Tailored Plan
Vaya Partners Tailored Plan is a Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan for Medicaid members. It focuses on whole-person care.
A Tailored Plan is a type of managed care health plan. For people with Medicaid, it includes:
- Physical healthcare
- Pharmacy benefits
- Behavioral health services
- I/DD services
- Traumatic brain injury (TBI) services
- Care management
Am I eligible for Tailored Plan?
You may qualify for Tailored Plan if you:
- Have NC Medicaid or are eligible for NC Medicaid
- Live in one of the 47 counties that Vaya Partners serves
- Need services for a serious mental health condition, severe substance use disorder, I/DD, and/or TBI
To enroll in Vaya Partners Tailored Plan, first apply for NC Medicaid. If you already have NC Medicaid, skip this step.
Apply for Medicaid in one of these ways:
- Apply online at healthcare.gov or at ePass
- Call or visit your local Department of Social Services (DSS) office
- Fill out a paper application and send it by mail, fax, or drop it off at your local DSS
To choose a health plan or primary care provider, call the NC Enrollment Broker at 1-833-870-5500 (TTY: 711), 7 a.m. to 6 p.m., Monday – Saturday.
If you have questions about Medicaid eligibility, contact your local DSS office.
How to get care
Your care starts by finding your primary care provider (PCP). This could be a doctor, nurse practitioner, or physician assistant who:
- Cares for your health
- Coordinates your needs
- Helps you get referrals for specialized services if you need them
You can choose your PCP. If you did not pick a PCP before enrolling in Tailored Plan, we will choose one for you and consider your previous healthcare providers. Your PCP’s name and contact information are on your Medicaid ID card.
Find your provider
Change your primary care provider
For help getting care, you can also call ACCESS Member Services at 1-888-235-4673, 7 a.m. to 6 p.m., Monday – Saturday.
If you need help with a mental health or substance use crisis, call our Behavioral Health Crisis Line at 1-800-849-6127. This line is available 24 hours a day, seven days a week.
Physical Health and Wellness services
The Tailored Plan covers doctor visits, hospital stays, and emergency services for adults and children. We can also help with medicine, special equipment, and wellness programs. From check-ups to big health issues, we’re here to support you.
All available services are listed in the Vaya Partners Tailored Plan Member Handbook.
The Vaya Partners’ Tailored Plan helps keep you healthy with regular check-ups and care. These services help find health problems early and keep you feeling your best.
Regular care includes:
- Office visits with your PCP, including check-ups, routine labs, and tests
- Referrals to specialists
- Vision/hearing exams
- Well-baby care
- Well-child care
- Immunizations (shots) for children and adults
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for members under age 21
- Help with quitting tobacco
Vaya Partners’ Tailored Plan always covers emergencies. You do not need approval from Vaya Partners or your doctor to get emergency care.
An emergency is when you need help right away to save your life or stop serious harm. Some examples are:
- Heart attack or bad chest pain
- Bleeding that won’t stop or a bad burn
- Broken bones
- Trouble breathing or passing out
- Feeling like you might hurt yourself or others
- Pregnancy problems like pain, bleeding, fever, or throwing up
- Taking too many drugs
You might need care in the emergency department, a hospital room, or somewhere else. There are different services that can help.
In a medical emergency, always call 911 or go to the nearest emergency department.
You can go to any doctor or clinic that takes Medicaid and offers family planning, maternity care, and reproductive health services. You can also visit one of our in-network providers.
Services for your reproductive health include:
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- Screenings for cancer and other related conditions
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- Testing, treating, and counseling for HIV and sexually transmitted infections (STIs)
Family planning services include:
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- Preparing for pregnancy
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- Preventing pregnancy
Maternity care services support you through your pregnancy. These services include:
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- Care before, during, and after your baby is born
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- Classes to help you prepare for your baby
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- Hospital care when you have your baby
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- A visit at home to check on you and your baby after you leave the hospital
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- Care management services to help if you need special care during pregnancy or after delivery
Home health services are delivered outside a hospital or a nursing home. They help people get the care and equipment they need to complete daily activities at home.
