NC Medicaid Direct Handbook

Your Trillium Health Resources (Trillium) Quick Reference Guide

Keywords Used In This Handbook

As you read this handbook, you may see some new words. Here is what we mean when we use them.

Adult Care Home: A licensed residential care setting with 7 or more beds for elderly or disabled people who need some additional supports. These homes offer supervision and personal care appropriate to the person’s age and disability.

Advance Directive: A written set of directions about how medical or mental health treatment decisions are to be made if you lose the ability to make them for yourself.

Advanced Medical Home Plus (AMH+): Certified primary care practices whose providers have experience delivering primary care services to LME/MCO members obtaining Tailored Care Management, including people with behavioral health, intellectual/developmental disabilities (I/DD) or traumatic brain injury (TBI). These providers are also certified to provide care management to you.

Adverse Benefit Determination: A decision your LME/MCO can make to deny, reduce, stop or limit your health care services.

Appeal: If your LME/MCO makes a decision you do not agree with, you can ask them to review it. This is called an "appeal." Ask for an appeal when you do not agree with your health care service being denied, reduced, stopped or limited. When you ask your LME/MCO for an appeal, you will get a decision on your appeal within 30 days. This decision is called a “resolution.” Appeals are different from grievances.

Behavioral Health Care: Mental health and substance use disorder treatment and recovery services.

Beneficiary: A person who is receiving Medicaid.

Benefits: A set of health care services covered by your LME/MCO.

Care Coordination: A service where a care coordinator or care manager helps refer you for services and supports you might need.

Community Care of North Carolina (CCNC): The organization that provides care management for physical health services for beneficiaries in NC Medicaid Direct.

CCNC Care Management: Care management provided to Medicaid beneficiaries with complex physical health care needs. A beneficiary can’t have CCNC care management and Tailored Care Management at the same time.

Copayment (Copay): An amount you pay when you get certain health care services or a prescription.

Covered Services: Health care services that are provided by your LME/MCO.

Department of Social Services (DSS): The local (county) public agency that is responsible for determining eligibility for Medicaid, and other assistance programs.

Durable Medical Equipment (DME): Certain items (like a walker or wheelchair) your doctor can order for you to use at home if you have an illness or an injury.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): A Medicaid benefit that provides comprehensive and preventive health care services for children under age 21 who receive Medicaid. When children need medical care, services are not limited by Trillium’s coverage policies. Medicaid makes sure that members under age 21 can get the medical care they need, when they need it, including health care services to prevent future illnesses and medical conditions.

Emergency Department Care (or Emergency Room Care): Care you receive in a hospital if you are experiencing an emergency medical condition.

Emergency Medical Condition: A situation in which your life could be threatened, or you could be hurt permanently if you do not get care right away.

Emergency Medical Transportation: Ambulance transportation to the nearest hospital or medical facility for an emergency medical condition.

Emergency Services: Services you receive to treat your emergency medical condition.

Enrollment Broker: Unbiased, third-party entity that provides managed care choice counseling, enrollment assistance and coordinates outreach and education to beneficiaries.

Excluded Services: Services that are not covered by NC Medicaid Direct.

Fair Hearing: See “State Fair Hearing.”

Grievance: A complaint about your provider, care or services. Contact your LME/MCO and tell them you have a “grievance” about your services. Grievances are different from appeals.

Habilitation Services and Devices: Health care services that help you keep, learn or improve skills and functions for daily living.

Health Insurance: A type of insurance coverage that pays for your health and medical costs. Your Medicaid coverage is a type of health insurance.

Health Plan (or Plan): The organization that offers physical health, pharmacy, care management and behavioral health services for members. Standard Plans and Tailored Plans are health plans.

Home Health Care: Certain services you receive outside a hospital or a nursing home to help with daily activities of life, like home health aide services, skilled nursing or physical therapy services.

Hospice Services: Special services for patients and their families during the final stages of terminal illness and after death. Hospice services include certain physical, psychological, social and spiritual services that support terminally ill individuals and their families or caregivers.

Hospital Outpatient Care: Services you receive from a hospital or other medical setting that do not require hospitalization.

Hospitalization: Admission to a hospital for treatment that lasts more than 24 hours.

Innovations Waiver: Special federal program designed to meet the needs of people with intellectual/developmental disabilities (I/DD) who prefer to get long-term services and supports in their home or community rather than in an institutional setting.

Institution: Health care facility or setting that may provide physical and/or behavioral supports. Some examples include, but are not limited to, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), skilled nursing facility (SNF) and adult care home (ACH).

Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID): Facility that provides residential, medical and other supports to people with intellectual/developmental disabilities who have behavioral and/or medical conditions.

Legal Guardian or Legally Responsible Person: A person appointed by a court of law to make decisions for an individual who is unable to make decisions on their own behalf (most often a family member or friend unless there is no one available, in which case a public employee is appointed).

Local Management Entity/Managed Care Organization (LME/MCO): The organization that coordinates services for you for a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI).

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Long-Term Services and Supports (LTSS): Care provided in the home, in community-based settings or in facilities to help individuals with certain health conditions or disabilities with day-to-day activities. LTSS includes services like home health and personal care services.

Medicaid: Medicaid is a health coverage program that helps certain families or individuals who have low income or serious medical problems. It is paid with federal, state and county dollars and covers many physical health, behavioral health and I/DD services you might need. You must apply through your local Department of Social Services. When you qualify for Medicaid, you have certain rights and protections.

Medically Necessary: Medical services, treatments or supplies that are needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Member: A person enrolled in and covered by an LME/MCO.

Member and Recipient Services: A phone number you can call to speak to someone and get help when you have a question. The number for Trillium is 1-877-685-2415.

NC Department of Health and Human Services (NCDHHS): The state agency that includes NC Medicaid (Division of Health Benefits), the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, the State Division of Social Services, the Division of Aging and Adult Services and other health and human services agencies. Visit the NCDHHS website.

NC Medicaid (State Medicaid Agency): Agency that manages Medicaid health care programs, pharmacy benefits and behavioral health services on behalf of the North Carolina Department of Health and Human Services.

NC Medicaid Direct: Previously known as Medicaid Fee-For-Service, this category of care includes care management provided by Community Care of North Carolina (CCNC) for physical health services and 6 Local Management Entity/Managed Care Organizations (LME/MCOs) that coordinate services for a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI).

NC Medicaid Ombudsman: An independent organization that provides education and advocacy for Medicaid beneficiaries whether they are in NC Medicaid Managed Care or NC Medicaid Direct. The NC Medicaid Ombudsman program is separate and distinct from the Long-Term Care Ombudsman Program.

Network (or Provider Network): A group of doctors, hospitals, pharmacies and other health professionals who have a contract with your LME/MCO to provide health care services for members.

Network Provider (or Participating Provider): A provider that is in your LME/MCO’s provider network.

Non-Covered Services: Health care services that are not covered by your LME/MCO.

Ongoing Course of Treatment: When a member, in the absence of continued services reflected in a treatment or service plan or as otherwise clinically indicated, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization.

Ongoing Special Condition: A condition that is serious enough to require treatment to avoid possible death or permanent harm. A chronic illness or condition that is life-threatening, degenerative or disabling and requires treatment over an extended period. This definition also includes pregnancy in its second or third trimester, scheduled surgeries, organ transplants, scheduled inpatient care or being terminally ill.

Out-of-Network Provider (or Non-Participating Provider): A provider that is not in your LME/MCO’s provider network.
Physician: A person who is qualified to practice medicine.

Physician Services: Health care services you receive from a physician, nurse practitioner or physician assistant.

Prescription Drug Coverage: Refers to how the LME/MCO helps pay for its members’ prescription drugs and medications. Trillium does not cover your prescription drug coverage. It is covered by NC Medicaid Direct.

Prescription Drugs: A drug that, by law, requires a provider to order it before a beneficiary can receive it. Trillium does not cover your prescription drugs. It is covered by NC Medicaid Direct.

Primary Care Provider (or Primary Care Physician): The doctor or clinic where you get your primary care (immunizations, well-visits, sick visits, visits to help you manage an illness like diabetes). Your PCP should also be available after hours and on weekends to give you medical advice. They also refer you to specialists (cardiologists, behavioral health providers) if you need it. Your PCP should be your first call for care before going to the emergency department.

Prior Authorization (or Preauthorization): Approval you must have from your LME/MCO before you can get or continue getting certain health care services or medicines.

Provider: A health care professional or a facility that delivers health care services, like a doctor, clinician, hospital or pharmacy.

