Request to Move to a Tailored Medicaid Plan

Fill out information for the person who has NC Medicaid

Tell us what type of condition or service need the beneficiary has

to disclose the health information specified in this form from my health records to NC Medicaid, its Enrollment Broker (Maximus) and my Standard Plan for the purposes of treatment under the NC Medicaid program, including determining my eligibility for a Tailored Plan; payment of covered services; and healthcare operations, including care coordination and/or case management by NC Medicaid and its Enrollment Broker. By signing this form, I authorize the following information which may include information relating to my communicable diseases or related conditions; mental health / psychiatric treatment; and substance use disorder diagnosis, condition and treatment to be shared and/or exchanged by the entities listed above. I also give my provider listed in this form, NC Medicaid, its Enrollment Broker and my Standard Plan permission to talk to each other and share information. Information may be shared through verbal, electronic or written communication.

My entire health record except for information related to:

I understand that I may refuse to release my health information and that my refusal will not affect my ability to obtain treatment, payment for services or my eligibility for NC Medicaid benefits in my current Standard Plan. However, I also understand that my request to move to a Tailored Plan may be denied if authorization is not given, as the information sought under this authorization is needed to evaluate my eligibility for a Tailored Plan.

Redisclosure and confidentiality

By signing below, I understand the following:

• • Once information is disclosed pursuant to this signed authorization, that the federal privacy law (45 CFR Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure.

If I indicated above to authorize the release of substance use disorder information, I also understand:

• is protected under federal regulations and cannot be released without my written consent unless otherwise provided in 42 CFR Part 2. • I am authorizing that my substance use disorder records (or information contained in the records) may be redisclosed in accordance with the permissions contained in the Health Insurance Portability & Accountability Act (HIPAA) regulations, except for uses and disclosures for civil, criminal, administrative and legislative proceedings against me. • When my substance use disorder diagnosis, condition or treatment information protected by 42 CFR Part 2 is disclosed, the recipient must be told that redisclosure is prohibited, except as permitted or required by law.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on it. This authorization will expire in one year from the date signed or upon completion of care coordination / case management activities by NC Medicaid and its Enrollment Broker, whichever occurs first, unless I withdraw my consent earlier. You may revoke your consent by contacting the Enrollment Broker at 1-833-870-5500 who will help you with completing the written request to revoke this authorization. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment for services or my eligibility for NC Medicaid benefits in my current Standard Plan. However, I also understand that my request to move to a Tailored Plan may be denied if authorization is not given, as the information sought under this authorization is needed to evaluate my eligibility for a Tailored Plan.

The beneficiary or legally responsible person must read and sign the beneficiary attestation. By signing below, I acknowledge that I am requesting to transition to a Tailored Plan, rather than remain enrolled in a Standard Plan. I have been fully informed of the differences between a Tailored Plan and a Standard Plan. I acknowledge that this request will be considered by NC Medicaid and its Enrollment Broker and may be denied based upon my individual circumstances. I understand that if this request is approved, I will be moved to a Tailored Plan. If I have been assigned to a Standard Plan, I understand that I will no longer be enrolled in that plan.

These services are only available in Tailored Plans:

State-funded behavioral health and I/DD services:

• Residential treatment facility services (child/adolescent) •Child and adolescent day treatment services • Intensive in-home services • Multi-systemic therapy services • Psychiatric residential treatment facilities (PRTFs) • Assertive community treatment (ACT) • Community support team (CST) • Psychosocial rehabilitation • Clinically managed residential services • Medically monitored intensive inpatient services • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) • 1915(i) Home and Community Based services • Community living and supports • Community transition • Individual and transitional supports •Individual placement and support (supported employment) for mental health & substance use • Respite • Supported employment for I/DD and TBI • 1915(c) Waiver services • Innovations Waiver services • TBI Waiver services

• Certain behavioral health and I/DD services are available for individuals who are uninsured or who do not have adequate insurance and are supported by state and federal funds. These services are available through Tailored Plans and vary by Tailored Plan. Examples of these services include developmental therapy and residential supports. The full state-funded services list is accessible at: ncdhhs.gov/state-funded- enhanced-mental-health-and-substance-use- services-2024-3-01-24/download?attachment The state-funded services available through the beneficiary’s Tailored Plan are accessible at:
• Alliance Health: www.alliancehealthplan.org/services
• Partners Health Management: providers.partnersbhm.org/benefit-grids
• Trillium Health Resources: trilliumhealthresources.org/for- providers/benefit-plans-service- definitions
• Vaya Health: providers.vayahealth.com/service- authorization/coverage-info
• • State-funded substance use disorder services • State-funded intellectual and developmental disabilities services • State-funded traumatic brain injury services