North Carolina added a significant structural change to its managed care program on July 1, 2024: Tailored Plans. If you serve members with serious mental illness, IDD, or traumatic brain injury, their PCS claims no longer go to NCTracks — they go to their Tailored Plan. CAP/DA remains a strong home care pathway because it has no waitlist. Medicaid expansion added over 600,000 members in December 2023. And WellCare and Carolina Complete Health are merging April 1, 2026. North Carolina is moving fast — here is the operational picture.
North Carolina Medicaid operates on three simultaneous tracks for different member populations. Which track your client is in determines where authorization comes from, where claims go, and which EVV requirements apply.
Members not enrolled in a managed care plan receive services through NC Medicaid Direct. PCS claims and most waiver service claims go to NCTracks for these members. CAP/DA and CAP/C waiver services primarily flow through NC Medicaid Direct, though Tailored Plan members in these waivers receive services through their plan.
NCTracks is NC's MMIS and billing system. Provider enrollment, eligibility verification, and FFS claims submission all go through NCTracks. Provider enrollment is a prerequisite to any NC Medicaid billing.
Most NC Medicaid members receive physical health, pharmacy, and behavioral health services through a Standard Plan (PHP). Standard Plans do not cover long-term care or CAP waiver services for most members — those remain in NC Medicaid Direct or Tailored Plans. But Standard Plans do cover PCS for their enrolled members who are not in Tailored Plans.
Current Standard Plans include Aetna, AmeriHealth Caritas, Blue Cross NC, CCME (Children and Families), United, and others. WellCare of NC and Carolina Complete Health are merging April 1, 2026 into a single statewide plan.
July 1, 2024 — Tailored Plans launched. Members with serious mental illness, severe substance use disorder, IDD, or TBI transitioned to Tailored Plans. This changed PCS billing for these members — PCS claims for Tailored Plan members go to the Tailored Plan, not to NCTracks. If you serve this population and are billing NCTracks for PCS, verify the member's plan enrollment before each claim. Wrong billing destination = claim rejection.
Tailored Plans are behavioral health and IDD specialty plans operated by the state's Local Management Entities/Managed Care Organizations (LME-MCOs). Each county is assigned to one specific Tailored Plan — unlike Standard Plans where members choose from available options. A member's Tailored Plan is determined by their administrative county.
| Tailored Plan | Counties Served (select major counties) | Provider Contact |
|---|---|---|
| Alliance Health | Cumberland, Durham, Johnston, Mecklenburg, Orange, Wake | 1-800-510-9132 |
| Partners Health Management | Anson, Cabarrus, Catawba, Davidson, Davie, Gaston, Iredell, Lincoln, Mecklenburg (portions), Rowan, Stanly, Union, and others | 1-888-235-4673 |
| Trillium Health Resources | Beaufort, Bertie, Brunswick, Camden, Carteret, Craven, Currituck, Dare, Duplin, Edgecombe, Greene, Halifax, Harnett, Hertford, Hyde, Jones, Lenoir, Martin, Nash, New Hanover, Onslow, Pender, Pitt, Sampson, Tyrrell, Washington, Wayne, Wilson | 1-877-685-2415 |
| Vaya Total Care | Alexander, Alleghany, Ashe, Avery, Buncombe, Burke, Caldwell, Cherokee, Clay, Cleveland, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Surry, Swain, Transylvania, Watauga, Wilkes, Yadkin, Yancey | 1-800-849-6127 |
Agencies serving members in multiple counties may work with multiple Tailored Plans. Each Tailored Plan has its own provider enrollment process, PCS authorization requirements, and EVV expectations for Tailored Plan members. Verify coverage county assignments using NC Medicaid's plan directory before building credentialing strategies.
The Community Alternatives Program for Disabled Adults (CAP/DA) is North Carolina's primary HCBS waiver for adults 18 and older with disabilities who need nursing facility level of care. CAP/DA has no waitlist. If an adult meets clinical and financial eligibility, they are entitled to services. This makes North Carolina meaningfully different from states like Georgia or Texas where HCBS waivers have years-long interest lists.
CAP/DA services include personal care, home health aide services, housekeeping, respite care, community integration, assistive technology, home modifications, and more. Services are authorized by the CAP case manager and delivered by enrolled providers. The ISP (Individual Support Plan) authorizes services before billing can occur.
CAP/C serves medically fragile children — a different population requiring different agency capabilities, licensing, and staffing. Agencies focusing on the adult population primarily work with CAP/DA.
CAP/DA waiver service claims generally go to NCTracks for NC Medicaid Direct members. For members who are in a Tailored Plan and also receive CAP/DA services, billing pathways can be more complex — verify with the Tailored Plan case manager whether waiver services bill to the plan or to NCTracks for that specific service type and member.
NCTracks handles provider enrollment for CAP/DA. You need a NPI, NC Medicaid provider ID, and enrollment approval for each service type before submitting claims.
NC Medicaid requires EVV for personal care and home health services under the 21st Century Cures Act. EVV requirements for Standard Plan and Medicaid Direct members flow through NCTracks. For Tailored Plan members, EVV requirements are set by the assigned Tailored Plan — verify EVV expectations and approved systems with each Tailored Plan you contract with.
NC Medicaid's provider enrollment portal and NCTracks are your primary operational systems for FFS and Standard Plan billing. For Tailored Plan billing, each LME-MCO operates its own claims portal and EVV process.
Tailored Plans launched July 1, 2024 for NC Medicaid members with serious mental illness, severe substance use disorder, IDD, or TBI. There are four Tailored Plans, each assigned to specific counties — a member's Tailored Plan is determined by their administrative county. For PCS, the billing destination changed: PCS claims for Tailored Plan members go to the assigned Tailored Plan, not to NCTracks. Before each billing cycle, verify whether a PCS member is enrolled in a Tailored Plan. If they are, bill the Tailored Plan directly. Billing NCTracks for a Tailored Plan member will result in rejection.
No. CAP/DA does not have a waitlist. Adults 18 and older who meet the clinical eligibility (nursing facility level of care) and financial eligibility requirements are entitled to services. This makes CAP/DA a more reliable referral pipeline than HCBS waivers in many other states where years-long waitlists constrain the available client pool. The challenge in North Carolina is not eligibility access — it is authorization management, EVV compliance, and billing accuracy across multiple potential payers depending on whether the member is in NC Medicaid Direct, a Standard Plan, or a Tailored Plan.
WellCare of North Carolina and Carolina Complete Health are merging into a single statewide plan effective April 1, 2026. Providers contracted with either plan should monitor communications from NC Medicaid and both plans about whether existing contracts carry forward automatically or require action. Members of both plans will be consolidated under the new unified entity. This affects provider directories, prior authorization contacts, and claims submission pathways for Standard Plan members in counties where either WellCare or Carolina Complete Health currently operates.
North Carolina agencies managing PCS billing across NCTracks, Tailored Plans, and Standard Plans simultaneously — with different EVV requirements and authorization contacts for each — are running significant operational precision requirements from the first client. CareBravo delivers scheduling, EVV compliance, authorization tracking, and plan-matched billing as completed work.