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A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunities Pilots

Medicaid funds typically cannot be used to pay for non-medical interventions that target the social determinants of health. However, in October 2018, CMS approved North Carolina’s Section 1115 waiver which provides financing for a new pilot program, called “Healthy Opportunities Pilots,” to cover evidence-based non-medical services that address specific social needs linked to health/health outcomes. The pilots will address housing instability, transportation insecurity, food insecurity, and interpersonal violence and toxic stress for a limited number of high-need enrollees. This waiver differs from others recently approved by the Trump Administration that aim to address health determinants by conditioning coverage on meeting work requirements. The pilot program may yield important evidence about how addressing certain non-medical needs may impact program costs and health outcomes. However, the scope and impact of the program is restricted by its limited funding. Implementing a long-term program on a broader scale would require larger sustainable financing streams and it’s unclear at this point whether CMS will use this waiver as a model for other states. This brief summarizes key features of the Healthy Opportunities Pilots.

Healthy Opportunities Pilots Key Highlights

Funding – CMS authorized $650 million in Medicaid funding for the pilot over five years, $100 million of which will be available for capacity building.

Pilot area – will include two to four regions of the state and is expected to serve approximately 25,000 to 50,000 beneficiaries, or about 1% to 2% of total Medicaid enrollees in North Carolina.

Eligible beneficiaries – must be enrolled in a managed care plan and must have at least one physical or behavioral health risk factor and at least one social risk factor.

Pilot services – will include evidence-based enhanced case management and other services, which must be approved by CMS, to address enrollee needs related to housing, food, transportation, and interpersonal safety.

Health plans – will manage the pilot budget and, working in close collaboration with care managers, will determine enrollee eligibility and authorize the delivery of pilot services.

Lead Pilot Entities (LPEs) – will develop, contract with, and manage the network of human service organizations that will deliver pilot services.

Timeline – The state will release an RFP for LPEs by November 2019 and anticipates beginning to deliver pilot services in late 2020.

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