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Care Management

Care management and care coordination are free benefits available to qualifying Vaya Health members and recipients. They help make sure you get the care you need and connect with other local resources. Care Managers and Care Coordinators work with you to identify your strengths, understand your needs, and build a personalized plan of care that is right for you.

Your Care Manager or Care Coordinator can connect you to community resources to help with needs such as housing, work, transportation, or food. To learn more, talk to your Care Manager or Care Coordinator, submit a Community Resources Referral Request, or visit our Local Resources webpage. For more information, call our Member and Recipient Services Line at 1-800-962-9003.

Vaya Health offers multiple care management/care coordination models based on your health plan and individual needs. To see if you qualify, read the descriptions below.

Please note the North Carolina Department of Health and Human Services (NCDHHS) determines eligibility for Tailored Care Management (TCM), while Vaya manages care management/care coordination eligibility and assignment for NC Medicaid beneficiaries who opt out of TCM and for uninsured recipients living in the Vaya region. 

Care management models

TCM is available to eligible Medicaid beneficiaries enrolled in a Vaya health plan. Under TCM, a Care Manager works with you and your health care providers to make sure you get needed care while connecting you to appropriate resources. NCDHHS manages TCM eligibility and assigns members to one of three TCM provider types: an Advanced Medical Home Plus, a Care Management Agency, or Vaya’s Care Management Department.

You can choose not to have a Care Manager and not receive the TCM benefit. We will help you coordinate services, but the coordination will be more limited than TCM. To opt out of or back in to TCM, or to choose or change your TCM provider or Care Manager, call our Member and Recipient Service Line at 1-800-962-9003 or submit the Tailored Care Management Opt In/Out or Change Form.

Am I eligible for TCM?

Eligibility for TCM depends on your health plan and individual needs. Please note, members receiving the following services, which include a care management component, may be ineligible for TCM:

  • Assertive Community Treatment
  • Intermediate Care Facility for Individuals for Intellectual Disabilities
  • Care Management for At-Risk Children
  • High-Fidelity Wraparound
  • Skilled Nursing Facility (for members residing/likely to reside in the facility for 90 calendar days or longer)
  • In lieu of services (ILOS) that NCDHHS deems duplicative of TCM
  • Critical Time Intervention (CTI)  
  • Primary Care Case Management, such as Community Care of North Carolina (CCNC) or the Eastern Band of Cherokee Indians (EBCI) Tribal Option  
  • Case Management through the Community Alternatives Program for Children (CAP/C) or for Disabled Adults (CAP/DA)  
  • Program of All-Inclusive Care for the Elderly (PACE) 

Note: Individuals who are incarcerated cannot obtain TCM due to suspended or terminated NC Medicaid eligibility. Upon release, eligible individuals may reenroll in TCM if eligible.

How can TCM help me?

TCM gives you more control over your personal health and wellness. Your Care Manager works closely with you to make sure your voice is heard. Together, you will create a plan that includes the services and supports you need to stay healthy, safe, and satisfied with your care.

Your Care Manager also pays attention to your life “outside the doctor’s office.” This may include linking you to appropriate medical specialists or supporting your healthy eating and sleep habits. Our person-centered planning process ensures that we work closely with you to make sure your choices are respected.

Your Care Manager can:

  • Conduct a full assessment of your needs
  • Help you identify your health goals and make a plan to meet them
  • Help arrange your appointments and free transportation to and from your provider(s)
  • Provide guidance and resources to help with school or work needs
  • Connect you to community resources for housing, food, and other needs
  • Find doctors who take Medicaid and have openings
  • Follow up with your doctors or specialists about your care
  • Answer questions about what your medicines do and how to take them
  • Help you manage chronic conditions, like diabetes
  • Be your main point of contact for all things Medicaid

TCM providers

View the list of providers that deliver TCM to Vaya members. The list includes Advanced Medical Homes Plus and Care Management Agencies.

