NC Rural Health Transformation Program Frequently Asked Questions

NCRHTP is a statewide program led by NCDHHS to transform rural health care delivery, improve health outcomes, and ensure sustainable access to care for nearly 3 million rural North Carolinians. The program is funded over five years by the Centers for Medicare & Medicaid Services (CMS). 

RHTP was authorized under federal legislation (H.R. 1), which allows states to apply for funding to improve access to and quality of care in rural areas through enhanced technology, strategic partnerships, workforce development, and new care models.

North Carolina has the second-largest rural population in the nation. Rural communities face persistent challenges, including provider shortages, hospital closures, chronic disease burden, and health disparities, that require coordinated, innovative solutions.

NCDHHS submitted North Carolina’s application to CMS on November 5, 2025. CMS notified North Carolina of a $213 million award for Year 1 on December 29, 2025. States that receive approval do not need to reapply annually; however, funding in future years is contingent on performance and outcomes in Year 1. 

• Catalyze innovative health care models for rural communities by changing the way providers work together to care for patients in rural NC.
• Transform the rural care experience, building community-based clinical, behavioral, and social supports close to home.
• Create a sustainable rural health delivery system through underlying systems changes in rural workforce pipelines and care team models, and rural provider financial models.

1. NC ROOTS Hubs – Locally governed, community-tailored networks that coordinate medical, behavioral, and social supports.\
2. Expanded Primary Care & Prevention – Improved access to primary care, chronic disease management, maternal health, and nutrition.
3. Behavioral Health & Substance Use Services – Expansion and integration of mental health and substance use disorder services, including crisis response and school-based care.
4. Workforce Development – Investments in rural training centers, residencies, fellowships, and certification programs.
5. Value-Based Payment Models – Support for rural providers and hospitals to participate in advanced payment models.
6. Digital Health & Technology – Expanded health information exchange, digital literacy, and adoption of advanced technologies. 

Initiatives were informed by robust stakeholder engagement, including:

• Over 400 public comments
• A town hall with more than 600 participants
• Targeted community conversations and legislative engagement

Selections reflect public input, federal priorities, sustainability potential, and evidence-based models that work in rural North Carolina. 

NC ROOTS (Rural Organizations Orchestrating Transformation for Sustainability) Hubs are regional, locally governed networks that coordinate care and implement NCRHTP initiatives. Each hub will support activities via hub network partnerships across primary care, behavioral health, workforce development, value-based payment, and digital health, tailored to regional needs. 

ROOTS Hubs are designed to serve as anchors for rural transformation, coordinating across sectors and aligning medical, behavioral, and social services in ways that are locally governed and community-informed. 

Details on eligibility, governance requirements and selection criteria will be released in a forthcoming RFA.

Additional guidance will be provided in the ROOTS Hub Lead Entity solicitation. 

Selection process, number of hubs, and evaluation criteria will be included in the RFA. 

A statewide learning and data-sharing approach will be established as part of program implementation. NC ROOTS hub networks will be expected to convene regularly through routine communication and meetings with ROOTS Hubs to exchange best practices, lessons learned, and identify ongoing areas for improvement. 

NCDHHS intentionally used the broadest federal definition of rural available for the NCRHTP application. This approach was selected to align with federal standards, maximize eligibility, and give North Carolina the strongest opportunity to secure resources for rural communities.

Specifically, North Carolina relied on:

• HRSA’s Rural Health Grants Eligibility Analyzer, and
• Federal Office of Rural Health Policy (FORHP) designations

Under this approach, any county with at least one census tract designated as rural was included. As a result, 85 of North Carolina’s 100 counties were designated as rural for NCRHTP purposes. This definition ensures that all rural communities in North Carolina have an opportunity to benefit from the NCRHTP. 

Yes. Organizations located outside designated rural counties may participate if they serve rural populations or support NCRHTP goals. This includes health systems, academic institutions, nonprofits and statewide organizations. 

Activities and investments may vary by region based on local needs, hub design and available funding. 

North Carolina will use the six Medicaid regions, with NCRHTP funding and activities focused on rural counties within those regions. 

North Carolina was awarded $213 million for Year 1. CMS guidance asked North Carolina to budget $200 million annually in years 2-5, but funding for subsequent years may increase or decrease depending on Year 1 performance. 

Details on funding flow, subgrants, administrative cost limits and payment mechanisms will be shared after CMS approval and through future RFAs. 

Specific percentages will be outlined in program guidance and funding solicitations. 

NCDHHS will post information on how to apply for NCRHTP funding on NCDHHS' Rural Health Transformation Program webpage following completion of required state and federal administrative steps. 

• Application submitted: November 2025
• CMS award notification: December 29, 2025
• Implementation begins: Early 2026
• Program duration: 5 years (through 2031) 

Yes. Additional details on technical assistance and application support will be shared prior to funding opportunities opening. 

Medicaid is a key lever for sustainability, particularly through value-based payment models, but NCRHTP is broader in scope and includes uninsured and underinsured populations.

The program is designed to align with health systems, Federally Qualified Health Centers, Certified Community Behavioral Health Clinics, Rural Emergency Hospitals, Local Management Entities/Managed Care Organizations (LME/MCOs), Health Service Organizations (HSOs), and other existing initiatives to avoid duplication and maximize impact. 

The program will expand CCBHCs, crisis services, mobile outreach, school-based care, and access to opioid treatment and mental health services. 

Through rural residencies and fellowships, training centers, simulation labs, pipeline programs, and incentives for rural service. 

Investments include telehealth, NC HealthConnex, AI-enabled tools, and digital literacy programs to modernize rural care delivery. 

Metrics include access to care, chronic disease outcomes, maternal and child health, behavioral health access, workforce recruitment and retention, and technology adoption. Continued funding is tied to demonstrated progress. 

Stakeholders participated through surveys, town halls, listening sessions, and direct engagement. NCDHHS is committed to continued engagement throughout implementation. 

Visit NCDHHS' Rural Health Transformation Program webpage for updates, documents, and engagement opportunities.