Referral: A documented order from your provider for you to see a specialist or receive certain medical services.

Rehabilitation and Therapy Services and Devices: Health care services and equipment that help you recover from an illness, accident, injury or surgery. These services can include physical or speech therapy.

Routine Care: Care for a mental health condition that needs medical attention within 14 days or a substance use disorder that needs medical attention within 48 hours.

Service Limit: The maximum amount of a specific service that can be received.

Skilled Nursing Care: Health care services that require the skill of a licensed nurse.

Specialist: A provider who is trained and practices in a specific area of medicine.

State Fair Hearing: When you do not agree with your LME/MCO’s resolution (answer to your appeal or grievance), you can ask for the state to review it. The NC Office of Administrative Hearings (OAH) will conduct your State Fair Hearing. The judge will carefully review Trillium’s resolution. The judge does not work for your LME/MCO. You may give the judge more medical updates. You may also ask questions directly to a member of the team who worked on your resolution.

Substance Use Disorder: A medical disorder that includes the misuse of or addiction to alcohol and/or legal or illegal drugs.

Tailored Care Management: Care management for certain members enrolled in LME/MCOs that is coordinated by a care manager who can help people with behavioral health, intellectual/developmental disability (I/DD) and/or traumatic brain injury (TBI) needs. The care manager works with you and a team of medical professionals and approved family members or other caregivers to consider your unique health-related needs and find the services you need in your community.

Telehealth: Use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.

Transition of Care: Process of assisting you to move between Medicaid delivery systems (like from an LME/MCO to a Standard Plan). This usually happens if your needs change or if you move locations in the state. It also means that you can get assistance when you need to change providers for any reason or if you are moving from a hospital back to your home.

Transitions to Community Living (TCL) Program: Program that provides eligible adults living with serious mental health conditions the opportunity to live and work in their communities.

Urgent Care: Care for a health condition that needs prompt medical attention but is not an emergency medical condition. You can get urgent care in a walk-in clinic for a non-life-threatening illness or injury.

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How NC Medicaid Direct Works

NC Medicaid Direct is North Carolina’s health care program for Medicaid beneficiaries who are not enrolled in health plans. NC Medicaid Direct includes:

• Physical health services, like regular checkups, maternity care, hospital care, vision care, pharmacy and nursing home services, provided by any NC Medicaid Direct provider
• Mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) services, provided by a Local Management Entity/Managed Care Organization (LME/MCO)—in your case, by Trillium
• Care management provided by Community Care of North Carolina (CCNC) or Trillium

How NC Medicaid Direct Works

Welcome to Trillium’s NC Medicaid Direct LME/MCO. Trillium provides Medicaid beneficiaries with behavioral health,1 intellectual/developmental disability (I/DD) and traumatic brain injury (TBI) services to meet their needs. Trillium works closely with the rest of the NC Medicaid Direct program, including services provided by Community Care of North Carolina (CCNC), Community Alternatives Program for Children (CAP/C) or Community Alternatives Program for Disabled Adults (CAP/DA).

We are a special organization with providers who have a lot of experience helping people who may need behavioral health, I/DD and/or TBI care to stay healthy. Trillium offers:

• Medicaid-covered behavioral health, I/DD and TBI services
• Intermediate care facilities for individuals with intellectual disabilities (ICF-IID) services (for people who qualify)
• NC Innovations Waiver services (for people who qualify)

We also provide care management and care coordination services to work with you and a care team to make sure your services are well coordinated to meet your needs. As a member of Trillium, you may qualify for a care manager who will work with your health care providers to help make sure you get the care that you need, including additional care beyond medical needs (such as help with housing or food assistance). You may also qualify for care management provided by CCNC.

You Have a Health Care Team. Trillium has a contract to meet the health care needs of people enrolled in NC Medicaid Direct. We partner with a group of health care providers (doctors, therapists, specialists, hospitals and other health care facilities) that make up our provider network.

• You can visit provider directory online or call Member and Recipient Services at 1-877-685-2415 to get a copy of the provider directory.

Help From Member and Recipient Services

Member and Recipient Services has people to help you. You can call Member and Recipient Services at 1-877-685-2415.

• For help with non-emergency issues and questions, call Member and Recipient Services Monday – Saturday, 7 a.m. to 6 p.m. If you are calling after business hours, you can leave a message and your call will be returned on the next business day.
• In case of a medical emergency, call 911.
• You can call Member and Recipient Services to get help when you have a question. You may call us to ask about benefits and services, to get help with referrals or ask about any change that might affect your or your family’s benefits.
• If English is not your first language, we can help. Call us at 1-877-685-2415 and we will find a way to talk with you in a language of your choice.
• If you are experiencing thoughts of hurting yourself or others, or emotional or mental pain or distress, call the Behavioral Health Crisis at 1-888-302-0738 at any time, 24 hours a day, 7 days a week, to speak with someone who will listen and help. This is a free call. We are here to help you with problems like stress, depression or anxiety. We can get you the support you need to feel better. If you are in danger or need immediate medical attention, call 911.

For People with Hearing, Vision or Speech Disabilities

You have the right to receive information about Trillium, your care and services in a format that you can understand and access. Trillium provides free services to help people communicate with us.

For People with Hearing Loss

If you are deaf, hard of hearing or deaf-blind, or you feel you have difficulty hearing and need help communicating, Trillium has resources available to help you. These include but are not limited to:

• Qualified American Sign Language interpreters
• Certified deaf interpreters
• Communication Access Realtime Translation (CART) captioning
• Personal amplification listening devices (ALDs) for your use
• Information in large print
• Staff trained to appropriately handle your relay service calls (videophone, captioned phone or TTY)

For People with Vision Loss

If you have vision loss, Trillium has resources available to help you. These include but are not limited to:

• Information in large print
• Written materials in accessible formats (large print, Braille, audio, accessible electronic format)

For People with Speech Disabilities

If you have a speech disability, Trillium has resources available to you. These include but are not limited to:

• Speech-to-Speech Relay (STS)
• Artificial larynx

For People with Multiple Disabilities

Access needs for people with disabilities vary. Special aids and services are provided free of charge.

Other Special Aids and Services for People with Disabilities

• Help in making or getting to appointments
• Care managers who can help you get the care you need
• Names and addresses of providers who specialize in your condition
• If you use a wheelchair, we can tell you if a provider’s office is wheelchair accessible and help you make or get to appointments
• Easy access to and from services (like ADA accessible, ramps, handrails and other services)

To ask for services, call Member and Recipient Services at 1-877-685-2415.

Trillium complies with federal civil rights laws and does not leave out or treat people with disabilities differently. If you believe that Trillium failed to provide these services, you can file a complaint. To file a complaint or to learn more, call Member and Recipient Services at 1-877-685-2415. Other ways to file a complaint are listed in the Notice of Nondiscrimination.

Your Medicaid ID Card

Your Medicaid ID card has been mailed to you. The mailing address on the card is the same as the address on file at your local DSS office. Your Medicaid ID card has:

• Your primary care provider’s (PCP’s) name and phone number
• Your Medicaid Identification Number
• Information on how to contact us with questions

If anything is wrong on your Medicaid ID card or if you lose your Medicaid ID card, call your local DSS office right away. Always carry your Medicaid ID card with you. You will need to show it each time you go for care.

How to Choose or Change Your PCP

Your PCP is a doctor, nurse practitioner or physician assistant who will:

• Care for your physical health when you are well and sick
• Help you get referrals for specialized services if you need them (like a cardiologist)

As a Medicaid beneficiary, you have an opportunity to choose your own PCP. You can find your PCP’s name and contact information on your Medicaid ID card. If you do not choose a PCP, NC Medicaid may choose one for you based on your past health care.

• You can change your PCP at any time and for any reason. If you have any questions about choosing or changing your PCP, call your local DSS office.

Out-Of-Network Referrals and Out-Of-Network Providers

• If Trillium does not have a specialist in our provider network who can give you the care you need, we will refer you to a specialist outside our LME/MCO or an out-of-network provider. This is called an “out-of-network referral.” A network provider must ask Trillium for prior authorization (approval) before you can get an out-of-network referral.
• If you need to see an out-of-network provider, please contact Member and Recipient Services at 1-877-685-2415.
• Sometimes we may not approve an out-of-network referral because Trillium has a provider who can treat you. If you do not agree with our decision, you can appeal our decision.
• Sometimes, we may not approve an out-of-network referral for a specific treatment because you asked for care that is similar to what you can get from a Trillium provider. If you do not agree with our decision, you can appeal our decision. See Appeals section to know how.
• For more information about getting services from an out-of-network provider, call Member and Recipient Services at 1-877-685-2415.

