Healthy Opportunities and Medicaid Transformation North Carolina is transitioning its Medicaid and NC Health Choice programs from predominantly fee-for-service to NC 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. One important way NCDHHS is operationalizing its commitment to buying health is through the Healthy Opportunities Pilots, a groundbreaking program that works in conjunction with the state’s transition to NC Medicaid Managed Care to test and evaluate the use of Medicaid to pay for a select set of evidence-based interventions designed to address non-medical factors that drive health outcomes and costs. 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 Pilot program was authorized by the Centers for Medicare & Medicaid Services (CMS) through Oct. 31, 2024 as part of North Carolina’s Section 1115 Medicaid Demonstration Waiver. The federal government has authorized up to $650 million in Medicaid funding for the Pilots over the five years of the waiver. The funds will primarily be used to: Cover the cost of the federally-approved, non-medical services, and Support capacity building in the early years of the demonstration for Healthy Opportunities Network Leads (formerly referred to as Lead Pilot Entities, or LPEs), and Human Service Organizations (HSOs, e.g., community-based organizations and social services agencies) to participate effectively in the Pilots.