These are special services for patients and their families during the final stages of terminal illness and after death. Hospice services include care that supports terminally ill individuals and their families or caregivers. Hospice care will be arranged by Vaya Partners if medically necessary.
Sometimes you may need care at the hospital. Hospital care services cover:
- Staying in the hospital when you’re sick (inpatient care)
- Getting care at the hospital without staying overnight (outpatient care)
- Tests to help doctors understand your health issues
If you have a certain health condition or disability, you may need help with day-to-day activities like eating, bathing, or doing household chores. Long-term Services and Supports includes things like home health and personal care services.
There are providers in our network that can help with care at a facility. There are two types of nursing home services:
- Short-term or rehabilitation stays
- Long-term care (first 90 days)
We work with many pharmacies to make getting your medications easy. To find a covered local pharmacy, visit our Find a Provider webpage and click “Find a Pharmacy.”
If you need specialized care, your PCP can refer you to a specialist. A specialist is a doctor who is trained and practices in a specific area of medicine.
Vision care services are provided by ophthalmologists, optometrists, and sometimes an optician. These services help with regular eye care and getting glasses or contact lenses.
Special equipment and services may also be available. This could include hearing aids, dental care, telehealth, and care from clinics near you.
Behavioral Health services
Behavioral healthcare includes treatment for mental health and substance use disorders. Vaya Partners covers these services to support well-being and recovery for youth and adults.
Mental health services support your emotional, psychological, and social well-being. Services and supports are designed for different ages and may be in different places – in your home, community, or a facility.
Our goal is to support you on your journey, no matter the path you choose. From ongoing care to crisis services, your care team works with you to make a plan that supports you and your goals.
Learn more about mental health
Substance use disorder services help you recover from the use of alcohol and other drugs. Services and supports are designed for different ages and may be in different places – in your home, community, or a treatment centers.
Our goal is to support you on your journey, no matter the path you choose. From ongoing care to crisis services, your care team works with you to make a plan that supports you and your goals.
Learn more about substance use disorders
I/DD and/or TBI services
Vaya Partners supports people with I/DD to live where they choose, spend their day the way they want, be part of their community, and be more independent.
The Vaya Partners Tailored Plan covers special services for individuals with I/DD.
- Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
- Innovations Waiver services, for people enrolled in the NC Innovations Waiver
Learn more about Intellectual/Developmental Disabilities (I/DD)
Some Tailored Plan members are eligible for the NC Innovations Waiver. This Medicaid waiver helps individuals with I/DD) get services and supports in their home and participate in their community.
The Innovations Waiver has a limited number of available slots. If slots are full, an individual will be added to the Innovations Waiver Waitlist (also known as the Registry of Unmet Needs).
Learn more about NC Innovations Waiver.
Vaya Partners covers special services for individuals with TBI.
Extra support
Sometimes you might need more than just regular healthcare. We offer additional services to support you in your daily life and in your community. These services can help you stay independent, comfortable, and connected to the things that matter to you.
Tailored Care Management is a free service that provides support for people with mental health needs, substance use disorders, I/DD, or TBI. As a Tailored Plan member, you may be eligible for Tailored Care Management.
With Tailored Care Management, a care manager works closely with you, your care team, and family or people important to you to create health goals and find needed services. Care managers help with things such as making appointments, understanding medications, and connecting you to community resources.
Members who opt out of Tailored Care Management may receive less intensive care coordination services instead. Vaya Partners will help you coordinate services, but it will be more limited than Tailored Care Management.
1915(i) services are a type of home- and community-based services. They can help you or a loved one live at home, find a job, learn skills to participate in the community, recover from substance use disorder, and more.
Services include:
- Community living and support
- Community transition
- Individual and transitional support
- Respite
- Supported employment services
Diversion means helping people stay in their own homes and communities, not in a facility. Our team will work with eligible members to find the right support and housing. Together, we can make a plan that helps you achieve your goals.