Behavioral Health Emergencies

If you need help with a mental health or drug use situation, feel stressed or worried or need someone to talk to, you can call the Behavioral Health Crisis at 1-888-302-0738, at any time, 24 hours a day, 7 days a week.

Care Outside North Carolina and the United States

In some cases, Trillium may pay for services you get from a provider located along the North Carolina border or in another state. Trillium can give you more information about which providers and services are covered outside of North Carolina and how you can get them if needed.

• If you need medically necessary emergency care while traveling anywhere within the United States and its territories, Trillium will pay for your care.
• Trillium will not pay for care received outside of the United States and its territories.
• If you have any questions about getting care outside of North Carolina or the United States, call Member and Recipient Services at 1-877-685-2415.

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Your Benefits

Trillium will provide or arrange for most behavioral health, I/DD and TBI services you need. The section below describes the specific services covered by Trillium. Other services, including primary care, women’s health services and family planning services are available through other NC Medicaid providers who are not a part of Trillium.

Ask your PCP or care manager or call Member and Recipient Services at 1-877-685-2415 if you have any questions about your benefits. For a full list of services covered by NC Medicaid Direct, see Appendix A.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): The Medicaid Health Benefit for Members Under Age 21

You can choose where to get EPSDT services. You can get these services from providers in the Trillium network or from another Medicaid provider. You do not need prior authorization from Trillium to get EPSDT services. If you have any questions, talk to your PCP or call Member and Recipient Services at 1-877-685-2415.

Members under age 21 have access to a broad menu of federal health care benefits referred to as “Early and Periodic Screening, Diagnosis and Treatment Services” (EPSDT).

Sometimes children need medical treatment for a behavioral health problem. Trillium might not offer every service covered by the Federal Medicaid program. When a child needs treatment, we will pay for any behavioral health service that the federal government’s Medicaid plan covers. The proposed treatment must be evaluated on its ability to treat, fix or improve your child’s behavioral health problem or condition. This decision is made specifically for your child.

Trillium cannot deny your child’s service just because of a policy limit. Also, we cannot deny a service just because that service is not included in our coverage policies. We must complete a special EPSDT review in these cases.

When Trillium approves services for children, important rules apply:

• There are no copays for Medicaid-covered services to members under age 21.
• There are no limits on how often a service or treatment is given.
• There is no limit on how many services the member can get on the same day.
• Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.

If you have questions about EPSDT services, talk with your child’s PCP or provider. You can also find out more about the Federal EPSDT guarantee in our EPSDT webpage or go to the NC Medicaid EPSDT webpage.

Services Covered by Trillium’s Network

You must get the services below from the providers who are in Trillium’s network. Services must be medically necessary and provided, coordinated or referred by your PCP. Call Member and Recipient Services at 1-877-685-2415 if you have questions or need help.

Behavioral Health Services (Mental Health and Substance Use Disorder Services)

Behavioral health care includes mental health (your emotional, psychological and social well-being) and substance (alcohol and drugs) use disorder treatment and rehabilitation services. All members have access to services to help with mental health issues like depression or anxiety or to help with alcohol or other substance use disorders.

The behavioral health services covered by Trillium include:

• Assertive community treatment (ACT)
• Behavioral health crisis services and withdrawal management services
  • Facility‑based crisis services for children and adolescents
  • Mobile crisis management services
  • Professional treatment services in a facility‑based crisis program
  • Ambulatory detoxification services
  • Medically supervised or alcohol and drug abuse treatment center detoxification crisis stabilization
  • Non-hospital medical detoxification services
• Child and adolescent day treatment services
• Community support team (CST)
• Diagnostic assessment services
• Early and periodic screening, diagnostic and treatment services (EPSDT) for members under age 21
• Multi-systemic therapy services
• Intensive in-home services
• Inpatient behavioral health services
• Outpatient behavioral health emergency department services
• Outpatient behavioral health services provided by direct‑enrolled providers
• Partial hospitalization
• Peer support services
• Psychiatric residential treatment facilities (PRTFs)
• Psychological services in health departments and school-based health centers sponsored by health departments
• Psychosocial rehabilitation
• Residential treatment facility services for children and adolescents
• Substance use disorder services
  • Outpatient opioid treatment services
  • Substance abuse comprehensive outpatient treatment (SACOT)
  • Substance abuse intensive outpatient program (SAIOP)
  • Substance abuse medically monitored residential treatment
  • Substance abuse non-medical community residential treatment

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Intellectual/Developmental Disability (I/DD) Services

The I/DD services covered by Trillium include:

• Intermediate care facilities for individuals with intellectual disabilities (ICF-IID) (for people who qualify)
  • To find out if you or a family member qualify for ICF-IID services, call Member and Recipient Services at 1-877-685-2415 or contact your care manager.
• Innovations Waiver services, for people enrolled in the NC Innovations Waiver (for people who qualify)
  • NC Innovations Waiver services support individuals with intellectual/developmental disabilities to live the life they choose. Individuals get services in their home or community.
  • To find out whether you or a family member qualify for NC Innovations Waiver services, call Member and Recipient Services at 1-877-685-2415 or contact your care manager.
  • NC Innovations Waiver services are limited. If you are determined to be eligible and there are no slots available, you or your family member’s name will be placed on the Registry of Unmet Needs, also known as the “Innovations waitlist.”
• Research‑based intensive behavioral health treatment for autism spectrum disorder.

1915(i) Services

Trillium offers additional services to address needs related to a mental health disorder, substance use disorder, I/DD or TBI. These include:

• Community living and support
• Community transition
• Individual and transitional supports
• Respite
• Supported employment services

In Lieu of Services

Trillium offers services or settings that are medically appropriate, cost-effective substitutions for services covered by NC Medicaid. These are called “in lieu of” services.

Here you can see the full list of the In Lieu of Services

Appointment Guide

It is important to Trillium that you can receive services within a reasonable amount of time. The Appointment Guide (below) lets you know how long you may have to wait to be seen.

If you are not getting the care you need within the time limits above, call Member and Recipient Services at 1-877-685-2415.

If You Get a Bill

If you get a bill for a treatment or service you do not think you owe, do not ignore it. Call Member and Recipient Services at 1-877-685-2415 right away. We can help you understand why you received a bill. If you are not responsible for payment, Trillium will contact the provider and help fix the problem for you.

You have the right to ask for an appeal and a State Fair Hearing if you think you are being asked to pay for something Medicaid or Trillium should cover. See the Appeals section for more information. If you have any questions, call Member and Recipient Services at 1-877-685-2415.

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Extra Support to Manage Your Health

Tailored Care Management

For extra support to get and stay healthy, you may have access to Tailored Care Management at no cost to you. Tailored Care Management provides you with a care manager, who is trained to help people with mental health, substance use, intellectual/developmental disability (I/DD) and/or traumatic brain injury (TBI) needs. Your care manager works with you, your team of medical professionals and your approved family members (or other caregivers) to consider your unique health-related needs and find the services you need in your community.

Your care manager can:

• Do a full assessment of your needs and help develop a set of health goals and a plan to achieve those goals
• Help arrange your appointments and transportation to and from your provider
• Answer questions about what your medicines do and how to take them
• Follow up with your doctors or specialists about your care
• Connect you to helpful resources in your community

Your Tailored Care Management provider may be your PCP (also called an Advanced Medical Home +, or AMH+), a Care Management Agency (CMA) or Trillium’s Care Management department.

You can choose or change your Tailored Care Management provider during the year. If you want to choose or change your Tailored Care Management provider, you can call Member and Recipient Services at 1-877-685-2415 or submit the form from the Members & Recipients Portal.

You can also choose not to have a care manager and not receive the Tailored Care Management benefit. Trillium will help you coordinate services, but the coordination will be more limited than Tailored Care Management. For example, you will not meet with a care manager on a regular schedule. This will not impact which providers you can see or what services are covered for you through Trillium. You can choose not to have Tailored Care Management at any time by calling Member and Recipient Services at 1-877-685-2415 or submit the form from the Members & Recipients Portal.

Care Coordination

Managing your health care alone can be hard, especially if you are dealing with many health problems at the same time. If you need extra support to get and stay healthy, we can help.

