Healthy Opportunities Pilot Projects: A New Dimension in Medicaid Services
by Ray McBeth, PhD
It is now a well-documented fact that only about 10%-20% of a person’s health is a direct result of the specific health care services they actually receive and that the remaining percentage is a by-product of the other factors that affect them including physical environment, socio-economic factors, health behaviors, and heredity. This, of course, is not new information, but only recently has more attention been paid to systematically addressing what are called these social determinants of health (SDOH) or unmet health-related needs.
To help address these social determinants in North Carolina, Medicaid Transformation, which is a shift from fee-for-service to managed care, includes a unique component: Healthy Opportunities Pilot Projects. These are demonstration projects that allow Medicaid funds of up to $650 million dollars, over and above funds provided for managed care itself, to fund non-medical services aimed at alleviating or improving adverse conditions that negatively affect health in specific areas of need. The goal is to use Medicaid funds to create healthier communities for its most vulnerable citizens who meet Medicaid eligibility standards. After the pilot projects have ended, those services determined to reduce health care costs and improve outcomes will be incorporated into the general Medicaid benefits package for all recipients going forward.
To receive grant funding as a pilot project, local communities had to organize and submit a comprehensive proposal designating a “Lead Pilot Entity (LPE)” and demonstrate their ability to manage the funds, establish community agency collaboration and mobilize the areas to be served. A total of nine proposals were submitted to NC-DHHS. Those who submitted proposals included: Access East, Inc., Carolina Collaborative Community Care, Community Care of the Lower Cape Fear, Dogwood Health Trust, Duke University Health Care System, Mecklenburg County Public Health, North Carolina Community Action Association, Piedmont Council Regional Development Corp., and Third Year Community Resilience. However, this initiative slowed when the launch of NC Medicaid Managed Care was delayed in 2019 due to state budgetary issues, followed by COVID-19 impacts in 2020. Now, Medicaid Managed Care is scheduled to launch July 1, 2021 and the pilot projects approximately a year later, in the spring of 2022. Three “Healthy Opportunities Network Leads” were selected and announced in late May 2021. They are:
Access East, Inc. to serve Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, and Pitt counties;
Community Care of the Lower Cape Fear to serve Bladen, Brunswick, Columbus, New Hanover, Onslow, and Pender counties; and
Dogwood Health Trust to serve Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, and Yancey counties.
For Medicaid beneficiaries to be eligible for services delivered through the pilots, they must meet three standards: they must live in one of the selected counties, they must meet certain specified needs-based criteria (e.g., multiple chronic conditions, high ED utilization or hospitalizations, high risk pregnancy, low birth weight), and they must also have selected social risk factors around food, housing, transportation and/or interpersonal violence. If these criteria are met, the beneficiary will be eligible for selected evidence-based services delivered by participating community-based organizations in the three pilot areas. The need for these services are to be assessed, managed by, and evaluated through Enhanced Care Management – an essential service of each selected pilot program.
An essential component of Medicaid Managed Care and a requirement of all Health Plans, is SDOH screening of every Medicaid member. Presumably, identified needs will be addressed through aspects of the Plan benefits and community partner linkages. Medicaid beneficiaries living within the counties receiving Healthy Opportunities pilot funding will undergo further SDOH stratification for enhanced services. While there are many more critical SDOH factors other than the four being targeted by the pilots (e.g., employment), efforts and services will initially be focused on these factors. An objective of the Healthy Opportunities grants is to identify SDOH needs and have them addressed by community-based service organizations. NCCARE360, a statewide referral system, will be used to track referrals and further identify service gaps. The Healthy Opportunities Network Lead is the facilitating connection between the PHPs and the human service and community-based organizations actually delivering the services. The Network Lead is also responsible for developing, managing, and paying for the pilot services with funds from the PHPs, as well as providing support and technical assistance to those in their networks.
For more information from NC-DHHS on the pilot projects see: