Your Partners Tailored Plan gives you the care and support you need to stay healthy.
You get all the regular Medicaid health benefits – like doctor visits, hospital care, maternity care, prescriptions, vision care and behavioral health services – plus extra support for people living with mental health, substance use, intellectual or developmental disabilities (I/DD) and traumatic brain injury (TBI).
You may also qualify for added help such as care management, long-term services and supports, non-emergency transportation and extra benefits through GreatDAY rewards and services.
Please see information below to learn about Partners’ plan benefits, pharmacy services and value-added benefits.
Need help understanding Benefits and Services?
Call us at 1-888-235-4673
(TTY: NC Relay 711; [English] 1-800-735-2962; [Spanish] 1-888-825-6570)
Services Overview
All services must be medically necessary. Your Primary Care Provider (PCP), who may be a doctor, will work with you to make sure you get the care and services you need. These services must be given by your Partners Network PCP or by another provider your PCP refers you to.
Some services may have copayments (copays) or require a referral and/or prior approval before starting services. There is a difference in a referral and a prior authorization.
Copayments (Copay)
An amount you pay when you get certain health care services or a prescription. These services may have coverage limits, need a doctor’s order and require a referral or prior authorization before starting the service.
Referrals
A documented order from your provider for you to see a specialist or receive certain medical services.
Prior Authorizations
Approval you must receive from Partners before you can get or continue getting certain health care services or medicines. Some services require preauthorization before your doctor can make a referral to a specialist. Your doctor can tell you what those services are.
Copayments
The following services may require copays unless you are part of an exempt population:
| Services | Copay |
| Doctor Visits | $4 per visit |
| Non-emergency and emergency department visits | $4 per visit |
| Optometrist and optical visits | $4 per visit |
| Outpatient visits | $4 per visit |
| Podiatrist visits | $4 per visit |
| Chiropractic visits | $4 per visit |
| Generic and brand prescriptions | $4 per prescription |
A provider cannot refuse to provide services if you cannot pay your copay at the time of service. If you have any questions about Medicaid copays, please call Member and Recipient Services at 1-888-235-4673.
There are no copays for the following members:
- Members under age 21
- Members receiving hospice care
- Federally recognized tribal members or members receiving services through Indian Health Services (IHS)
- Members enrolled in Breast and Cervical Cancer Medicaid through the North Carolina Breast and Cervical Cancer Control Program (NC BCCCP)
- Members residing in institutions who receive coverage for cost of care
- Members in foster care
- Members enrolled in NC Innovations and NC TBI waiver programs
- Members enrolled in Community Alternatives Programs for Children (CAP/C) and Disabled Adults (CAP/DA)
- Members enrolled in Long-Term Support Services (LTSS)
There are no copays for the following services:
- Services related to pregnancy, childbirth and postpartum care – to include prenatal care
- Behavioral health, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI) services
- Family Planning Services
- Services covered by Medicare and Medicaid
- Adult vaccines and vaccine administration
- HIV antiretroviral (ARV) medications
- Drugs used to reverse opioid overdose, drugs used to treat opioid use disorder and nicotine replacement drugs per the State Protocol
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 1-888-235-4673 (TTY: NC Relay 711; [English] 1-800-735-2962; [Spanish] 1-888-825-6570) right away. We can help you understand why you received a bill. If you are not responsible for payment, Partners Tailored Plan will contact the provider and help fix the problem for you.
Referrals
If you need specialized care that your PCP cannot give, your PCP will refer you to a specialist who can. A specialist is a doctor who is trained and practices in a specific area of medicine (like a cardiologist or a surgeon).
- If your PCP refers you to a specialist, Partners will pay for your care if it is medically necessary. Most specialists are Partners Tailored Plan providers. Talk with your PCP to be sure you know how referrals work.
- If you have trouble getting a referral you think you need, contact Member and Recipient Services at 1-888-235-4673.
Out-of-Network Referrals
If Partners Tailored Plan 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 health plan. This is called an out-of-network referral. Your PCP or another network provider must ask Partners Tailored Plan for approval (called a prior authorization) before you can get an out-of-network referral.
Contact your care manager or Member and Recipient Services to begin the process. They will work with Provider Network staff who will send the provider a one-page application within one business day. As soon as Partners receives the application, providers are notified that they can start delivering services.
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 Partners Tailored Plan provider. If you do not agree with our decision, you can appeal our decision.
For more information about getting a referral for services from an out-of-network provider, call Member and Recipient Services at 1-888-235-4673; Relay NC 711 or TTY (English) 1-800-735-2962; (Spanish) 1-888-825-6570.
