Value Added Services Application FY24-25

Value Added Services Application FY24-25

Members must meet the eligibility requirements for the service and not have any other funding source available to meet the need for the program. Vendor approval is at the discretion of the program administrator. Value-Added Service availability is subject to funding availability. Members with NC Medicaid Direct and State-funded Recipients are not eligible for Value-Added Services.

Applicant Information

First and Last name*

Physical Address Where you Live*

Please include your full address with street, city and zip code

Mailing Address (if different from Physical Address)

Please include your full address with street, city, and zip code.

Preferred Method of Contact*

Phone Call

Text Message

Which program are you applying for?*

Please choose only one program per application. Each program requires a separate application.

Select

Child Education Support

The Child Education Support program offers up to $75 per year in school supplies to support our member's education when enrolled in grades Pre-K through 12. If eligible, an Amazon school supply bundle will be shipped to your home based on the grade the member is enrolled. Please ensure that the physical/mailing address you entered above is correct.

Do you have a child in your home that is currently attending school from Pre-K through 12th grade?

Yes

There must be a child in your home attending school Pre-K through 12th grade to be eligible for this program.

Name of Child

(Please complete a separate application for each child that is currently a Trillium member.)

What school does your child attend?

Name of city where the school is located

GED Test Voucher

The GED Test Voucher program assists any member 18 years of age or older that would like to pursue obtaining their GED by assisting with the cost of in-person testing at an approved General Educational Development testing center near their home. The program covers up to $120 in testing costs for the four subjects offered to obtain the certificate that is equivalent to the high school diploma. For eligible members that are 16 or 17 years old, the test can be taken under certain circumstances with your parent's permission.

Do you have transportation to get to the testing site?*

Select

Are you 18 or older?*

Yes

Parent/Guardian Name*

Parent/Guardian Address*

Parent/Guardian Phone Number*

Phone

Parent/Guardian Email*

Parent/Guardian Preferred Method of Contact*

Phone Call

Text Message

Gym Membership

The Gym Membership program assists eligible members with the annual cost of a gym membership, up to $250 per year, to assist them with staying active and well.

I am...*

18 or Older

Parent Applying for Child

Do you have transportation available to go to the gym at least one time per week?*

Yes

Please reach out to your care manager to assist you with transportation options.

I am committed to exercising at least one time per week during my membership.*

Please Enter Initials

Member/Child's Name*

Member/Child's Date of Birth*

Do you have transportation available to bring your child to the gym at least one time per week?*

Yes

Please reach out to your care manager to assist you with transportation options.

I am committed to providing an exercise opportunity for my child at least one time per week during their membership.*

Please enter initials

Please choose the YMCA closest to your home*

Select

If none of the above YMCAs are near your home, please enter the name and address of the gym that is closest to your house.

PLEASE NOTE: Planet Fitness is NOT available at this time. If Planet Fitness is your preferred gym, please do not apply now, but check back for that option around June.

Please enter the name, street address, city and zip code

Please list two ways that you will exercise and keep moving after your gym membership is over:*

Some examples would be walking around my neighborhood, walking laps around a mall near me, taking an online aerobics or dance class with my phone, joining a group that exercises together around your town, free places to exercise, etc. Please be specific!

Tailored Care Management (TCM) Engagement

The TCM Engagement program provides a $50 gift card when a member completes their Care Management Comprehensive Assessment (CMCA) with their Care Manager within 60 days of the beginning of a Tailored Care Management Authorization.

Please note that any Care Management Comprehensive Assessment that took place and is dated BEFORE July 1st will not be considered. Only assessments that take place on July 1st or thereafter will be reviewed.

Please look under Authorizations to see when the member's last TCM Auth took place.

I have completed my Care Management Comprehensive Assessment with my Care Manager.*

Yes

Please do not submit this application. Please contact your Care Manager to discuss completion of your Care Management Comprehensive Assessment (CMCA). Once your CMCA is completed, then come back here to apply for this reward.

What is the name of your Care Manager you completed your assessment with?*

***Please do not apply if you do not have a care manager.***

If you have a care manager, but don't know their name, please call 877-685-2415 to find out the name of your care manager.

Please enter your care manager's first and last name here:

What is the name of the Provider's Office where your Care Manager works?*

Your care manager will either work at Trillium or work for an agency outside of Trillium. If you do not know what the name of the agency is where your care manager works, please call 877-685-2415 to find out where your care manager works.

Please enter the name of your care manager's office here:

What city or town is your Provider's office located?*

Please write in the city or town where your care manager's office is located.

If your care manager works for Trillium, you can enter "Trillium" here.

Youth Support

The Youth Support program offers up to $100 per year for Boys and Girls Club membership (if available in child member's county) or if not available, other child after school sports/activities or youth club memberships for covered members, age 6-18.

Do you have a child in your home in grades K-12 that is interested in attending an after school program?

Yes

You must have a child in your home in grade K-12 that you are interested in an after school program for to be eligible for this program.

Is there transportation available to bring your child to the after-school activity either from you or an organization that provides transportation to the program?

Yes

Transportation must be arranged before completing this application. Please re-apply after transportation to the program is confirmed for your child.

What type of transportation will your child utilize?

Choose all that apply

What Other type of transportation will your child utilize?

What is your child's first and last name?

What is your child's date of birth?

What type of school does your child attend?

Public School

Home School

Charter School

Other

What OTHER type of school does your child attend?

What is the name of your child's school?

What grade is your child in currently?

Select

Which Boys and Girls Club is affiliated with your child's school or closest to your home?

Please choose the name of the Boys and Girls Club you would like your child to attend after school. If none of the Boys and Girls Clubs listed are near your home or are not available to you child, please choose "None of the Above" at the end of the list.

Select

If there is no Boys and Girls Club available in your child member's county, enter name of organization(s) near you that provides after-school activities and the address of the organization.

The organization must require a fee to participate and be an after school program. Fees can only be used for membership, they cannot be used for supplies, uniforms, or equipment, etc.

File Upload

Members Applying: Please upload a copy of your CMCA if you have it. If you don't have a copy or are unable to upload your CMCA, we will reach out to your care manager.

Care Managers Applying: Please upload your copy of the CMCA.

Drag and drop files here or

Send me a copy of my responses