The Vaya Partners Tailored Plan can help you get to your healthcare appointments and other important places. We offer free rides for:
- Medical visits, like doctor appointments (Non-Emergency Medical Transportation – NEMT)
- Picking up medicines (NEMT)
- Non-medical trips, like going to the grocery store (Value-Added Service)
Find more details about help with rides on our Transportation Assistance webpage.
For more information about eligibility, services, or approvals, always check the Vaya Partners Tailored Plan Member Handbook.
Value-Added Services
Recipient Rights and Responsibilities, Grievances, and Appeals
As a NC Medicaid Direct member, you have certain rights and responsibilities. It is important to know what those are.
If you have a complaint about your health plan, provider, care, or services, contact us. You can send a complaint, also called a grievance.
Sometimes Vaya Partners may make a decision about your services that you do not agree with. You can ask us to review it. This is called an appeal.
Questions and Answers
We’re here to help you understand your choices and the Vaya Partners Tailored Plan. Here are answers to questions you may have.
If you have other questions, call ACCESS Member Services at 1-888-235-4673. This line is available 7 a.m. to 6 p.m., Monday – Saturday.
Access to Healthcare
Your PCP is someone who takes care of your health. They may be a doctor, nurse practitioner, or a physician assistant. This person will:
- Look after your overall health
- Help you get the care you need
- Send referrals to special doctors if you need it
You can find your PCP’s name and phone number on your Medicaid card. If you didn’t pick a PCP, Vaya Partners chose one for you based on where you live or doctors you’ve seen before.
Vaya Partners can help you arrange an initial visit to your PCP, including transportation. Call ACCESS Member Services at 1-888-235-4673.
If you have questions about which providers you can see, call us at 1-888-235-4673. You can view providers in our network on our website or on the Find page at ncmedicaidplans.gov.
Call ACCESS Member Services at 1-888-235-4673 (7 a.m. to 6 p.m., Monday – Saturday).
You should have received a Vaya Partners Tailored Plan Welcome Packet in the mail. The packet includes the name of your primary care provider and how to contact them. It also includes your new Medicaid ID card. Your PCP’s information is on the card.
If you can’t find your packet or have questions, call ACCESS Member Services at 1-888-235-4673 (7 a.m. to 6 p.m., Monday – Saturday).
You can change your PCP twice a year without giving a reason. This is known as a change “without cause.” Here is how:
- Within 30 days of getting a welcome packet, call ACCESS Member Services at 1-888-235-4673 to make a change.
- After that, you can change one more time during the year.
You can change your doctor more than twice for certain reasons. This is known as a change “with cause.” Some goods reasons are:
- Your PCP doesn’t give you the right care
- You don’t agree with your treatment plan
- Your PCP moves too far away
- Your PCP changes when they see patients
- You have trouble talking to your PCP
- Your PCP can’t meet your special needs
- You and your PCP both think a new PCP would be better for you
To request a PCP change, call ACCESS Member Services at 1-888-235-4673.
Vaya Partners is still adding primary care providers to grow our provider network (group). If the doctor you used to see joins our network, we will let you know.
You can get extra help to get and stay healthy. Tailored Care Management is a free benefit with a care manager. A care manager is a trained professional who works with you and your doctors. They make sure you get the right care when you need it. They can also help you find free resources in your community.
Your care manager might be from:
- Your PCP (also called an Advanced Medical Home Plus, or AMH+)
- A Care Management Agency (CMA)
- Vaya Partners’ Care Management Department
You don’t have to have a care manager if you don’t want one. If you decline Tailored Care Management, Vaya Partners can still help you with some care coordination services. If you’re on the NC Innovations Waiver and don’t want Tailored Care Management, you will still get the care coordination services required in the waiver.
You can choose not to have a care manager at any time by calling ACCESS Member Services at 1-888-235-4673.