For information on filing an appeal, click here.
Services that do not need a referral
Primary Care
You do not need a referral to primary care services. Call your PCP to make an appointment (Your assigned PCP’s name and contact information is listed on your Medicaid ID card).
Behavioral Health
You do not need a referral for your first behavioral health or substance use disorder assessment completed in a 12-month period. Ask your PCP or call Member and Recipient Services at 1-888-235-4673 for a list of mental health providers and substance use disorder providers. You can also find a list of our behavioral health providers online using our provider search tool.
Mobile Crisis
Mobile crisis services are teams who can meet you in a safe location, including your home, school or office to help you if you are experiencing a behavioral health crisis. Call the Behavioral Health Crisis Line at 1-833-353-2093, at any time, 24 hours a day, seven days a week if you are experiencing a behavioral health crisis.
Prior Authorizations
If you are requesting a service or treatment that requires prior authorization (preauthorization), Partners must meet specific timelines in reviewing those requests.
- 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 three days of your request.
- If your request is for a pharmacy review, a decision will be made within 24 hours.
- 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 Partners Tailored Plan or by Medicaid, even if we later deny payment to the provider.
Services that Require Prior Authorizations
- 1915(i) Community Living and Supports Live in Caregiver Individual and Group
- 1915(i) Community Transition
- 1915(i) Individual and Transitional Support
- 1915(i) Respite for Children and Adults, Individual and Group Settings
- 1915(i) Supported Employment, Individual and Group Settings
- Adolescent Substance Abuse Intensive Outpatient
- Adult Developmental Vocational Program
- Alternative Family Living Residential Supports Levels 1-4
- Ambulatory Withdrawal Management without Extended On Site Monitoring
- Ambulatory Withdrawal Management with Extended On-Site Monitoring
- Assertive Community Treatment Team
- Assertive Community Treatment Team Step Down
- Assistive Learning Device
- Behavioral Consultation
- Child First
- Child/Adolescent Day Treatment
- Communication Device-Purchase
- Community Living and Supports Live in Caregiver Individual and Group
- Community Navigator
- Community Navigator Annual Information Session on Self Direction
- Community Navigator Class & Conference
- Community Navigator Employer of Record Training Monthly
- Community Navigator Start Up Training
- Community Networking, Individual and Group
- Community Support Team
- Community Transition Supports
- Companion Living Long-Term Community Supports Level 3
- Critical Time Intervention
- Day Supports Developmental Day
- Day Supports Individual and Group
- Day Supports, Intellectual Developmental Delay and Traumatic Brain Injury
- Facility Based Crisis for Adolescents and Adults
- Family Centered Treatment
- Family Living Low, Moderate, Therapeutic Leave
- Financial Services Employer Supplies
- Group Living Long-Term Community Supports Level 5
- Group Living Low and Moderate, High, Therapeutic Leave
- Guardianship
- Home Living Long-Term Community Supports Levels 1-2
- Inpatient Hospitalization for Mental Health
- Intensive Alternative Family Treatment
- Intensive Eating Disorder Treatment for Adolescents and Adults
- Intensive In-Home
- Intercept
- Intermediate Care Facilities for Individuals with Intellectual Disabilities
- Long-Term Vocational Support for Intellectual Developmental Delay
- Meal Delivery
- Medically Monitored Inpatient Withdrawal Management
- Medically Monitored Intensive Inpatient Services for Adolescents and Adults
- Mental Health Partial Hospitalization
- Mobile Outreach, Response, Engagement and Stabilization
- Multi-Systemic Therapy
- Natural Supports Education, Individual and Conference
- Out of Home Crisis
- Partial Hospitalization
- Peer Support
- Psychiatric Residential Treatment Facility
- Research-Based Behavioral Health Treatment
- Residential Supports Levels 1-4
- Residential Level I Family Type
- Residential Level III Group Home
- Respite Nursing by a Registered Nurse
- Respite Nursing by Licensed Practical Nurse
- Respite: Individual, Group and Facility Settings
- Self Determination Support
- Supervised Living Long-Term Community Supports Level 4
- Youth Assertive Community Treatment Team
- Abdominal (Hernia repair, intestinal or stomach repairs)
- Bariatric and weight loss (gastric bypass and gastric sleeve)
- Cancer-related (biopsies, tumor removal, CAR-T, stem cell)
- Eye, ENT and sleep related (cataract, nasal or sinus, cochlear implant, cataract repair)
- Gender affirming (related reconstructive surgeries)
- Joint repair or replacement (hip, knee, shoulder, elbow, wrist, hand or ankle)
