Coverage Information

Our health plans cover a wide array of both Medicaid and non-Medicaid-funded behavioral healthcare and intellectual/developmental disability (IDD) services to members with mental health, substance use disorder and/or IDD healthcare needs. Vaya Health offers three distinct health plans:

Medicaid 1915(b) services (including in lieu of services)

Section 1915(b) Waiver: NC MH/IDD/SAS Health Plan (07/01/2019) identifies Medicaid 1915(b) services offered by Vaya. We also offer alternative medically appropriate, cost-effective services or settings as substitutes for some services or settings covered under this plan. Refer to the following links for service definitions and requirements:

Medicaid 1915(b)(3) services

Vaya spends all Medicaid service dollars on services you deliver to our members. We do this by utilizing savings we achieve from efficient management of the 1915(b)/(c) Waiver to offer Medicaid (b)(3) services. Unlike regular Medicaid, (b)(3) services are not an entitlement, meaning they can only be reimbursed if service funding is available. Denials based on lack of funding may not be appealed. Current available (b)(3) services are:

Medicaid 1915(c) services (N.C. Innovations)

N.C. Innovations is a 1915(c) Home and Community-Based Services (HCBS) Waiver for individuals with an IDD who would otherwise meet the intermediate care facility level of care. The 1915(c) N.C. Innovations Waiver allows individuals with an IDD, or a related qualifying condition, to receive services and supports in their own community and live as independently as possible.

Vaya’s Innovations benefit package includes all services required by the 1915(c) N.C. Innovations Waiver and NC Medicaid Clinical Coverage Policy No. 8-P.

NC Medicaid provides additional guidance for us to use in making authorization decisions. Guidelines for understanding individual level of support needs are set forth in the N.C. Department of Health and Human Services (DHHS) Operational Rules.

Non-Medicaid services

Vaya’s Non-Medicaid Benefit Plan includes public safety net services funded with state single-stream, federal and state block grants and county funds. Vaya is committed to making sure our limited resources benefit people who need it most. 

People who meet “priority population” criteria based on screening, triage and referral information are first in line to receive these funds. Priority populations are groups of people with the most severe types of mental illness, severe emotional disturbances and substance use disorders with key complicating life circumstances, conditions and/or situations.

Non-Medicaid services are not an entitlement. Vaya can only fund services under this benefit plan within the limited resources allocated to us. 

Transitions to Community Living (TCLI) population non-Medicaid Services

Services specific to the TCLI population identified in the 2012 settlement agreement between the state of North Carolina and the U.S. Department of Justice include:

NC START Child services

Children between age 5 and 20 who live in Vaya’s catchment area and who have documented diagnoses of an IDD and a mental health and/or substance use disability may be referred to the NC START Child program. NC START provides community-based crisis intervention and prevention services to children and their families.  Services include:

  • Consultation, education and training on crisis intervention
  • Collaboration with providers, care coordinators, mobile crisis management (MCM), hospitals and state facilities
  • Crisis intervention planning, linkages and outreach, including the development of a Cross-Systems Crisis and Intervention Plan
  • Expertise on dual-diagnosed individuals
  • Crisis response
  • START coordination

Children who are eligible for NC START Child services must be referred through a Complex Care Management referral.

1915(i) services

Because Behavioral Health and I/DD Tailored Plans will operate under North Carolina’s 1115 Demonstration Waiver, they will not be able to provide services under 1915(b)(3) authority. To ensure people maintain access to HCBS when Tailored Plans launch, North Carolina is transitioning 1915(b)(3) services to 1915(i) services, which all Tailored Plans will offer. NC Medicaid Direct members (including individuals enrolled in the Tribal Option) and members of the Children and Families Specialty Plan will also have access to 1915(i) services.

Along with this transition, which will occur by July 1, 2023, North Carolina is expanding the populations eligible for some of these services. Find more information on the North Carolina Department of Health and Human Services (NCDHHS) 1915(i) Fact Sheet.

View the 1915(i) Service Guidelines. 

Other coverage resources