Healthy Opportunities Pilots Overview

The Healthy Opportunities Pilots (the Pilots) present an unprecedented opportunity to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety to high-needs Medicaid enrollees. The federal government has authorized up to $650 million in Medicaid funding for the Pilots over the next five years. Pilots will operate in two to four geographic regions of the state and will be procured through an RFP to be released in mid-2019.

The Pilots will operate in two to four geographic areas of the state and, where they are operational, Pre-Paid Health Plans (PHPs) will be able to pay for CMS-approved evidence-based interventions. Many players will have important roles in the successful implementation of a pilot:

  • All Medicaid Pre-Paid Health Plans serving a Pilot region will be responsible for approving which enrollees qualify for Pilot services (based on State-defined criteria) and which services they qualify to receive. PHPs will work closely with care managers at Tier 3 AMH practices, LHDs and other contracted local care management entities to carry out these responsibilities.
  • Care managers who work with Medicaid enrollees on their full range of physical, behavioral and non-medical needs will help identify people who would benefit from and qualify for Pilot services, propose services that may benefit the enrollee and manage and coordinate services.
  • Human service organizations, (HSOs) also known as community-based organizations or social service agencies, will deliver Pilot services to Medicaid enrollees. In recognition that it will be a new experience for human service organizations to receive Medicaid payments for their services, the Pilot design calls for providing them with resources to build the necessary infrastructure and expertise.
  • A Lead Pilot Entity will play a critical role in bridging the gap between health and human service organizations, contracting with PHPs to manage a network of HSOs providing Pilot services. The Department will procure one Lead Pilot Entity for each Pilot region and provide resources to support the establishment of the HSO network.

Pilot Qualifying Criteria and Services: Pilot services are intended to be used by Medicaid enrollees who can benefit most from them, to maximize the benefit of limited Pilot funding. Specifically, a Medicaid enrollee must meet at least one State-defined health criteria and at least one State-defined social risk factor.

Physical/Behavioral Health Risk Factors (varies by population):

  • Adults (such as two or more chronic conditions).
  • Pregnant women (such as multifetal gestation).
  • Children, age 0-3 (such as a baby that was in a neonatal intensive care unit).
  • Children, age 0-21 (such as experiencing three or adverse childhood experiences).

Social Risk Factors:

  • Homeless and/or housing insecure.
  • Food insecure.
  • Lack of transportation.
  • At risk of, witnessing or experiencing interpersonal violence.

 

Pilot Service Fee Schedule
Pursuant to 1115 Waiver requirements, the Department will develop a first-of-its-kind Medicaid fee schedule that will define and price Pilot interventions, which will address housing instability, food insecurity, transportation insecurity, interpersonal violence and toxic stress. Prior to Pilot launch, the Pilot Service Fee Schedule will be reviewed and approved by the Centers for Medicare & Medicaid Services (CMS).

The Commonwealth Fund and Manatt Health are convening an expert advisory panel to offer feedback on this groundbreaking effort. Panel meetings will be held in Raleigh in the spring of 2019 and will be open to the public. The Department encourages stakeholders to attend and weigh in on the materials discussed during panel meetings. Visit the Advisory Panel webpage for more information.

 

Evaluation
To ensure accountability for state and federal funding, the Department has developed a preliminary design for rigorously evaluating the Pilots, including rapid cycle assessments and a summative evaluation delivered upon the conclusion of the demonstration. The Department intends to introduce a process, called sequential multiple assignment randomized trials, or SMART design, to randomize higher intensity services during the later years of the Pilots to allow for the most reliable evaluation findings.

Comprehensive evaluation of the Pilots will be conducted by the University of North Carolina, Cecil G. Sheps Center for Health Services Research. All Pilot participating entities will be expected to support the data collection and reporting efforts needed to support the Department’s evaluation efforts. Participating Pilot entities will not need to conduct their own evaluations of the Pilots.