- Reconstructive and cosmetic (removal of excess skin, facial bones)
- Spine surgeries (fusion, decompression, disc procedures, vertebral repair)
- Transplant (organ, stem cell)
- Urology (prostate or bladder procedures)
- Vascular and vein surgeries (vein repair or closure)
- Gene testing and sequencing
- Microbiology and infectious disease testing
- Mitochondrial DNA testing
- Tumor and matched normal genetic sequencing
- Autoimmune and inflammatory disease panels
- Cardiac risk and heart disease panels
- Neurologic or dementia biomarker tests
- Tumor biomarker testing
- Dermatology services (skin lesion removal, cosmetic skin procedures, advanced wound treatments)
- Endocrinology services (diabetes-related procedures, hormone-related testing or treatments)
- Pain management services (spinal injections, nerve blocks, nerve stimulation procedures)
- Reproductive & women’s health services (fertility-related procedures, prenatal testing, gynecologic procedures)
- Sleep medicine services (sleep studies, sleep apnea testing, in-office airway procedures)
- Urology services (prostate and bladder treatments, urinary tract procedures)
- Weight management services (bariatric surgery consultation, gastric procedures, weight-loss interventions)
- Hearing and communication devices (hearing aids, speech-generating or assistive listening devices)
- Home medical equipment (hospital beds, specialty mattresses)
- Mobility devices (wheelchairs and accessories for positioning)
- Nerve stimulators (spinal cord, vague nerve)
- Nutritional support equipment (tube feeding devices and related equipment)
- Orthotic devices (braces for the arms, legs, neck, spine, hips, knees, ankles or wrists)
- Positioning and transfer equipment (patient lifts, positioning supports)
- Prosthetic devices (artificial arms or legs, prosthetic sockets, joints, liners or covers)
- Respiratory and breathing support devices (home oxygen, ventilator, sleep assistive devices)
- Specialty bathroom equipment (rolling shower and toilet chairs)
- Wearable, implantable or non-implantable medical devices (glucose monitoring systems, insulin pumps)
- Home health aide
- Nursing
- Physical, Occupational, Speech therapy
- Air ambulance or helicopter transport
- Non‑emergency medical transportation
- Specialty or long‑distance medical transport
- Infusion‑based therapies
- Injectable medications administered in clinical settings
- Advanced wound dressings for chronic or non-healing wounds
- Amniotic membrane products
- Biologic skin substitutes and dermal skin coverings
- Burn and surgical wound grafts
Services that Do Not Require Prior Authorizations
- Anesthesia
- Basic home equipment (walkers, canes, bedside commodes and shower chairs)
- Compression garments
- Emergency Department and Urgent Care
- Preventative and Primary Care
- Routine Diagnostic Imaging and Laboratory (x-ray, EEG)
- Routine OB and newborn services
Partners Tailored Plan Benefits and Services
*Some Medicaid members may not have all the benefits listed.
Care for mental health and substance use problems like depression, anxiety and drug or alcohol use.
Includes:
- Assertive Community Treatment (ACT)
- Crisis and withdrawal management:
- Facility-based crisis services for children and adolescents
- Mobile crisis management
- Professional treatment in a facility-based crisis program
- Ambulatory detoxification
- Medically supervised or alcohol and drug use treatment center detoxification crisis stabilization
- Non-hospital medical detoxification
- Child and adolescent day treatment
- Community Support Team (CST)
- Diagnostic assessments
- Early and periodic screening, diagnostic and treatment (EPSDT) for members under age 21
- Multi-systemic therapy
- Intensive in-home services
- Inpatient behavioral health care
- Outpatient behavioral health emergency department services
- Outpatient behavioral health services provided by direct-enrolled providers
- Partial hospitalization
- Peer support
- Psychiatric residential treatment facilities (PRTFs)
- Psychological services in health departments and school-based health centers sponsored by health departments
- Psychosocial rehabilitation
- Research-based intensive behavioral health treatment
- Residential treatment facility services for children and adolescents
- Substance Use Disorder Services
- Outpatient opioid treatment
- 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
- Always covered for serious or life-threatening conditions, including:
- Chest pain
- Trouble breathing
- Heavy bleeding
- Drug overdose
- Broken bones and more
- For less serious issues, use urgent care or your PCP.
- No referral needed.
- Includes:
- Birth control and devices (IUDs, implants, etc.)
- Emergency contraception
- Sterilization (21+)
- HIV and STI testing and treatment
- Screenings for cancer and related conditions
- Must be medically necessary and approved.
