Healthy Opportunities Pilots

The Healthy Opportunities Pilots is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees. The federal government has authorized up to $650 million in Medicaid funding for the Pilots over five years. Through the Healthy Opportunities Pilots, the North Carolina Department of Health and Human Services (NCDHHS) is dedicated to:

• Ensuring members can access Pilot services in a timely manner and in a way that meets their needs and improves their health. 
• Demonstrating equity across all aspects of the Pilot program—including through ensuring diverse and equitable participation in the Pilots for Medicaid members and human service organizations. 
• Strengthening community capacity to provide high-quality, member-centered services.  

Importantly, the Pilots will allow for the establishment and evaluation of a systematic approach to integrating and financing evidence-based, non-medical services into the delivery of healthcare. If shown to be effective in improving health outcomes and reducing healthcare costs after rigorous evaluation, the NC Department of Health and Human Services will look to systematically integrate high-value Pilot services statewide through NC Medicaid Managed Care.

Pilot Launch

Services are launching for eligible Standard Plan members as follows across all three Pilot regions:  

• March 15, 2022: Food services became available across all Pilot regions (see next section below)
• May 1, 2022: Housing and transportation services were added and became available across all Pilot regions
• Between June 15 and the end of July 2022:Toxic Stress and cross-domain services are becoming available in all Pilot regions. 

All Pilot services will be available to eligible members of Tailored Plans beginning in the second quarter of 2023.

Pilot Regions

A larger version of the map is available here.

The Pilots will operate in three geographic regions of the state, which were defined by the three Healthy Opportunities Network Leads (the Network Leads) that the Department procured through a Request for Proposal (RFP). The following organizations serve as Network Leads, two in eastern North Carolina and one in western North Carolina:

• Access East, Inc. - counties: Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, Pitt.
• Community Care of the Lower Cape Fear - counties: Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender.
• Impact Health - counties: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey.

For additional information about Human Service Organization (HSO) responsibilities, please go to Healthy Opportunities Pilots Webinar: Human Service Organizations (below).

Pilot Services

The Healthy Opportunities Pilots will cover the cost of 29 interventions defined and priced in the Department’s Pilot Service Fee Schedule. These services were selected based on their potential to improve health outcomes and/or lower health care costs and address the housing, food, transportation, interpersonal violence and toxic stress needs of qualifying Medicaid members. Each Network Lead must contract with HSOs in their Pilot region to cover all domains of services for all types of enrolled members (pregnant women, children and adults) in their region.

Eligibility Criteria

To maximize the impact of limited Pilot funding, Pilot services will be provided to eligible NC Medicaid Managed Care members expected to benefit most from them, as determined by PHPs and in accordance with NCDHHS standards and guidelines. To be eligible for and receive Pilot services, NC Medicaid Managed Care members must live in a Pilot region (in one of the counties listed above) and have at least one qualifying physical or behavioral health condition and one qualifying social risk factor, as defined by the Department.

Key Pilot Entities

Many players will have important roles in the successful implementation of the Pilots:

• All Medicaid Pre-Paid Health Plans (PHPs) will play a central role in implementing the Healthy Opportunities Pilots and are ultimately responsible for managing Pilot participants’ physical, behavioral and social needs. PHPs’ key Pilot responsibilities include:
  • Managing a capped allocation of funding to spend on Pilot services and maximizing value within their allocations; 
  • Leading the integration of non-medical services into their health care delivery approach, including via their care management entities;
  • Determining which members meet Pilot eligibility criteria and authorizing Pilot services; and 
  • Paying non-traditional providers (HSOs) with Pilot funds.
• Care managers who work with Medicaid enrollees on their full range of physical, behavioral and non-medical needs will work with the PHPs to identify people who would benefit from and qualify for Pilot services, propose services that may benefit the enrollee coordinate, track and manage their Pilot services over time.
• Network Leads (formerly referred to as Lead Pilot Entities, or LPEs), are new, innovative entities in North Carolina that will play a critical role in the Pilots by connecting the health care and social service sectors. Network Lead responsibilities include:
  • Serving as a single point of accountability for HSOs and PHPs, effectively bridging the gap between the healthcare and social services industries;
  • Serving as a local anchor to build the capacity of HSOs to participate in Medicaid, including by distributing capacity-building funds and providing technical assistance; and
  • Developing and managing a high-quality network of HSOs.
• Human Service Organizations (HSOs) are community-based organizations or social service agencies that are contracted to deliver Pilot services. They will play a critical role in delivering the 29 Pilot interventions to Pilot enrollees and other members of the community. HSO key Pilot responsibilities include: 
  • Delivering high-quality Pilot services in a culturally competent manner in accordance with Pilot standards;
  • Building service capacity to meet community needs; and
  • Developing capabilities to participate in the health care delivery system, including tracking, reporting and invoicing for Pilot services delivered to Pilot enrollees. 

For additional information about HSO responsibilities, refer to Healthy Opportunities Pilots Webinar: Human Service Organizations

Evaluation

A key component of the Pilots is a comprehensive and rigorous approach to evaluation. In collaboration with the University of North Carolina, Cecil G. Sheps Center for Health Services Research, NCDHHS will:

• Evaluate the effectiveness of the non-medical interventions and the role of the Network Lead in improving health outcomes and reducing health care costs for high-risk NC Medicaid Managed Care members. 
• Leverage evaluation findings to embed cost-effective interventions that improve health outcomes into the Medicaid program statewide, furthering NCDHHS’ goals for a sustainable Medicaid program. 
• Support the sustainability of delivering non-medical services identified as effective through the evaluation, including by strengthening the capabilities of HSOs and partnerships with health care payers and providers.