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Services for Specialty Populations

Areas include individuals without Medicaid, care for minors, complex case management program, priority care for pregnant women, and veterans resources.

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Individuals Without Medicaid

While the majority of Alliance’s services are available through our network only to individuals covered by Medicaid, we do offer a range of services to individuals without Medicaid coverage. Most state-funded services require prior authorization by Alliance and can be accessed by contacting Alliance via our 24-hour Access and Information Line at (800) 510-9132. Part of the State-funded service eligibility process is based on an individual’s level of income in addition to clinical needs, but there are some crisis services available to individuals within Alliance’s four-county region regardless of ability to pay.

Alliance has a limited amount of State funds to pay for treatment services so entry requirements and benefit maximums may be different than the Medicaid requirements for the same service.

Every individual enrolled with Alliance is evaluated to determine their ability to pay for State-funded services. The combination of an individual’s adjusted gross income and the number of dependents will show if they have the ability to pay. An individual meets financial eligibility if household income is at or below 300% of the federal poverty level and there are no assets or third-party funding or insurance available to pay for services. If an individual’s income exceeds this amount, the individual will be required to pay 100% of the cost for the state-funded services provided to him or her. You can access the 2019 Federal Poverty Guidelines.

Click here for a link to the Alliance Health Medicaid and Non-Medicaid Benefit Plans.

Care For Minors

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit entitles Medicaid beneficiaries under the age of 21 to receive medically necessary screening, diagnostic and treatment services within the scope of the Social Security Act that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether the requested service is covered in the NC State Plan for Medical Assistance. This means that children under 21 years of age can receive services in excess of benefit limits or even if the service is no longer covered under the State Plan. To request a service that is not covered by the State Plan but that is covered under 1905(a) of the Social Security Act, please email the Non-Covered State Medicaid Plan Services Request Form for Recipients Under the Age of 21 to the Alliance Health Utilization Management Department at [email protected].

According to CMS, “ameliorate” means to improve or maintain the beneficiary’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Basic EPSDT criteria are that the service must be covered under 1905(a) of the Social Security Act, and that it must be safe, effective, generally recognized as an accepted method of medical practice or treatment, and cannot be experimental or investigational. (This means that most clinical trials cannot be covered).

Requests for MH/IDD/SUD services for Medicaid-eligible children under the age of 21 will be reviewed using EPSDT criteria. Requests for NC Innovations Waiver services will be reviewed under EPSDT if the request is both a waiver and an EPSDT service. Most NC Innovations Waiver services (i.e. respite, home modifications and all habilitative services) are not covered under the Social Security Act.

Complex Case Management Program

The Complex Case Management program helps our members and their families achieve their goals following discharge from the LEAP program, a specialty psychiatric residential treatment program for dually diagnosed children with mental health and co-occurring autism. This program provides extensive care coordination to children with complex needs. Children with complex needs often face many challenges in getting the help they need.

Members who are eligible for this program will work with Care Coordination staff to:

  • Complete assessments to identify their areas of need, and
  • Develop a plan of care to address the needs identified.

Care Coordination will support the member’s family in creating a team that brings together community partners, medical staff, natural supports, and family in treatment planning and decision making. The goal is to reduce barriers to plan for moving back into the community with the right services and supports in place.

For more information on the referral process, please contact our Access and Information line at (800) 510-9132.

Priority Care for Pregnant Women

Pregnant women who abuse controlled substances, including alcohol, or are injection drug users may receive priority admission to appropriate services through Alliance.

Alcohol use by a woman who is pregnant can cause lifelong physical and behavioral problems in children, including fetal alcohol syndrome. Using illegal drugs may cause underweight babies, birth defects, or withdrawal symptoms after birth. Abuse of intravenous (IV) drugs is harmful to the mother as well and can damage the skin at the site of injection as well as internal organs. Infections can spread through the sharing of needles and contaminants in the drugs can cause serious health problems.

To access priority services, please call the Alliance Access and Information Center at (800) 510-9132.

Veterans Resources

The Veterans Crisis Line connects veterans in crisis and their families and friends with qualified, caring Department of Veterans Affairs responders through a confidential toll-free hotline, online chat, or text. Veterans and their loved ones can call (800) 273-8255 and press 1, chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year.

You can access a publication that introduces some of the behavioral health problems facing veterans who have served in Afghanistan and Iraq, including substance abuse, post-traumatic stress disorder, depression, and suicide, and discusses screening tools and interventions.

Additional information and resources are available from SAMHSA.

This page was last reviewed for accuracy on 07/06/2021