Healthy Opportunities Pilots – NC Medicaid’s Effort to Buy Health, Not Just Health Care

Blog | June 22, 2021


By Brieanne Lyda-McDonald


Implementation of Medicaid managed care in North Carolina will begin July 1, 2021. (Read our previous blog posts to learn about the basics of Medicaid transformation and the difference between transformation and expansion.) Transformation to Medicaid managed care brings another exciting development with the Healthy Opportunities pilots, a first of their kind. Understanding that individuals’ health is impacted by a broad variety of non-medical factors, NC Medicaid is launching the innovative Healthy Opportunities pilots, which will allow Medicaid dollars to purchase non-medical services that address unmet needs in housing, transportation, food, and interpersonal safety. A list of covered services and rates is available in the North Carolina Department of Health and Human Services (NC DHHS) Healthy Opportunities FAQs.

Under the Healthy Opportunities pilots, Medicaid enrollees in the three pilot regions (see below for regions) will be evaluated by care managers from their prepaid health plan (PHP) for unmet non-medical needs. Enrollees are eligible for pilot services if they live in a pilot region, have at least one unmet need, and have at least one qualifying physical or behavioral health condition. (Learn more about the Healthy Opportunities pilots at NC DHHS.)

Medicaid enrollees participating in the pilots will be directed to human services organizations (HSOs) in their community to receive services to address their needs. PHPs and HSOs will be linked using a web-based platform called NCCARE360. This platform is another first of its kind – a statewide coordinated care network. NCCARE360 provides a way to identify HSOs that can provide needed services, electronically links patients with those services, and tracks follow-up and access to services. Patients, HSOs, PHPs, and health care providers can all be linked electronically, assisting with care management and evaluation of whether services were received. Read more about NCCARE360 in this previous blog post.

NCCARE360 worked to meet the challenges faced by North Carolinians during the COVID-19 pandemic by rolling out its network to all 100 counties at a faster pace than planned. As of the end of February 2021, over 2,200 organizations had been onboarded across the state, with nearly 37,000 users.

Healthy Opportunities Network Leads (previously called Lead Pilot Entities) were announced on May 27, 2021. They have been selected to develop a network of HSOs within their region, provide technical assistance to HSOs, facilitate payment and learning collaboratives between HSOs and PHPs, and manage evaluation data for their region. Selected network leads and regions are:

  1. Access East, Inc.: Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, Pitt
  2. Community Care of the Lower Cape Fear: Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender
  3. Dogwood Health Trust: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey

Network leads will be developing their network of HSOs over the coming year, with pilot service delivery scheduled to begin in spring of 2022. The pilots will be evaluated by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. NC DHHS will also conduct rapid-cycle evaluations using “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.”