- Includes:
- Short-term skilled nursing
- Therapies (physical, speech, occupational)
- Home health aides (help with daily living)
- Medical equipment and supplies
- Care and support at the end of life, when medically necessary.
- Hospice helps patients and their families with the special needs that come during the final stages of illness and after death.
- Hospice 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.
- Inpatient care
- Outpatient care
- Labs, X-rays and other tests
- Extra supports that replace standard Medicaid services when appropriate.
- Must be approved and medically necessary.
- Includes:
- Behavioral Health Urgent Care (BHUC)
- Enhanced Crisis Response (ECR) Child/Adolescent
- Family Centered Treatment
- High Fidelity Wraparound
- In Home In Lieu Of Service: In Home Therapy Services (IHTS)
- Long-Term Community Supports
- Rapid Response Beds
- Residential Services – Complex Needs
- Youth Focused Assertive Community Treatment Team (Youth ACTT)
The Tailored Plan covers special services for individuals with intellectual/developmental disabilities:
- Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
- Innovations waiver services, for people enrolled in the NC Innovations Waiver
- NC Innovations Waiver services support individuals with intellectual/ developmental disabilities to live the life they choose. Individuals get services in their home or community.
- Applying for NC Innovations Waiver services. To find out whether you or a family member are eligible to get NC Innovations Waiver services, call Member and Recipient Services at 1-888-235-4673 or contact your care manager.
- Eligibility for NC Innovations Waiver services. A member who has an intellectual disability or a condition that results in the same needs as someone who has an intellectual disability may be eligible for NC Innovations Waiver services. You may be eligible to participate in the NC Innovations Waiver if you meet several requirements related to the level of your needs and your living arrangements.
- NC Innovations Waiver services are limited. If you are determined to be potentially 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.” Your Partners Tailored Plan can help you or your family member get other supportive services, including 1915(i) or State-funded services, while you or your family member are on the waiting list.
- NC Innovations Waiver participants can see the Member Handbook NC Innovations Waiver supplement for more information on the NC Innovations Waiver, call Member and Recipient Services at 1-888-235-4673 or contact your care manager.
1915(i) Services
Partners Health Management 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 Support
- Respite
- Supported Employment Services
- For members with serious health needs or disabilities.
- Helps with daily activities like eating, bathing or chores.
- Care may be at home, in the community or in a nursing home.
- Includes:
- Prenatal visits and care
- Childbirth education classes
- Hospital and professional delivery services
- One postpartum home visit (within 60 days of delivery)
- Care management for high-risk pregnancies
- StrongSTART services
- Free 24/7 phone line for health questions.
- Call 1-888-369-2452 anytime.
- Get advice on when to see your doctor, ask about symptoms or get help with medicines.
- Must be ordered by a doctor and approved.
- Covers:
- Short-term rehab stays (up to 90 days)*
*After the 90th day, your nursing services will be covered by NC Medicaid Direct and not Partners Tailored Plan. - Long-term care for daily living needs (medical supervision, 24/7 nursing, therapies)
- Short-term rehab stays (up to 90 days)*
- Durable medical equipment/prosthetics/orthotics
- Hearing aid products and services
- Extra support to manage your health
- Home infusion therapy
- Rural Health Clinic (RHC) services
- Federally Qualified Health Center (FQHC) services
- Local health department services
- Free clinic services
Covered:
- Covers prescriptions and many over-the-counter medicines (with a provider’s prescription).
- 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
Lock-In Program:
- We also provide a Lock-In Program that 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).
Pharmacy Help Line (CVS Caremark):
- 1-866-453-7196, open 24/7.
- Office visits, check-ups, labs and tests with your PCP.
- Specialist referrals as needed.
- Vision and hearing exams, immunizations, well-baby and well-child care.
- EPSDT for members under 21.
- Help with quitting tobacco.
- Includes care from specialists like:
- Cardiac care
- Chiropractic services
- Podiatry
- Respiratory care
- Surgical care
A care manager helps you:
-
- Assess your health needs and set goals
- Arrange appointments and transportation
- Answer medicine questions
- Follow up with providers
- Connect you to community resources
- You can choose or change your Tailored Care Management provider (PCP, Care Management Agency or Partners Care Management)
- You can opt out of Tailored Care Management at any time
- Talk to a licensed healthcare provider within minutes.
- Get care for cold, flu, allergies and more without going to urgent care.
- Available 24/7 at 1-800-835-2362 or online at the Teladoc website.
- Free rides to medical appointments for Medicaid-covered care.
