North Carolina Medicaid Healthy Opportunities Overview

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North Carolina Medicaid Transformation

In 2015, the North Carolina General Assembly enacted Session Law 2015-245 with the intent of transforming the state’s Medicaid and NC Health Choice programs. The legislature’s stated goals for this transformation include budget predictability and sustainable, quality care for those in need. In October 2018, the federal Centers for Medicare and Medicaid Services (CMS) approved the state’s 1115 Demonstration Waiver application for Medicaid transformation.

As part of the waiver, most Medicaid beneficiaries in North Carolina will transition from the current fee-for-service program managed directly by the state to a managed care plan offered by commercial prepaid health plans (PHPs). Some beneficiaries will have the option of enrolling with a PHP, some will have delayed enrollment, and others with specialized needs will not enroll with a PHP.

NC Medicaid Healthy Opportunities

Research shows social, environmental, and behavioral factors can impact up to 80% of a person’s health. Managed care plans (or PHPs) will address these non-medical drivers or social determinants of health as part of Medicaid Transformation. The North Carolina Department of Health and Human Services (NC DHHS) will launch two to four regional Medicaid Healthy Opportunities Pilots (the Pilots) to test the effectiveness of non-medical, evidence-based interventions in addressing the health outcomes of eligible Medicaid beneficiaries.

A Lead Pilot Entity (LPE) will serve as a backbone organization in each pilot to oversee a network of human services organizations (HSOs) who will provide pilot services. The Pilots will receive Medicaid funding to deliver services related to food, housing, transportation, interpersonal safety and toxic stress to beneficiaries who demonstrate both medical and social needs. NC DHHS will rigorously evaluate how well pilot services impact health outcomes and healthcare costs. Based on the results, the state will consider integrating effective pilot services into statewide Medicaid managed care. 

What is “Healthy Opportunities of The Piedmont”?

For 50 years, the Piedmont Triad Regional Council (PTRC) has developed and supported an HSO network by establishing partnerships and providing management, planning, financial oversight, and technical assistance. Leveraging this experience, PTRC has been convening regular meetings with the region’s healthcare systems and key HSOs with the goal of establishing a Medicaid pilot in the Piedmont Triad region. Area stakeholders chose to initiate pilot services in Forsyth, Guilford, and Rockingham counties and designated PTRC as the LPE for this collaborative effort, entitled “Healthy Opportunities of the Piedmont.”

How can I get involved?

To find out more, attend our upcoming Healthy Opportunities of the Piedmont events. To be added to our e-mail distribution, please contact Yolanda Davenport at ydavenport@ptrc.org or 336-904-0300.

For More Information

Please click on the links below for additional information about:

Healthy Opportunities of the Piedmont and PTRC’s collaborative efforts to improve health outcomes for North Carolinians in the Piedmont

NC Medicaid Healthy Opportunities for NC’s statewide efforts to achieve Healthy Opportunities

NC Medicaid Transformation on state plans for achieving whole-person care

NC Medicaid Managed Care for background and enrollment timelines for beneficiaries transitioning to Prepaid Health Plans

FAQs about Medicaid Transformation

NC Medicaid Policy Papers to learn more about NC Medicaid Transformation policies, design of the Healthy Opportunities Pilots, and the impact of social determinants of health