Vaya provides care coordination to assist with care transitions for all Vaya Medicaid members in accordance with 42 C.F.R. § 438.208, regardless of whether you opt out of, do not engage with, or are ineligible for TCM. Vaya Care Coordinators help manage your services, but the coordination is more limited than TCM. NC Innovations Waiver participants and members receiving 1915(i) services who opt out of TCM will continue to receive care coordination through Vaya.

Medicaid members living in the community may be eligible for 1915(i) care coordination if they receive 1915(i) services. Vaya Care Coordinators help manage your services, but the coordination is more limited than TCM. Care Coordinators assess your needs, help plan your care, and connect you to and monitor services and supports, based on need and living arrangements.

You may be eligible for 1915(i) services if you have NC Medicaid and need support with activities at home or in the community due to one or more of the following conditions:

  • Serious mental health condition
  • Severe substance use disorder
  • Intellectual/developmental disability (I/DD)
  • Traumatic brain injury (TBI)

Please note Innovations Waiver and TBI Waiver participants are not eligible for 1915(i) services, as these waivers provide similar services. However, people on the waitlist for either waiver may be eligible for 1915(i) services.

NC Medicaid Direct members who are ineligible for TCM may be assigned to complex care coordination. Under this benefit, an assigned Care Coordinator helps you with care transition planning, connects you to needed services and supports, provides education about services, encourages communication between providers, and helps resolve issues and answer questions.

You may be eligible for complex care coordination if you:  

  • Are an NC Medicaid Direct member
  • Are not eligible for TCM
  • Do not otherwise meet eligibility criteria for the Behavioral Health I/DD Tailored Plan
  • Have a behavioral health transitional care need and/or a special health care need
  • Are receiving care management through another entity and are not engaged in TCM

Vaya provides State-funded care management to eligible recipients of State-funded services with the highest needs. State-funded care management is a short-term service and should not exceed 90 calendar days.  It involves structured activities to enhance coordination of care, eliminate duplication of services and supports, and ensure delivery of appropriate services.

Recipients with behavioral health needs are eligible for State-funded care management if they:

  • Are ineligible for Medicaid;
  • Have experienced four or more crisis events (e.g., psychiatric emergency department visits or psychiatric inpatient admissions) in the previous six months; and
  • Are not engaged with an outpatient treatment provider or a behavioral health case manager. 

Recipients with I/DD or TBI needs are eligible for State-funded care management if they:

  • Are ineligible for Medicaid;
  • Are not connected to or are disengaged from community-based services that are available to meet their clinical needs;
  • Require coordination between two or more agencies, including medical or non-medical providers, and there is no natural or community support that can provide this coordination;
  • Are expected to have difficulty engaging in treatment services without additional support;
  • Are ineligible for provider-based case management services; and
  • Meet one of the following criteria: 
    • Reside in or are at risk of entry into institutional settings (e.g., State Developmental Facility, Intermediate Care Facility for Individuals with Intellectual Disabilities, State Psychiatric Facility, or Adult Care Home); 
    • Are involved with the justice system;
    • Have behavioral complexities resulting in recurrent crisis service usage (e.g., emergency department visits, Behavioral Health Urgent Care, and Facility-Based Crisis); or 
    • Are at risk for out-of-home placement. 

Note: Vaya offers State-funded care management to recipients based on eligibility, risk level/need, and availability of funding and resources.

If you are a member of a federally recognized tribe or eligible for services through the U.S. Indian Health Service, you may also be a member of the Eastern Band of Cherokee Indians (EBCI) Tribal Option and receive Tribal Option Care Management. The EBCI Tribal Option is offered primarily in five counties: Cherokee, Graham, Haywood, Jackson, and Swain. Eligible Medicaid beneficiaries in the following counties may opt in: Buncombe, Clay, Henderson, Macon, Madison and Transylvania.

For more information on Tribal Option Care Management, call the EBCI Tribal Option Member Services Line at 1-800-260-9992.

Care management resources

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