Trillium will give you extra help and support:

• If you have a behavioral health, I/DD or TBI need that is not being met or have other special health care needs
• If you move from a hospital inpatient stay back to your home and community and need behavioral health services

This extra support is called care coordination. Trillium will work with you to figure out the care you need and develop a plan with your other health care providers to help meet your needs.

Trillium will also work with your other health care providers to help you move back to your community and connect you to resources and local providers if you are leaving a hospital inpatient stay.

If most of your needs are about physical or medical care, you might be best served by care management support from CCNC. You can talk to your PCP, call Member and Recipient Services at 1-877-685-2415 or call the NC Medicaid Contact Center for more information about getting a CCNC care manager.

Community Inclusion, Diversion, System Of Care

Community Inclusion

Some members may require services and supports that are sometimes provided in long-term facility settings, such as a state psychiatric hospital, adult care home (ACH) or intermediate care facility for individuals with intellectual disabilities (ICF-IID).

Trillium will reach out to members living in these types of facilities to explain the choice they have to leave these facilities to live in community settings. Trillium may also contact family and friends with the member’s permission.

Trillium will work with members living in these types of facilities who choose to leave to create a plan to receive services in their homes and communities. A care manager will work with the member to prepare them for the move and continue to work with them once they move to the community to make sure they have the right services and supports.

Members leaving facility settings who require long-term housing supports may also qualify for the Transitions to Community Living (TCL) program. To learn more about Trillium’s Community Inclusion and Transitions to Community Living programs, contact your care manager or call Member and Recipient Services at 1-877-685-2415.

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Diversion

Trillium will provide diversion interventions to eligible members who are at risk of requiring supports in an institutional setting or adult care home. We will work with you to provide information on, and access to community-based services. For those who choose to remain in the community, we will work with you to create a plan with community resources and/or services to support your needs. We will provide services and support, including permanent supportive housing as needed.

SYSTEM OF CARE

Trillium uses the System of Care model to support children and youth receiving behavioral health services. North Carolina’s System of Care model brings together community-based services, including those provided by Trillium and through schools and other state agencies, such as juvenile justice or child welfare. System of Care Family Partners are available to support families to make sure the services that a child and their family receive are coordinated and address the specific needs and strengths of both child and family. Family Partners can also be part of the care management team.

For more information, contact your child’s care manager or call Member and Recipient Services at 1-877-685-2415. You may also reach out to your local System of Care Community Collaborative SOC@TrilliumNC.org to learn about local resources for Trillium members.

Help with Problems Beyond Medical Care

It can be hard to focus on your health if you have problems with housing or worry about having enough food to feed your family. Trillium can connect you to resources in your community to help you manage issues beyond your medical care.

Call Member and Recipient Services at 1-877-685-2415 if you:

• Worry about your housing or living conditions
• Have trouble getting enough food to feed yourself or your family
• Find it hard to get to appointments, work or school because of transportation issues
• Feel unsafe or are experiencing domestic or community violence. If you are in immediate danger, call 911.

Services to Help You Stop Using Tobacco

Trillium wants to help you and your family get and stay healthy. If you want to quit smoking, we can connect you with the right program for support. Call Member and Recipient Services at 1-877-685-2415.

Service Authorizations and Actions

Trillium will need to approve some treatments and services before you receive them. Trillium may also need to approve some treatments or services for you to continue receiving them. This is called “prior authorization.”

The following treatments and services must be approved before you get them:

Asking for approval of a treatment or service is called a “service authorization request.” To get approval for these treatments or services you need to:

• Work with your provider to submit an electronic Service Authorization Request (SAR) through Provider Direct, the Trillium Business Platform (TBS).
• If your provider is unable to access TBS, providers can fax SAR’s to Trillium Health Resources at 252-215-6875;
• Email SAR’s to UM@TrilliumNC.org or mail SAR’s to Trillium Health Resources, 201 W 1st Street, Greenville, NC 27858.

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What Happens After We Get Your Service Authorization Request?

Trillium uses a group of qualified health care professionals for reviews. Their job is to be sure that the treatment or service you asked for is covered and that it will help with your behavioral health condition. Trillium’s nurses, providers and behavioral health clinicians will review your provider’s request.

Trillium uses policies and guidelines approved by the North Carolina Department of Health and Human Services (NCDHHS) to see if the service is medically necessary.
Sometimes Trillium may deny or limit a request your provider makes. This decision is called an “adverse benefit determination.” When this happens, you can request any records, standards and policies we used to decide on your request.

If you receive a denial and you do not agree with our decision, you may ask for an “appeal.” You can also ask for an appeal if a decision has not been made within 14 days unless an extension is granted. You can call or send in the appeal form you will find with your decision notice. See the Appeals section for more information.

Prior Authorization Requests for Children Under Age 21

Special rules apply to decisions to approve behavioral health services for children under age 21. Trillium cannot say no to a request for children under age 21 just because of our policies, policy limits or rules. We must complete another review to help approve needed care. Trillium will use Federal EPSDT guidelines for this review. These rules help Trillium take a careful look at:

• Your child’s behavioral health problem
• The service or treatment your provider asked for

Trillium must approve services that are not included in our coverage policies when our review team finds that your child needs them to get well or to stay healthy. This means that Trillium’s review team must agree with your provider that the service will:

• Correct or improve a behavioral health problem
• Keep the behavioral health problem from getting worse
• Prevent the development of other behavioral health problems

Services must meet EPSDT criteria including not being experimental or investigational, and services must be safe and effective.

Important Details about Services Coverable by the Federal EPSDT Guarantee

• Your provider must ask Trillium for the service.
• Your provider must ask us to approve services that are not covered by Trillium.
• Your provider must explain clearly why the service is needed to help treat your child’s behavioral health problem. Trillium’s EPSDT reviewer must agree. We will work with your provider to get any information our team needs to make a decision. Trillium will apply EPSDT rules to your child’s behavioral health condition. Your provider must tell us how the service will help improve your child’s behavioral health problem or help keep it from getting worse.

Trillium must approve these services with an “EPSDT review” before your provider gives them.

Prior Authorization and Timeframes

We will review your request for a prior authorization within the following timeframes:

• Standard review: A decision will be made within 14 days after we receive your request.
• Expedited (fast track) review: A decision will be made, and you will hear from us within 3 days of your request.
• In most cases, you will be given at least 10 days’ notice if any change (to reduce, stop or restrict services) is being made to current services. If we approve a service and you have started to receive that service, we will not reduce, stop or restrict the service during the approval period unless we determine the approval was based on information that was known to be wrong.
• If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. These notices are not bills. You will not have to pay for any care you received that was covered by Trillium or by Medicaid, even if we later deny payment to the provider.

Information from Member and Recipient Services

You can call Member and Recipient Services at 1-877-685-2415 to ask about benefits and services, to get help with referrals or ask about any change that might affect you or your family’s benefits. We can answer any questions about the information in this handbook.

• If English is not your first language, we can help. Call us and we will find a way to talk with you in a language of your choice.
• For people with disabilities: If you have difficulty hearing or need assistance communicating, please call us. If you are reading this on behalf of someone who is blind, deafblind or has difficulty seeing, we can help. We can tell you if a provider’s office is equipped with special communications devices. Also, we have services like:
  • TTY machine—our TTY phone number is 711 or 1-800-735-2962
  • Information in large print
  • Help in making or getting to appointments
  • Names and addresses of providers who specialize in your condition

If you use a wheelchair, we can tell you if a provider’s office is wheelchair accessible.

You Can Help with LME/MCO Policies

We value your ideas. You can help us develop policies that best serve our members. We have several member committees or with NCDHHS, like:

• Trillium Consumer and Family Advisory Committee (CFAC) – a group that meets at least quarterly where you can give input on our programs and policies.
• State Consumer and Family Advisory Committee (CFAC) – a statewide group that gives advice to NC Medicaid and lawmakers to help them plan and manage the state’s behavioral health program.
• Trillium Long-Term Services and Supports (LTSS) Advisory Committee – a group that meets at least quarterly where you can give input on our Long-Term Services and Supports programs and policies.
• Medical Care Advisory Committee (MCAC) – a statewide group that gives advice to NC Medicaid about Medicaid and medical care policies and quality of care.

Call Member and Recipient Services at 1-877-685-2415 to learn more about how you can help.

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Appeals

Sometimes Trillium may decide to deny or limit a request your provider makes for you for services offered by our LME/MCO. This decision is called an “adverse benefit determination.” You will receive a letter from Trillium notifying you of any adverse benefit determination.