- Provided through Modivcare.
- Covers trips for medical, dental, vision, behavioral health and prescription pickup.
- Transportation types: car, taxi, van, bus or public transit.
- Call 1-833-577-2309 or Member Services at 1-888-235-4673 (Option 3).
- Must schedule at least 2 business days before your appointment.
- 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.
- Specialist referrals for eye diseases or defects.
- Fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses and ophthalmic frames, is provided to you through the NC Medicaid Direct program. Although these eyeglasses are covered through NC Medicaid Direct, Partners Tailored Plan providers who work in an office that offers eye exams and eyeglasses must give you your eye exam and your NC Medicaid Direct eyeglasses.
Services Not Covered by Partners Tailored Plan
Benefits Not Covered by Partners Tailored Plan
These services are available under NC Medicaid Direct:
- Dental services
- Services provided or billed by local education agencies that are included in your child’s Individualized Education Plan, Individual Family Service Plan, section 504 Accommodation Plan, Individual Health Plan or Behavior Intervention Plan
- Services provided and billed by Children’s Developmental Agencies (CDSA) or by a provider contracted with a CDSA to provide those services, which are included in your child’s Individualized Family Service Plan
- Fabrication of eyeglasses, including complete eyeglasses, eyeglass lenses and ophthalmic frames
If you have questions or need help with accessing benefits you can only get through NC Medicaid Direct, talk with your primary care provider (PCP) or call Member and Recipient Services at 1-888-235-4673.
Not Covered by Partners Tailored Plan or NC Medicaid Direct
This is not a complete list of excluded services:
- 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
- Hypnosis
- Liposuction
- Ultrasound to determine the gender of a child
- Hearing aid products and services for beneficiaries age 21 and older
- Services from a provider who is not part of Partners Tailored Plan, unless it is a provider you are allowed to see as described elsewhere in the Tailored Plan Member Handbook or Partners Tailored Plan or your primary care provider (PCP) sent you to that provider
- Tattoo removal
Need Help?
Call Member and Recipient Services at 1-888-235-4673
Review Partners Tailored Plan Member Handbooks
Visit the NC Medicaid Website
Extra Benefits
Pyx Health
Get support for loneliness, depression and overall wellness with the free Pyx Health mobile app for adults 18 and older.
Living Tobacco Free
Receive tools, coaching and resources to help you quit tobacco and improve your health.
StrongSTART
Get pregnancy support, kits, rewards and education to stay healthy during pregnancy and postpartum.
Free2BREATHE
Children and teens 18 and under with asthma can receive a free kit with items to reduce in-home triggers.
Partners Health Library
Find easy-to-read, trusted health information and tools to help you make good choices for your care.
GreatDAY Rewards
GreatDAY Rewards is Partners’ program that thanks you for taking steps to stay healthy.
Members can earn up to $75 each year from all GreatDAY Rewards combined.
Eligibility may vary by program.
Call Partners Member and Recipient Services at 1-888-235-4673 (Relay NC 711) for help with questions.
Annual Wellness Visit
Complete your yearly wellness check-up and earn a $20 gift card. An annual wellness visit helps check your overall health, spot risks for certain conditions and connect you to resources that keep you healthy.
- To qualify, visit your primary care provider for your annual wellness appointment.
- After your visit, provide your visit summary to Partners.
- Supporting documentation is required.
- One reward per year.
Care Needs Screening
- Earn a $25 gift card when you complete your Care Needs Screening.
- The screening is short and helps Partners learn about your health needs so we can better support your care.
- A Partners staff member will contact eligible members to complete it.
- Need help reaching your care manager? Call Member Services at 1-888-235-4673.
- Supporting documentation is required.
- One reward per year.
Prenatal Visits (StrongSTART)
- Earn up to $75 in gift cards by keeping up with your prenatal visits. Each completed visit is worth $25, claimable during pregnancy and up to 6 months postpartum.
- Rewards are for members who notify Partners of their pregnancy.
- Must be engaged in prenatal care and provide proof of visits.
- Limit of 3 rewards per pregnancy (maximum $75).
Pyx Health App Enrollment
- Download and sign up for the Pyx Health app to earn a $10 gift card. The app provides daily check-ins, resources and support for your mental and physical health.
- Must be age 18 or older to participate.
- Register with your Partners or Medicaid ID at HiPyx.com.
- Use your smartphone, answer a few questions and start using the app.
- Call Pyx Health at 1-855-499-4777 if you need help registering.
- After registering, complete the GreatDAY Reward Form to claim your reward.
