Our health plans cover a wide array of Medicaid services, plus State-funded mental health, substance use disorder, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) services for individuals who cannot afford care. For details, visit our Benefit Plans page.
Vaya Total Care includes all health services required by the NC Medicaid 1115 Demonstration Waiver and the North Carolina Medicaid State Plan. This plan includes physical and behavioral health care, pharmacy benefits, I/DD and TBI services, and Long-term Services and Supports (LTSS), plus 1915(i) and “in lieu of” services.
- NC Medicaid Program Specific Clinical Coverage Policies
- Vaya Total Care Medicaid Clinical Coverage Policy 1K-7 (Outpatient Imaging Services)
NC Innovations is a 1915(c) home- and community-based services (HCBS) waiver for individuals with I/DD who would otherwise meet the intermediate care facility level of care. Vaya Innovations Waiver participants are also Vaya Total Care members with access to all services required by the waiver and NC Medicaid.
Vaya’s NC Medicaid Direct Prepaid Inpatient Health Plan (PIHP) serves beneficiaries who are not enrolled in NC Medicaid Managed Care. This plan includes behavioral health, I/DD, and TBI services required by the North Carolina Medicaid State Plan, plus 1915(i) services and Vaya’s “in lieu of” services. NC Medicaid manages physical health and pharmacy benefits for beneficiaries in this plan.
North Carolina’s 1915(i) Waiver allows qualifying Medicaid members to receive HCBS to meet behavioral health, I/DD, and TBI health care needs.
“In lieu of” services (ILOS) are services or settings that are medically appropriate, cost-effective substitutes for services covered under the Medicaid State Plan services. Vaya offers the following ILOS:
- Acute and Subacute Services Provided in an Institute for Mental Disease
- Assertive Community Treatment Team Step Down (ACT-SD)
- Behavioral Health Crisis Risk Assessment and Intervention (BH-CAI)
- Child-Focused Assertive Community Treatment (Child ACT)
- Enhanced Crisis Response
- Family Centered Treatment
- First-Episode Psychosis – Assertive Community Treatment (FEP-ACT)
- High Fidelity Wraparound
- In-Home Therapy Services
- Long-Term Community Supports
- Outpatient Plus
- Rapid Care
- Residential Services – Complex Needs
- Transitional Youth Services
State-funded (non-Medicaid) services serve as a public safety net for uninsured/ underinsured individuals in our region who cannot afford care. These services are supported though State single-stream funds, federal and state block grants, and county allocations as part of the Vaya Tailored Plan.
People who meet “priority population” criteria based on screening, triage, and referral information are first in line to receive State-funded services. Priority populations are groups of people with the most severe types of mental health disorders, severe emotional disturbances, and substance use disorders with key complicating life circumstances, conditions and/or situations. State-funded services are not an entitlement and are dependent on available funding.
Transitions to Community Living (TCL) State-Funded Services
Services specific to the TCL population identified in the 2012 settlement agreement between the state of North Carolina and the U.S. Department of Justice include:
- Non-Medicaid-Funded Critical Time Intervention (07/01/2016)
- Non-Medicaid-Funded Transition Management Services (02/17/2023)
NC START Child Services
Children between ages 5 and 20 who live in Vaya’s region and who have documented diagnoses of I/DD and a mental health and/or substance use disorder may be referred to the North Carolina Systemic, Therapeutic, Assessment, Resources and Treatment (NC START) Child program. NC START provides community-based crisis intervention and prevention services to children and their families.
Children who are eligible for NC START Child services must be referred through a Care Management and Care Coordination Referral.