Medicaid members have a right to appeal adverse benefit determinations to Trillium. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our decisions on an appeal, they can ask the NC Office of Administrative Hearings for a State Fair Hearing.

When you ask for an appeal, Trillium has 30 days to give you an answer. You can ask questions and give any updates (including new behavioral health documents from your providers) that you think will help us approve your request. You may do that in person, in writing or by phone.

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider, a lawyer or Trillium to help you. You can call Trillium at 1-877-685-2415 or visit our Appeals & Grievances page if you need help with your appeal request. We can help you fill out the form and understand the steps of the appeal process.

It’s easy to ask for an appeal by using one of the options below:

• Mail: Fill out, sign and mail the Appeal Request Form in the notice you receive about our decision. You will find the address listed on the form. We must receive your form no later than 60 days after the date on the notice.
• Fax: Fill out, sign and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form. We must receive your form no later than 60 days after the date on the notice.
• Phone: Call 1-877-685-2415 and ask for an appeal. When you appeal, you and any person you have chosen to help you can see the health records and criteria Trillium used to make the decision. If you choose to have someone help you, you must give them permission.
• Website: You can complete a form through our Member and Recipient Portal and Trillium staff will respond.

You can also contact the NC Medicaid Ombudsman to get more information about your options. See more information about the NC Medicaid Ombudsman.

Expedited (Faster) Appeals

You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to attain, maintain or regain your good health. This faster review is called an expedited appeal.

You or your provider can ask for an expedited appeal by calling us at 1-855-250-1539.

You can ask for an expedited appeal by phone, by mail or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal.

Provider Requests for Expedited Appeals

If your provider asks us for an expedited appeal, we will give a decision no later than 72 hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within 72 hours from the day we received the expedited appeal request.

Member Requests for Expedited Appeals

Trillium will review all member requests for expedited appeals. If your request for an expedited appeal is denied, we will call you during our business hours promptly following our decision. We also will tell you and the provider in writing if your request for an expedited appeal is denied. We will tell you the reason for the decision. Trillium will mail you a written notice within 2 calendar days.

If you do not agree with our decision to deny an expedited appeal request, you may file a grievance with us (see Grievance for more information).

When we deny a member’s request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within 30 days of your request. In all cases, we will review appeals as fast as a member’s behavioral health condition requires.

Timelines for Standard Appeals

If we have all the information we need, we will make a decision on your appeal within 30 days from the day we get your appeal request. We will mail you a letter to tell you about our decision.

If we need more information to decide about your appeal, we:

• Will write to you and tell you what information is needed.
• Will explain why the delay is in your best interest.
• May take an additional 14 days to decide your appeal if you request it or there is a need for additional information and the delay is in your best interest.

If you need more time to gather records and updates from your provider, just ask. You or a helper you name may ask us to delay your case until you are ready. Ask for an extension by calling Member and Recipient Services at 1-877-685-2415 or writing to 201 W First St, Greenville, NC 27858.

Decisions on Appeals

When we decide your appeal, we will send you a letter. This letter is called a “Notice of Decision.” If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the date on the Notice of Decision.
If you do not receive a letter from Trillium about our decision, you can ask for a State Fair Hearing.

State Fair Hearings

If you do not agree with Trillium’s decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session. This meeting is held before your State Fair Hearing date.

Free and Voluntary Mediations

When you ask for a State Fair Hearing, you will get a phone call from the Mediation Network of North Carolina. The Mediation Network will call you within 5 business days after you request a State Fair Hearing. During this call you will be offered a mediation meeting. The state offers this free meeting to help resolve your disagreement quickly. These meetings are held by phone.

You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of Trillium’s review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing.

State Fair Hearings

State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). An administrative law judge will review your request along with new information you may have. The judge will make a decision on your service request. You can give any updates and facts you need to at this hearing. A member of Trillium’s review team will attend. You may ask questions about Trillium’s decision. The judge in your State Fair Hearing is not a part of Trillium in any way.

It is easy to ask for a State Fair Hearing. Use one of the options below:

• Mail: Fill out, sign and mail the State Fair Hearing Request Form that comes with your notice. You will find the addresses listed on the form.
• Fax: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax numbers you need listed on the form.
• Phone: Call OAH at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court.

Continuation of Benefits During an Appeal

Sometimes Trillium’s decision reduces or stops a behavioral health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. You can also ask the person helping you with your appeal to make that request for you. Your provider cannot ask for your services to continue during an appeal.

The rules in the section are the same for appeals and State Fair Hearings.

There are special rules about continuing your service during your appeal. Please read this section carefully!

You will get a notice if Trillium is going to reduce or stop a service you are receiving. You have 10 calendar days from the date we send the letter to ask for your services to continue. The notice you get will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal.

If you ask for your services to continue, Trillium will continue your services from the day you ask for them to continue until you the day get your appeal decision. You or your authorized representative may contact Member and Recipient Services at 1-877-685-2415 or contact the Appeals Coordinator on your adverse benefit determination letter to ask for your service to continue until you get a decision on your appeal.

Your appeal might not change the decision Trillium made about your services. When this happens, Medicaid allows Trillium to bill you for services we paid for during your appeal. We must get approval from NC Medicaid before we can bill you for services we paid for during your appeal.

Appeals During Your Transition Out of Trillium

If you leave Trillium, your appeal may be impacted by this transition. Please see below for additional information for how we will process appeals at transition. If you will be transitioning out of our LME/MCO soon and have an appeal with us, contact Member and Recipient Services at 1-877-685-2415 for additional information.

In the event that a member leaves Trillium during an appeal, that member’s appeal information is included in the member’s Behavioral Health and I/DD Tailored Plan Transition Summary in accordance with the Department’s Transition of Care Policy.

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If You Have Problems with Your LME/MCO, You Can File a Grievance

We hope Trillium serves you well. If you are unhappy or have a complaint, you may talk with your PCP. You may also call Member and Recipient Services at 1-877-685-2415 or write to 201 W First St, Greenville, NC 27858 at any time.

A grievance and a complaint are the same thing. Contacting us with a grievance means that you are unhappy with your LME/MCO, provider or your behavioral health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your problem and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.

You can ask a family member, a friend, your provider or a legal representative to help you with your complaint or complaint process. If you need our help because of a hearing or vision impairment, or if you need translation services or help filling out any forms, we can help you. We can also help you fill out the form and understand the steps of the grievance process.

You can contact us by phone or in writing at any time:

• Mail: Write to us with your complaint at 201 W First St, Greenville, NC 27858.
• Phone: Call Member and Recipient Services at 1-877-685-2415, Monday through Saturday, 7 a.m. to 6 p.m. After business hours, you may leave a message and we will contact you during the next business day.
• Website: You can complete a form through our Member and Recipient Portal and Trillium staff will respond.

Resolving Your Grievance

We will let you know in writing that we got your grievance within 5 days of receiving it.

• We will review your complaint and tell you how we resolved it in writing within 30 days of receiving your complaint.
• If your grievance is about your request for an expedited (faster) appeal, we will tell you how we resolved it in writing within 5 days of getting your complaint.
• Trillium may extend the timeframes for resolution of a grievance by up to 14 Calendar Days if:
  • You request the extension or Trillium determines that there is a need for additional information and the delay is in the member’s interest.
• If the timeframe is extended other than at the member’s request, Trillium will:
  • Make reasonable efforts to give you verbal notice of the delay;
  • Within 2 Calendar Days, provide written notice and inform you of the right to file a grievance if you disagrees with that decision; and
  • Resolve the grievance as quickly as possible to ensure there is no impact to your health.
• If you are not happy with the resolution of your grievance, you have the right to file an appeal. Your resolution letter will have instructions for how to do that or you can call 1-877-685-2415 for help.

