NC Medicaid
Healthy Opportunities Pilots Fact Sheet
In October 2018, the federal Centers for Medicare & Medicaid Services (CMS) approved North Carolina’s 1115 waiver
for a five-year demonstration period. The waiver provides the North Carolina Department of Health and Human
Services (DHHS) authority to transition its fee-for-service delivery system to a managed care program and, as part
of the transition, important flexibility to implement a groundbreaking pilot program in select regions to promote value
through evidence-based interventions designed to address non-medical factors that drive health outcomes and costs.
NORTH CAROLINA’S APPROACH
DHHS is committed to improving the health and
well-being of North Carolinians with an innovative,
well-coordinated system of care that addresses both
the medical and non-medical drivers of health. While
high-quality medical care is crucial, up to 80 percent
of a person's health is determined by social and
environmental factors. To create a system that improves
health and promotes value. North Carolina must look
beyond the four walls of a hospital or clinic.
All of North Carolina's Medicaid managed care plans
— known as Prepaid Health Plans (PHPs) — will have a
role in addressing the medical and non-medical factors
that drive health outcomes and costs. For example,
PHPs will implement a standardized screening tool
for all beneficiaries that assesses their non-medical
needs, such as unstable housing, insufficient food and
interpersonal violence. Where identified, PHPs will
connect beneficiaries to community resources using
North Carolina's new Resource Platform and, in high-
need cases, provide more support, such as navigating
to a local food bank or domestic violence shelter.
HEALTHY OPPORTUNITIES PILOTS
North Carolina will launch “Healthy Opportunity Pilots"
in two to four geographic areas of the state to test
evidence-based interventions designed to reduce
costs and improve health by more intensely addressing
housing instability, transportation insecurity, food
HEALTHY OPPORTUNITIES
“We want to build an innovative, whole-person centered, and
well-coordinated system of care that addresses both medical
and non-medical drivers of health.”
Mandy Cohen, Secretary of the North Carolina Department
of Health and Human Services
insecurity, interpersonal violence and toxic stress for
eligible Medicaid beneficiaries.
The federal government has authorized up to $650 million
in state and federal Medicaid funding for the pilots over
the five-year life of the waiver, including capacity-building
funding in the early years to support the launch of the
project. PHPs will implement the pilots in collaboration
with a network of human service organizations (e.g.,
community-based organizations and social services
agencies) established and overseen by Lead Pilot Entities
(LPEs), described later in this document.
To ensure there is accountability for investment in these
pilots, rapid-cycle assessments will track enrollees'
health outcomes and costs to determine which
interventions are most and least effective, enabling
North Carolina to shift pilot dollars to interventions
with a demonstrated impact on cost and outcomes.
Additionally, the demonstration will increasingly use
value-based payments over time, starting with incentive
payments that reward PHPs, LPEs and participating
community-based providers for successfully preparing
for pilot launch and executing their responsibilities.
HEALTHY OPPORTUNITY PILOTS - A FEDERAL PERSPECTIVE
“As we seek to create a health care system that truly rewards value, we must consider the impact that factors beyond medical care have in
driving up health costs. That’s why many states are beginning to think about ways to better address the root cause of chronic illness. As part
of this demonstration, North Carolina will implement a groundbreaking program in select regions to pilot evidence-based interventions
addressing issues like housing instability, transportation insecurity, food security, interpersonal violence and toxic stress.”
Seema Verma, CMS Administrator; Health Affairs, Oct. 24, 2018
1