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Healthy Opportunities and Medicaid Transformation

North Carolina is transitioning its Medicaid and NC Health Choice programs from predominantly fee-for-service to Medicaid managed care, as directed by the North Carolina General Assembly.

The Department’s vision for Medicaid Transformation is to improve the health of North Carolinians through an innovative, whole-person centered and well-coordinated system of care that addresses medical and non-medical drivers of health.

Health is affected by many factors beyond the medical care provided within the four walls of a hospital or clinic. While access to high-quality medical care is critical, research shows up to 80 percent of a person’s health is determined by social and environmental factors and the behaviors that emerge as a result. A substantial body of research has established that having an unmet resource need — including experiencing food insecurity, housing instability, unmet transportation needs and interpersonal violence or toxic stress — can significantly and negatively impact health and well-being. It can also increase healthcare utilization and costs.

With this in mind, North Carolina is launching the Healthy Opportunities pilots as part of its Medicaid Transformation efforts. The pilots are an opportunity for payers, providers and community-based organizations to have the tools, infrastructure and financing to integrate non-medical services directly related to improved health outcomes into the delivery of care.

Recognizing that North Carolina is breaking new ground with the Heathy Opportunity pilots, the Department will rigorously evaluate them to assess their effectiveness and identify key elements that should be extended to the Medicaid program statewide.

Financing

The federal government has authorized up to $650 million in Medicaid funding for the pilots over the five years of the waiver. The funds can be used to:

  • Cover the cost of the federally-approved pilot services, and
  • Support capacity building in the early years of the demonstration for Lead Pilot Entities and human services organizations to participate effectively in the pilots.