Transition of Care

Your Care When You Change Health Care Options or Providers

• If you join Trillium from another LME/MCO or delivery system, we will work with your previous health care providers to get your behavioral health information, like your service history, service authorizations and other information about your current care into our records.
• You can finish receiving any services, except for in lieu services that have already been authorized by your previous LME/MCO or delivery system. After that, if necessary, we will help you find a provider in our network to get any additional services if you need them.
• If your provider with your former LME/MCO is not part of Trillium’s network, there are some instances when you can still see the provider that you had before you joined Trillium. You can continue to see your provider if:
  • At the time you join Trillium, you are receiving an ongoing course of treatment or have an ongoing special condition, such as an intellectual/developmental disability (I/DD), mental health disorder, substance use disorder or traumatic brain injury (TBI). In that case, you can ask to keep your provider for up to 180 days.
  • You are pregnant when you join Trillium and you are receiving services from a behavioral health treatment provider. In that case, you can keep your provider until after your delivery.
• If your provider leaves Trillium, we will tell you in writing within 15 days from when we know this will happen.
• If you want to continue receiving care from a provider who is not in our network:
  • You can keep seeing a provider not in our network under certain circumstances for a period of up to 90 days if the provider is not removed from our network due to a quality issue. If we think that a provider could cause harm to members, members will be removed immediately and provided with a written notification of the change. When a provider is leaving our network they may also request that a member receive continued treatment. In these cases, the request is reviewed to check whether it qualifies for continuation of care. Trillium’s Medical Director chooses the services that qualify for continuation of care. If the request is approved, we will contact the member to let them know.
• When a Provider chooses to end their Provider Agreement with Trillium, the Provider will start the process by submitting an email to NetworkServicesSupport@TrilliumNC.org. Trillium shall give written notice to all members who have been receiving services from that provider. Trillium shall give notice within fifteen (15) calendar days after Trillium receives notice that the Provider has ended the Provider Agreement. When the Division of Health Benefits (DHB) or Trillium ends a Provider Agreement with a network provider, Trillium shall give written notice of the termination to all members who have been receiving services from the provider. Trillium shall give notice within fifteen (15) calendar days after Trillium receives notice that DHB has ended the Provider Agreement or after Trillium provides notice to the Provider (after the appeals deadline expires or all appeals have been exhausted).
• If you need further assistance in your transition, please contact Trillium Member and Recipient Services at 1-877-685-2415 to find a provider that can offer services to you.
• Trillium will help you move to a new care manager if necessary. Your current and new care manager will work together to come up with a plan to make sure you continue to receive the care you need.

If you have any questions, call Member and Recipient Services at 1-877-685-2415.

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Member Rights and Responsibilities

As a member of Trillium, you have certain rights and responsibilities. Trillium will respect your rights and make sure that no one working for us, or any of our providers, will prevent you from exercising your rights. Also, we will make sure that you are aware of your responsibilities as a member of Trillium. For a full list of your rights and responsibilities as a member of Trillium, visit our page Members Rights & Privacy, or call Member and Recipient Services at 1-877-685-2415 to get a copy.

Your Rights

As a member of Trillium, you have a right to:

• Be cared for with respect and with consideration for your dignity and privacy without regard for health status, race, color, national origin, age, marital status, disability, creed, religious affiliation, ancestry, sex, sexual orientation, or gender identity.
• Be told what services are available to you.
• Be told where, when and how to get the services you need from Trillium.
• Be told of your options when getting services so you or your guardian can make an informed choice.
• Be told by your providers what behavioral health issues you may have, what can be done for you and what will likely be the result, in a way you understand. This includes other languages in addition to English.
• Get a second opinion about your care.
• Give your approval of any treatment.
• Give your approval of any plan for your care after that plan has been fully explained to you.
• Refuse care and be told what you may risk if you do.
• Get information about your behavioral health care.
• Get a copy of your behavioral health record and talk about it with your provider.
• Ask, if needed, that your behavioral health record be amended or corrected.
• Be sure that your behavioral health record is private and will not be shared with anyone except as required by law, contract or with your approval.
• Use the Trillium complaint process to settle complaints. You can also contact the NC Medicaid Ombudsman any time you feel you were not fairly treated (see NC Medicaid Ombudsman for more information).
• Use the State Fair Hearing system.
• Appoint someone you trust (relative, friend or lawyer) to speak for you if you are unable to speak for yourself about your care and treatment.
• Receive considerate and respectful care in a clean and safe environment, free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

Your Rights if You Are a Minor

Minors have the right to agree to some treatments and services without the consent of a parent or guardian:

• Treatment for sexually transmitted diseases
• Services related to pregnancy
• Services to help with alcohol and/or other substance use disorders
• Services to help with emotional conditions

Your Responsibilities

As a member of Trillium, you agree to:

• Work with your provider to protect and improve your behavioral health.
• Find out how your behavioral health coverage works.
• Listen to your provider’s advice and ask questions.
• Treat health care staff with respect.
• Tell us if you have problems with any health care staff by calling Member and Recipient Services at 1-877-685-2415.
• Keep your appointments. If you must cancel, call as soon as you can.
• Use the emergency department only for emergencies.
• Call Trillium’s Behavioral Health Crisis if you are having a behavioral health crisis.

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Reasons Why You May Have to Leave Trillium

There are some reasons why you may have to leave Trillium, even when you did not ask to leave our organization. The following are reasons why you may have to leave Trillium when you did not ask to leave:

• You move outside of Trillium’s service area and move to another LME/MCO
• You no longer need the services covered by Trillium
• You qualify for a health plan
• You become incarcerated (go to jail), and Trillium suspends your services
• You lose your Medicaid eligibility
  • You may have to leave Trillium if you are notified that you are no longer eligible to receive benefits and services through the Medicaid program. If you are no longer eligible for Medicaid, you will receive a letter letting you know that all benefits and services that you may be receiving under the program will stop and information on how to appeal that decision if you disagree. If this happens, call your local DSS office.

State Fair Hearings for Disenrollment Decisions

You have a right to ask for a State Fair Hearing if you disagree with a disenrollment decision. State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). You will have a chance to give more information and ask questions about the decision for you to make a change before an administrative law judge. The judge in your State Fair Hearing is not a part of Trillium in any way. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session that is held before your Hearing date, see State Fair Hearings to learn more.

Requesting a State Fair Hearing for Disenrollment Decisions

If you disagree with a disenrollment decision, you have 30 days from the date on the letter telling you of the decision to ask for a State Fair Hearing. You can ask for a State Fair Hearing yourself. You may also ask a friend, family member, your provider or a lawyer to help you.

You can use one of the following ways to request a State Fair Hearing:

• Mail: Fill out, sign and mail the State Fair Hearing Request Form that comes with your notice. You will find the address listed on the form.
• Fax: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax number listed on the form.
• Phone: Call OAH at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call. When you ask for a State Fair Hearing, you and any person you have chosen to help you can see the records and criteria used to make the decision. If you choose to have someone help you, you must give them permission. Include their name and contact information on the State Fair Hearing Request Form.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing Final Decision to appeal to the Superior Court.

Advance Directives

There may come a time when you become unable to manage your own health care. If this happens, you may want a family member or other person close to you making decisions on your behalf. By planning in advance, you can arrange now for your wishes to be carried out. An advance directive is a set of written directions you give about the medical and mental health care you want if you ever lose the ability to make decisions for yourself.

Making an advance directive is your choice. If you become unable to make your own decisions, and you have no advance directive, your doctor or behavioral health provider will consult with someone close to you about your care. Discussing your wishes for medical and behavioral health treatment with your family and friends now is strongly encouraged, as this will help to make sure that you get the level of treatment you want if you can no longer tell your doctor or other physical or behavioral health providers what you want.

North Carolina has 3 ways for you to make a formal advance directive. These include living wills, health care power of attorney and advance instructions for mental health treatment.

Living Will

In North Carolina, a “living will” is a legal document that tells others that you want to die a natural death if you:

• Become incurably sick with an irreversible condition that will result in your death within a short period of time.
• Are unconscious and your doctor determines that it is highly unlikely that you will regain consciousness.
• Have advanced dementia or a similar condition which results in a substantial loss of attention span, memory, reasoning and other brain functions and it is highly unlikely the condition will be reversed.

In a living will, you can direct your doctor not to use certain life-prolonging treatments such as a breathing machine (called a “respirator” or “ventilator”), or to stop giving you food and water through a feeding tube.

A living will goes into effect only when your doctor and one other doctor determine that you meet one of the conditions specified in the living will. You are encouraged to discuss your wishes with friends, family and your doctor now, so that they can help make sure that you get the level of care you want at the end of your life.

Health Care Power of Attorney

A “health care power of attorney” is a legal document in which you can name one person (or more) as your health care agent(s) to make medical and behavioral health decisions for you as you become unable to decide for yourself. You can always say what medical or behavioral health treatments you would want and not want. You should choose an adult you trust to be your health care agent. Discuss your wishes with the people you want as your agents before you put them in writing.

Again, it is always helpful to discuss your wishes with your family, friends and your doctor. A health care power of attorney will go into effect when a doctor states in writing that you are not able to make or to communicate your health care choices. If, due to moral or religious beliefs, you do not want a doctor to make this determination, the law provides a process for a non-physician to do it.

