Member Benefit Plans | Service Definitions
Member Benefit Plans
Trillium coordinates services for Medicaid members in the Trillium Tailored Plan or NC Medicaid Direct, and state-funded recipients. Services covered and listed below will be either for members, recipients, or both as noted.
Some members may be required to pay a copay. A “copay” is a fee you pay when you get certain health care services from a provider or pick up a prescription from a pharmacy. Eligible Trillium recipients receiving State-funded Services may not have to pay a copay to their provider. Please view the member and recipient handbooks for more details.
Members and recipients do not have to file claims for services received.
Some services may require a referral to a specialist. You can ask your primary care physician or other provider if you have any questions, or check the member and recipient handbooks for more details.
If you need specialized care that your primary care provider (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 surgeon). If your PCP refers you to a specialist, we will pay for your care if it is medically necessary. Most specialists are Trillium providers. Talk with your PCP to be sure you know how referrals work.
Trillium coordinates the following plans:
- Trillium Tailored Plan: This is our integrated Medicaid plan . It brings together behavioral health, intellectual/developmental disability (I/DD) services, physical health, long-term services and supports (LTSS), and pharmacy. Trillium will issue your Medicaid ID card.
- NC Medicaid Direct: This plan serves as our Medicaid BH-IDD carve-out plan. It is dedicated to individuals with behavioral health and I/DD needs who are not enrolled in a Standard Plan or the Trillium Tailored Plan. It's important to note that this is not an integrated care plan and does not include physical health, LTSS or pharmacy services.
- State-funded Recipients: This is our state-funded behavioral health and I/DD plan. It serves individuals who are uninsured or underinsured. This plan ONLY covers mental health, substance use, intellectual/ developmental disabilities specific benefits.
- County Plan: This plan is our county level plan. Trillium receives funding from various counties and also invests locally back into our communities. We address the local needs of each county. This plan demonstrates to local communities all the ways that Trillium gives back to the communities where we live, work and play in.
Intellectual Developmental Disability (I/DD) and Traumatic Brain Injury (TBI) Benefits
Trillium covers special services for individuals with intellectual and developmental disabilities that include Intermediate care facilities for individuals with intellectual disabilities (ICF/IID) and Innovations waiver services for people enrolled in the NC Innovations Waiver.
NC Innovations Waiver services support individuals with intellectual and developmental disabilities to live the life they choose. Individuals get services in their homes or community.
The services covered by Trillium include:
- I/DD Services
- Home & Community-Based 1915(i) Services
- Traumatic Brain Injury (TBI): until the TBI Waiver is available at all Tailored Plans, certain services will be available for those diagnosed with a TBI including some state-funded and 1915i services.
Mental Health/Substance Use (MH/SU) Benefit Plan
Behavioral health care includes mental health (your emotional, psychological and social well-being) and substance (alcohol and other 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 if they are abusing drugs.
The services covered by Trillium include:
Medicaid In Lieu of Services (ILOS)
Tailored Plan Medicaid Member Pharmacy Benefits
- Medicaid Member Pharmacy Benefits - Prescription drugs, over-the-counter medicines, and other supplies covered for Medicaid members.
Tailored Plan Medicaid Member Physical Medical Benefits
- Medicaid Member Physical Medical Benefits - Medically necessary physical health care for Medicaid members including regular office visits and specialist care.
Services for Medicaid–Eligible Children: Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Services for Medicaid–Eligible Children: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) - Trillium covers services, products, or procedures for a Medicaid member under age 21 if the service is medically necessary to correct a defect, physical or mental illness, or a health problem identified through a screening examination.
Prior Authorization Services
Trillium will need to approve some treatments and services before you receive them. Trillium may also need to approve some treatments for services for you to continue receiving them. This is called “preauthorization.”
Please use this tool to determine if prior authorization is required for specific services and codes. However, using this tool does NOT guarantee payment. Member eligibility, benefit plans, codes in provider contracts, and other details may impact payment. Please note it is up to the provider (not the member or recipient) to get prior authorization if necessary before providing services.
Service Definitions
- 1915i Service Definitions
- Service Definitions for State-funded Services
- Medicaid Clinical Coverage Policies
Utilization Management
Trillium's Utilization Management (UM) Department reviews all treatment authorization requests for members or recipients in our region.
UM decisions are made by qualified health professionals. Trillium’s licensed clinicians and behavioral healthcare professionals gather only relevant and necessary clinical information to make decisions about the medical necessity of requests. “Medical necessity” means necessary for the treatment or diagnosis of a health condition.
For more information, see our Clinical Review Criteria and Utilization Management Program Policy.
Members can review the Clinical Practice Guidelines our providers use.