Pharmacy services
Vaya Partners connects Medicaid members to a large pharmacy network for access to the medications you need when you need them. We work with a pharmacy benefit manager called Navitus Health Solutions to help you get the medications you need. For help, call our Pharmacy Service Line at 1-800-540-6083, 7 a.m. to 6 p.m., Monday – Saturday, including holidays.
Eligible Medicaid members may receive any medication covered by NC Medicaid. For a full list of covered medications, visit our Medication Search webpage.
You can get medications from most pharmacies in North Carolina. To find a participating pharmacy near you, visit our Find a Provider webpage and click the “Find a Pharmacy” link.
You can also call the Pharmacy Service Line at 1-800-540-6083 for help finding a pharmacy. This line is available 7 a.m. to 6 p.m., Monday – Saturday, including holidays. If you call before or after business hours, you can leave a message and have your call returned the next day.
If you can’t find your packet or have questions, call ACCESS Member Services at 1-888-235-4673.
Most adult Medicaid members have a $4 copay. There are no copays for members under age 21, NC Innovations Waiver participants, pregnant members, members receiving hospice care, federally recognized American Indians/Alaska Native members, children in foster care, and people living in an institution.
Some pharmacy medications and products also do not have a copay. These include diabetic supplies, COVID-19 tests, medication to treat HIV, nicotine replacement therapy, and naloxone.
The Vaya Partners Lock-in Program helps identify members who are at risk for possible overuse or improper use of pain medications (opioids) and nerve medications (benzodiazepines). If you have questions about the program, call the Pharmacy Service Line at 1-800-640-6083.
Visit our Pharmacy Lock-in Program webpage for more information.
Information for members
Vaya Partners will send you a Welcome Packet that includes a letter, your Medicaid ID Card, a Tailored Plan Member Handbook, and other helpful information. You can also call ACCESS Member Services at 1-888-235-4673 to request another copy.
After you are enrolled in Tailored Plan, we will mail you a welcome packet with information about services, benefits, providers, and your Medicaid ID card. These are sent to the mailing address on file at your local Department of Social Services.
Your Medicaid card has:
- Your primary care provider’s (PCP’s) name and phone number
- Your Medicaid ID Number
- Information on how to contact us with questions
If anything is wrong on your Medicaid card or if you need a new copy, call ACCESS Member Services at 1-888-235-4673.
Always carry your Medicaid ID card with you. You will need to show it each time you go to your doctor or provider.
Find the number you need below or visit our Contact Us webpage.
ACCESS Member Services: 1-888-235-4673
- For general information or help with a question or complaint
- Available 7 a.m. to 6 p.m., Monday – Saturday, including holidays
Behavioral Health Crisis Line: 1-800-849-6127
- For help in a mental health or substance use crisis
- Available 24/7
Pharmacy Service Line: 1-800-540-6083
- For information about pharmacy benefits
- Available 7 a.m. to 6 p.m., Monday – Saturday, including holidays
Nurse Line: 1-800-290-1623
- For guidance about physical health concerns
- Available 24/7
Non-Emergency Medical Transportation Line: 1-888-621-2084
- To make a reservation with Modivcare for transportation services
- Available 7 a.m. to 6 p.m., Monday – Saturday
Avēsis Customer Service Line: 1-866-889-4457
- For information about vision services
- Available 7 a.m. to 6 p.m., Monday – Saturday
Resources
We serve children and adults with Medicaid in the following North Carolina counties:
Alamance, Alexander, Alleghany, Ashe, Avery, Buncombe, Burke, Cabarrus, Caldwell, Caswell, Catawba, Chatham, Cherokee, Clay, Cleveland, Davidson, Davie, Forsyth, Franklin, Gaston, Graham, Granville, Haywood, Henderson, Iredell, Jackson, Lincoln, Macon, Madison, McDowell, Mitchell, Person, Polk, Rockingham, Rowan, Rutherford, Stanly, Stokes, Surry, Swain, Transylvania, Union, Vance, Watauga, Wilkes, Yadkin, and Yancey.