Advance Instruction for Mental Health Treatment

An “advance instruction for mental health treatment” is a legal document that tells doctors and mental health providers what mental health treatments you would want and what treatments you would not want if you later became unable to decide for yourself. It can also be used to nominate a person to serve as guardian if guardianship proceedings are started. Your advance instruction for behavioral health treatment can be a separate document or combined with a health care power of attorney or general power of attorney. An advance instruction for behavioral health may be followed by a doctor or behavioral health provider when your doctor or an eligible psychologist determines in writing that you are no longer able to make or communicate behavioral health decisions.

Forms You Can Use to Make an Advance Directive

You can register your advance directive with the NC Secretary of State’s Office so that your wishes will be available to medical professionals. You can find the advance directive forms at Advance Health Care Directives. The forms meet all the rules for a formal advance directive. For more information, you can also call 1-919-807-2167 or write to:

• Advance Health Care Directive Registry
  Department of the Secretary of State
  P.O. Box 29622
  Raleigh, NC 27626-0622

You can change your mind and update these documents at any time. We can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you cannot speak for yourself. Talk to your PCP or call Member and Recipient Services at 1-877-685-2415 if you have any questions about advance directives.

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Concerns about Abuse, Neglect, and Exploitation

Your health and safety are very important. You should be able to lead your life without fear of abuse or neglect by others or someone taking advantage of you (exploitation). Anyone who suspects any allegations of abuse, neglect or exploitation of a child (age 17 or under) or disabled adult must report these concerns to the local DSS office. There are also rules that no one will be punished for making a report when the reporter is concerned about the health and safety of an individual.

Providers are required to report any concerns of abuse, neglect or exploitation of a child or disabled adult receiving mental health, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) services from an unlicensed staff to the local DSS office and the Healthcare Personnel Registry Section of the North Carolina Division of Health Service Regulation for a possible investigation. The provider will also take steps to ensure the health and safety of individuals receiving services.

For additional information on how to report concerns, contact your care manager or Member and Recipient Services at 1-877-685-2415.

Fraud, Waste, and Abuse

If you suspect that someone is committing Medicaid fraud, report it. Examples of Medicaid fraud include:

• An individual does not report all income or other health insurance when applying for Medicaid.
• An individual who does not get Medicaid uses a Medicaid member’s card with or without the member’s permission.
• A doctor or a clinic bills for services that were not provided or were not medically necessary.

You can report suspected fraud and abuse in any of the following ways:

• Call Trillium hotline at 1-855-659-7660.
• Complete the online form through EthicsPoint
• Call the Medicaid Fraud, Waste and Program Abuse Tip at 1-877-362-8471.
• Call the State Auditor’s Waste at 1-800-730-TIPS (1-800-730-8477).
• Call the U.S. Office of Inspector General’s Fraud at 1-800-HHS-TIPS (1-800-447-8477).

Important Phone Numbers

• Member and Recipient Services 1-877-685-2415 available Monday-Saturday 7 a.m-6 p.m.
• Behavioral Health Crisis 1-888-302-0738 available 24/7/365
• Provider Services 1-855-250-1539 available Monday-Saturday 7 a.m.-6 p.m.
• NC Medicaid Enrollment Broker 1-833-870-5500
• NC Medicaid Ombudsman 1-877-201-3750
• NC Medicaid Contact Center 1-888-245-0179
• The NC Mediation Network 919-663-5650
• Free Legal Services Legal Aid of North Carolina 1-866-219-LANC (5262)
• File a grievance/complaint Advance Health Care Directive Registry phone number 919-814-5400
• NC Medicaid Fraud, Waste and Abuse Tip 1-877-362-8471
• State Auditor Waste 1-800-730-TIPS (1-800-730-8477)
• U.S. Office of Inspector General Fraud 1-800-HHS-TIPS (1-800-447-8477)

Keep Us Informed

Call Member and Recipient Services at 1-877-685-2415 whenever these changes happen in your life:

• You have a change in Medicaid eligibility
• You give birth
• There is a change in household family members
• There is a change in Medicaid coverage for you or your children
• If you no longer get Medicaid, check with your local DSS office.

NC Medicaid Ombudsman

The NC Medicaid Ombudsman is a resource you can contact if you need help with your health care needs. The NC Medicaid Ombudsman is an independently operated, nonprofit organization whose only job is to ensure that individuals and families under NC Medicaid get access to the care that they need.
The NC Medicaid Ombudsman can:

• Answer your questions about the benefits
• Help you understand your rights and responsibilities
• Help you understand a notice you have received
• Help you get answers to problems you have already tried to solve with your provider
• Refer you to other agencies that may be able to assist you with your health care needs
• Be an advocate for you if you are dealing with an issue or a complaint affecting access to health care
• Provide information to assist you with your appeal, grievance, mediation or fair hearing
• Connect you to legal help if you need it to help resolve a problem with your health care

You can contact the NC Medicaid Ombudsman at 1-877-201-3750 or visit NC Medicaid Ombudsman.

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Appendix A: Services Covered by NC Medicaid Direct

You may receive the services below from any NC Medicaid provider. Services must be medically necessary. In most cases, services must be provided, coordinated or referred by your PCP. All Trillium members can get the services below, but only some are directly available through Trillium.

If you have any questions about NC Medicaid Direct services, talk to your PCP or care manager or call Member and Recipient Services at 1-877-685-2415.

Regular Health Care

• Office visits with your PCP, including regular checkups, routine labs and tests
• Referrals to specialists
• Vision/hearing exams
• Well-baby care
• Well-child care
• Immunizations (shots) for children and adults
• Help with quitting smoking or other tobacco use

Early And Periodic Screening, Diagnosis, and Treatment (EPSDT) Services For Members Under Age 21

Members under age 21 have access to a broad menu of federal health care benefits referred to as “Early and Periodic Screening, Diagnosis and Treatment Services” (EPSDT). The “EPSDT guarantee” covers wellness visits and treatment services.

Early and Periodic Screening and Diagnosis

These “screening” visits are wellness care. They are free for members under age of 21. These visits include a complete exam, free vaccines, vision and hearing tests. Your provider will also watch your child’s physical and emotional growth and well-being at every visit and “diagnose” any conditions that may exist. At these visits, you will get referrals to any treatment services your child needs to get well and to stay healthy.

The “T” in EPSDT: Treatment for Members Under Age 21

Sometimes children need medical treatment for a health problems. NC Medicaid Direct might not offer every service covered by the Federal Medicaid program. When a child needs treatment, NC Medicaid Direct will pay for any service that the federal government’s Medicaid plan covers. The proposed treatment must be evaluated on its ability to treat, fix or improve your child’s health problem or condition.

This decision is made specifically for your child. NC Medicaid Direct cannot deny your child’s service just because of a policy limit. Also, NC Medicaid Direct cannot deny a service just because that service is not included in our coverage policies. We must complete a special “EPSDT review” in these cases.
When NC Medicaid Direct approves services for children, important rules apply:

• There are no copays for Medicaid-covered services to members under 21 years old.
• There are no limits on how often a service or treatment is given.
• There is no limit on how many services the member can get on the same day.
• Services may be delivered in the best setting for the child’s health. This might include a school or a community setting.

Maternity Care

• Prenatal, delivery and postpartum care
• Childbirth education classes
• Professional and hospital services related to maternal care and delivery
• One medically necessary postpartum home visit for newborn care and assessment following discharge, but no later than 60 days after delivery
• Care management services for high-risk pregnancies during pregnancy and for 2 months after delivery

Hospital Care

• Inpatient care
• Outpatient care
• Labs, X-rays and other tests

Behavioral Health Services (Mental Health And Substance Use Disorder Services)

Behavioral health care includes mental health (your emotional, psychological and social well-being) and substance (alcohol and drugs) use disorder treatment and rehabilitation services. All members have access to services to help with mental health issues like depression or anxiety, or to help with alcohol or other substance use disorders. Trillium offers these services.

