By Brieanne Lyda-McDonald
North Carolina’s Section 1115 Medicaid Waiver  was approved by the Centers for Medicare & Medicaid Services on October 24, 2018, and paves the way for Medicaid transformation in the state. The waiver includes five-year pilot programs designed to allow for more substantial investments of Medicaid dollars in non-clinical health-related services. The goal is to learn how to finance interventions for health-related social needs and incorporate them into value-based payments. These pilots, referred to as Healthy Opportunities Pilots, will allow the North Carolina Department of Health and Human Services (NC DHHS) to test an Accountable Care Community (ACC)-style model with a Medicaid population. The primary difference between this and other ACC models is that others typically incorporate a broader network of payers, local government, and organizations that address non-clinical social needs outside of the state’s priority domains (i.e., food, housing, transportation, and interpersonal violence).
Pilots will be conducted in two to four “regions” of the state consisting of at least two contiguous counties that cover both rural and urban areas . Funding for each pilot will come from both public and private (e.g., philanthropic) sources. Services covered through the pilot include housing transition or tenancy sustaining services, targeted meal delivery services, transportation to health-related and social services, and home visiting programs and parent support . Populations included will be those with “complex health and social needs and children (and families) experiencing or at risk of significant and multiple adverse childhood experiences .” Areas participating in the pilots must meet the following objectives:
Organizational participants in the Healthy Opportunities Pilots will include Prepaid Health Plans serving Medicaid enrollees, health care providers, behavioral health agencies or providers, public agencies (e.g., local health department or department of social services), and community partners (e.g., philanthropies or human services organizations). Prepaid Health Plans will identify beneficiaries eligible for the pilots, assess their needs, connect them to pilot services, and manage funds allocated for those services . A Lead Pilot Entity for each pilot will serve as an NC DHHS contact and coordinator of pilot partners, finances, and required reports . Human services organizations that want to be involved in the pilots will need to contract with the Lead Pilot Entity to deliver services to pilot enrollees .
All entities involved in the pilot will be responsible for collecting and submitting data to assist with rapid-cycle evaluation of the pilots . This data collection and evaluation is critical to developing sustainable funding models for investments in non-clinical health services. While NC DHHS is focused on the Medicaid population, the lessons learned will be applicable to all payers and helpful in the development of ACCs across the state.
NC DHHS plans to release a Request for Information in early 2019, followed by a Request for Proposals in mid-2019. Lead Pilot Entities will be selected toward the end of 2019 and service delivery will begin in late 2020 .
The Healthy Opportunities Pilots will make North Carolina a national leader in testing innovative strategies for improving health and well-being and have the potential to change the way care is delivered and paid for across the state.
 North Carolina Department of Health and Human Services. North Carolina Medicaid and NC Health Choice: Amended Section 1115 Demonstration Waiver Application. November 20, 2017. https://files.nc.gov/ncdhhs/documents/files/NC-Amended-1115-Demonstration-Waiver-Application_20171120.pdf
 North Carolina Department of Health and Human Services. Healthy Opportunities Pilots Fact Sheet. https://files.nc.gov/ncdhhs/SDOH-HealthyOpptys-FactSheet-FINAL-20181114.pdf. Accessed November 16, 2018.