. Tailored Care Management is specialized care management designed for people with significant behavioral health needs. It is built on the Health Home model created in the Affordable Care Act. All individuals enrolled in a Tailored Plan are eligible for Tailored Care Management. 
 
A Closer Look at Tailored Care Management
In keeping with the NC DHHS’ goal of provider-lead, community-based care management, Tailored Care Management can be provided to Tailored Plan enrollees either by: 
 

• AMH+ Primary Care Practices – these are primary care practices certified by NC DHHS to provider tailored care management. 
• Care Management Agencies – these are organizations that provide behavioral health or I/DD services, certified by the NC DHHS to provide tailored care management 
• Tailor Plan-Based Care Manager – these are health plan-based care managers

 
While tailored care management from a Tailored Plan care manager is an option, NC DHHS has made clear that it expects there to be a significant shift over time to provider-lead, community-based care management. In fact, the NC DHHS has set increasing targets over the next 3 years with the expectation that the Tailored Plans are working with providers to prepare them to serve as AMH+ or a CMA and to shift patients to providers for care management. As of July 2022, there are a total of 47 providers certified by NC DHHS as either AMH+ or a CMA. 
 
I applaud the NC DHHS’ efforts to ensure that AMH+ and CMA applicants can truly provide the level of care management expected. This is demonstrated by the review process. In the most recent round of site reviews, of the 37 applicants that advanced to site reviews, 13 were approved. NC DHHS, in partnership with the regional AHECs, is working with provider organizations to ensure their readiness to operate as an AMH+ or CMA. This indicates that we still have a long way to go to ensure capacity in the communities across the state to provide community-based tailored care management. 
 
A few additional quick things to know about Tailored Plans. 
 

1. Tailored Plans are distinct from Standard Plans (the managed care plans that launched last year and cover most Medicaid enrollees) in that Tailored Plans cover specific services that Standard Plans do not cover. These include enhanced behavioral health services such as Assertive Community Treatment, intensive in-home services, as well as Innovations Waiver and TBI waiver services. Patients that require these services must enroll in a Tailored Plan to receive them. Standard Plans cover many other State Plan behavioral health services. It is important for providers to understand the differences to 1. Determine if contracting with a Tailored Plan is necessary and 2. Educating patients on the differences in coverage options. 
2. Tailored Plans are required to have a physical health provider network. When operating as an LME/MCO, the plans did not cover physical health care and so did not have such a network. To ease the burden of building and maintaining a physical health network, state law requires Tailored Plans to partner with Standard Plans to, among other things, leverage the Standard Plans provider network, if necessary. To learn which Standard Plans the Tailored Plans have partnered with and whether the Tailored Plan is utilizing the Standard Plan’s network in whole or in part, see this resource. Tailored Plan networks for physical health are open networks, meaning the plan must contract with any willing provider. However, the behavioral health network remains closed, as it was under the LME/MCO model. This means that the Tailored Plan need not contract with behavioral health providers if it determines that its current network is adequate. My colleague Sarah Jagger has written some tips for providers when contracting with Tailored Plans.  

 
Bringing it all together
While that was a lot of background to cover, it is important to understand the administrative and clinical infrastructure upon which Medicaid Behavioral Health services are provided and paid for. When reading how this is going to work, it likely feels complex. That’s because it is. 
 
There is a lot of “management” happening here. I have lots of questions and concerns about what is being managed – and to what purpose. Traditionally, the LME/MCO model managed access to and utilization of services to contain costs. In theory the Tailored Plan model centers more on improved coordination and integration, but it remains to be seen if those aspirational goals are feasible and sustainable. 
 
In coming to that question and solution honestly there is at least one hard truth that we have to acknowledge: We have a woefully underfunded behavioral health system. The idea of taking out more money makes my head hurt. What we need is additional funding into the system (Medicaid expansion would have a huge impact here) and we need more effective use of the funding to ensure that patients receive the right care. It remains to be seen if the additional infrastructure and management of the Tailored Plan model, when paired with the stated objectives, will translate to improved patient outcomes and clinical efficiency. Second, we need to recognize that we will never find ourselves in a world where intensive behavioral health services are not needed. That includes institutional services. However, we can do more to decrease the need for such services and reduce the length of time such services are needed. 
 
I’m not convinced that the Tailored Plan construct enables us to do that. I’m taking a watch and see approach though – skeptical open-mindedness. The Standard Plans have a lot of work to do to ensure that enrollees with mild to moderate needs receive the services they need when they need it to ensure that patients do not reach a crisis point. Tailored Plans have the unfortunate disincentive to utilize effective care management and other services to ensure that patients receive the care and support they need so that their needs are stabilized and no longer need the intensive behavioral health services, thereby being able to transition out of the Tailored Plan to a Standard Plan (in case you were wondering why I’m skeptical, this is why.) Essentially, if Tailored Plans do their jobs well, they won’t really have a population to insure. 
 
My expectation is that North Carolina ultimately takes the path that other states, like Washington, have taken resulting in fully integrated managed care, in which Medicaid managed care organizations are responsible for managing the full continuum of Medicaid-covered physical health and behavioral health services, rather than having a fragmented system. But, we’ve got some time before we get there.