The behavioral health services include:

• Assertive community treatment (ACT)
• Behavioral health crisis services and withdrawal management services
  • Facility‑based crisis services for children and adolescents
  • Mobile crisis management services
  • Professional treatment services in a facility‑based crisis program
  • Ambulatory detoxification services
  • Medically supervised or alcohol and drug abuse treatment center detoxification crisis stabilization
  • Non-hospital medical detoxification services
• Child and adolescent day treatment services
• Community support team (CST)
• Diagnostic assessment services
• Early and periodic screening, diagnostic and treatment services (EPSDT) for members under age 21
• Multi-systemic therapy services
• Intensive in-home services
• Inpatient behavioral health services
• Outpatient behavioral health emergency room services
• Outpatient behavioral health services provided by direct‑enrolled providers
• Partial hospitalization
• Peer support services
• Psychiatric residential treatment facilities (PRTFs)
• Psychological services in health departments and school-based health centers sponsored by health departments
• Psychosocial rehabilitation
• Residential treatment facility services for children and adolescents

The substance use disorder (SUD) services include:

• Outpatient opioid treatment services
• Substance abuse comprehensive outpatient treatment (SACOT)
• Substance abuse intensive outpatient program (SAIOP)
• Substance abuse medically monitored residential treatment
• Substance abuse non-medical community residential treatment

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Intellectual/Developmental Disability (I/DD) Services

The I/DD services include:

• Intermediate care facilities for individuals with intellectual disabilities (ICF-IID) (for people who qualify)
• Innovations Waiver services, for people enrolled in the NC Innovations Waiver (for people who qualify)
• Research based intensive behavioral health treatment for autism spectrum disorder

Home Health Services

• Time-limited skilled nursing services
• Specialized therapies, including physical therapy, speech-language pathology and occupational therapy
• Home health aide services for help with activities such as bathing, dressing, preparing meals and housekeeping
• Medical equipment and supplies

Personal Care Services

• Help with common activities of daily living, including eating, dressing and bathing for individuals with disabilities and ongoing health conditions

Hospice Care

• Helps patients and their families with the special needs that come during the final stages of illness and after death
• Provides medical, supportive and palliative care to terminally ill individuals and their families or caregivers
• You can get these services in your home, in a hospital or in a nursing home

HIV and STI Screening

• You can get human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing and treatment and counseling service any time from your PCP. When you get this service as part of a family planning visit, you can go to any doctor or clinic that takes Medicaid and offers family planning services. You do not need a referral when you get this service as part of a family planning visit.
• You can choose to go either to your PCP or to the local health department for diagnosis and/or treatment. You do not need a referral to go to the local health department.

Vision Care

• Services provided by ophthalmologists and optometrists, including routine eye exams, medically necessary contact lenses and dispensing fees for eyeglasses. Opticians may also fit and dispense medically necessary contact lenses and eyeglasses.
• Coverage frequency for routine eye exams and eyeglasses varies for children and adults.
  • Children may receive services once every year (365 days).
  • Adults may receive services once every 2 years (730 days).
  • Early eye exams and eyeglasses can be approved, based on medical necessity.
• Specialist referrals for eye diseases or defects

Pharmacy

• Prescription drugs
• Some medicines sold without a prescription (also called “over-the-counter”), like allergy medicines
• Insulin and other diabetic supplies like syringes, test strips, lancets and pen needles
• Smoking cessation agents, including over-the-counter products
• Emergency contraception
• Medical and surgical supplies, available through DME pharmacies and suppliers
• NC Medicaid Direct also provides a Pharmacy Lock-In Program, which helps identify members that are at risk for possible overuse or improper use of pain medications (opioid analgesics) and nerve medications (benzodiazepines and certain anxiolytics).
• The Pharmacy Lock-In Program also helps identify members who get the medications from more than one prescriber (doctor, nurse practitioner or physician assistant). If you qualify for this program, NC Medicaid Direct will notify you by mail and only pay for your pain medications and nerve medications when:
  • Your medications are ordered by one prescriber. You will be given a chance to pick a prescriber enrolled in NC Medicaid Direct.
  • You have these prescriptions filled from one pharmacy. You will be given a chance to pick a pharmacy enrolled in NC Medicaid Direct.
  • If you qualify for the Pharmacy Lock-In Program, you will be in the program for a 2-year period. If you do not agree with our decision that you should be in the program, you can appeal our decision using the appeals form, which is included with your notification letter.

Emergency Care

• Procedures, treatments or services needed to evaluate or stabilize a health emergency
• After you have received emergency care, you may need other care to make sure you remain in stable condition.
• Depending on the need, you may be treated in the Emergency Department, in an inpatient hospital room or in another setting.

Specialty Care

• Respiratory care services
• Podiatry services
• Chiropractic services
• Cardiac care services
• Surgical services

Nursing Home Services

• Includes short-term or rehabilitation stays and long-term care
• Covered nursing home services include medical supervision, 24-hour nursing care, assistance with daily living, physical therapy, occupational therapy and speech-language pathology

Transportation Services

• Emergency: If you need emergency transportation (an ambulance), call 911.
• Non-Emergency: Transportation to help you get to and from your appointments for Medicaid-covered services. This service is free to you. If you need an attendant to go with you to your doctor’s appointment, or if your child (18 years old or younger) is a member of the LME/MCO, transportation is also covered for the attendant, parent or guardian. Non-emergency transportation includes personal vehicles, taxis, vans, mini-buses, mountain area transports and public transportation.
• How to Get Non-Emergency Transportation. Call your local DSS office to schedule transportation services.

Long-Term Services And Supports (LTSS)

If you have a certain health condition or disability, you may need help with day-to-day activities like eating, bathing or doing light household chores, including services like home health and personal care services.

Family Planning

You can go to any doctor or clinic that takes Medicaid and offers family planning services. You can also visit one of our family planning providers. You do not need a referral from your PCP for family planning services. Family planning services include:

• Birth control
• Birth control devices such as IUDs, implantable contraceptive devices and others that are available with a prescription
• Emergency contraception
• Sterilization services
• HIV and sexually transmitted infection (STI) testing, treatment and counseling
• Screenings for cancer and other related conditions

Other Covered Services

• Durable medical equipment/prosthetics/orthotics
• Hearing aid products and services
• Telehealth
• Home infusion therapy
• Rural Health Clinic (RHC) services
• Federally Qualified Health Center (FQHC) services
• Local Health Department services
• Free clinic services
• Dental services
• Services provided or billed by Local Education Agencies that are included in your child’s Individualized Education Program, Individual Family Service Plan, a section 504 Accommodation Plan, an Individual Health Plan or a Behavior Intervention Plan
• Services provided and billed by Children’s Developmental Agencies (CDSAs) or providers contracted with CDSAs that are included in your child’s Individualized Family Service Plan

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Appendix B: Services Not Covered

Below are some examples of services that are not available from Trillium or NC Medicaid Direct. If you get any of these services, you may have to pay the bill:

• Cosmetic surgery if not medically necessary
• Personal comfort items such as cosmetics, novelties, tobacco or beauty aids
• Routine foot care, except for beneficiaries with diabetes or a vascular disease
• Routine newborn circumcision (medically necessary circumcision is covered for all ages)
• Experimental drugs, procedures or diagnostic tests
• Infertility treatments
• Sterilization reversal
• Sterilization for patients under age 21
• Medical photography
• Biofeedback
• Hypnosis
• Blood tests to determine paternity (contact your local child support enforcement agency)
• Chiropractic treatment unrelated to the treatment of an incomplete or partial dislocation of a joint in the spine
• Erectile dysfunction drugs
• Weight loss or weight gain drugs
• Liposuction
• “Tummy tuck”
• Ultrasound to determine sex of child
• Hearing aid products and services for beneficiaries age 21 and older
• Services from a provider who is not part of Trillium, unless it is a provider you are allowed to see as described elsewhere in this handbook or Trillium, or your PCP sent you to that provider
• Services for which you need a referral in advance, and you did not get it
• Services for which you need prior authorization (approval) in advance, and you did not get it
• Medical services provided out of the United States
• Tattoo removal

This list does not include all services that are not covered. To determine if a service is not covered, call Member and Recipient Services at 1-877-685-2415.
A provider who agrees to accept Medicaid generally cannot bill you. You may have to pay for any service that your PCP or Trillium does not approve. Or, if before you get a service, you agree to be a "private pay” or “self-pay” patient, you will have to pay for the service. This includes:

• Services not covered (including those listed above)
• Unauthorized services
• Services provided by providers who are not part of Trillium

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Appendix C: Copays

You may be required to pay a copay. A “copay” is a fee you pay when you get certain health care services from a provider of pick up a prescription from a pharmacy.

Copays if You Have Medicaid*

*There are NO Medicaid copays for the following people or services

• Members under the age of 21
• Members who are pregnant
• Members receiving hospice care
• Federally recognized tribal members
• North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
• Children in foster care
• People living in an institution who are receiving coverage for cost of care
• Behavioral health services

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