Healthy Opportunities Pilots
Service Interruptions
Due to Hurricane Helene, many Healthy Opportunities Pilots (HOP) services in western NC (Impact Health) were temporarily down. HOP enrollment has resumed, and services have been restored at limited capacity, but there may be a delay in service delivery due to ongoing recovery efforts. If you need immediate help, please call NC 211.
The Healthy Opportunities Pilots (HOP) is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees. The federal government has authorized up to $650 million in Medicaid funding for the Pilots over five years.
NC Medicaid is authorized to implement HOP via an 1115 waiver, for which we have received an extension. Additionally, the Department continues negotiations for the waiver renewal request, which includes an additional five years and statewide expansion. Find more information on NC Medicaid’s request to renew the waiver at Waiver Renewal Request.
Read real life stories and get data on the impact of Healthy Opportunities on the lives of North Carolinians on the Healthy Opportunities Pilots at Work page.
Background
Through the Healthy Opportunities Pilots, the North Carolina Department of Health and Human Services (NCDHHS) is dedicated to:
- Ensuring members can access Pilot services in a timely manner and in a way that meets their needs and improves their health.
- Demonstrating equity across all aspects of the Pilot program—including through ensuring diverse and equitable participation in the Pilots for Medicaid members and human service organizations.
- Strengthening community capacity to provide high-quality, member-centered services.
Importantly, the Pilots will allow for the establishment and evaluation of a systematic approach to integrating and financing evidence-based, non-medical services into the delivery of healthcare. If shown to be effective in improving health outcomes and reducing healthcare costs after rigorous evaluation, the NC Department of Health and Human Services will look to systematically integrate high-value Pilot services statewide through NC Medicaid Managed Care.
Services launched for eligible Standard Plan members as follows across all three Pilot regions:
- March 15, 2022: Food services became available across all Pilot regions (see next section below).
- May 1, 2022: Housing and transportation services were added and became available across all Pilot regions.
- April 5, 2022: Toxic Stress and cross-domain services became available in all Pilot regions.
As of the second quarter 2023 all Pilot services are available to eligible members of Tailored Plans.
Pilot Regions
A larger version of the map is available here.
The Pilots will operate in three geographic regions of the state, which were defined by the three Healthy Opportunities Network Leads (the Network Leads) that the Department procured through a Request for Proposal (RFP). The following organizations serve as Network Leads, two in eastern North Carolina and one in western North Carolina:
- Access East, Inc. - counties: Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, Pitt.
- Community Care of the Lower Cape Fear - counties: Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender.
- Impact Health - counties: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey.
For additional information about Human Service Organization (HSO) responsibilities, see the Healthy Opportunities Pilots Webinar: Human Service Organizations slide presentation.
Pilot Services
The Healthy Opportunities Pilots will cover the cost of 29 interventions defined and priced in the Department’s Updated HOP Fee Schedule (effective July 1, 2024). These services were selected based on their potential to improve health outcomes and/or lower health care costs and address the housing, food, transportation, interpersonal violence and toxic stress needs of qualifying Medicaid members. Each Network Lead must contract with HSOs in their Pilot region to cover all domains of services for all enrolled members in their region.
Eligibility Criteria
To be eligible for and receive Pilot services, NC Medicaid Managed Care members must live in a Pilot region (in one of the counties listed above) and have at least one qualifying physical or behavioral health condition and one qualifying social risk factor, as defined by the Department and CMS.
In October 2023, CMS approved an expansion of Pilot-qualifying clinical conditions in an effort to ensure more individuals that can benefit from Pilot services are eligible to receive them.
Key Pilot Entities
Many players have important roles in the successful implementation of the Pilots:
All Medicaid HOP Administrators will play a central role in implementing the Healthy Opportunities Pilots and are ultimately responsible for managing Pilot participants’ physical, behavioral and social needs. HOP Administrators’ key Pilot responsibilities include:
- Managing a capped allocation of funding to spend on Pilot services and maximizing value within their allocations;
- Leading the integration of non-medical services into their health care delivery approach, including via their care management entities;
- Determining which members meet Pilot eligibility criteria and authorizing Pilot services; and
- Paying non-traditional providers (HSOs) with Pilot funds.
Care managers who work with Medicaid enrollees on their full range of physical, behavioral and non-medical needs work with the HOP Administrators to identify people who would benefit from and qualify for Pilot services, propose services that may benefit the enrollee, coordinate, track and manage their Pilot services over time.
Network Leads (formerly referred to as Lead Pilot Entities, or LPEs), are new, innovative entities in North Carolina that play a critical role in the Pilots by connecting the health care and social service sectors. Network Lead responsibilities include:
- Serving as a single point of accountability for HSOs and HOP Administrators, effectively bridging the gap between the healthcare and social services industries;
- Serving as a local anchor to build the capacity of HSOs to participate in Medicaid, including by distributing capacity-building funds and providing technical assistance; and
- Developing and managing a high-quality network of HSOs.
Human Service Organizations (HSOs) are community-based organizations or social service agencies that are contracted to deliver Pilot services. They play a critical role in delivering the 29 Pilot interventions to Pilot enrollees and other members of the community. HSO key Pilot responsibilities include:
- Delivering high-quality Pilot services in a culturally competent manner in accordance with Pilot standards;
- Building service capacity to meet community needs; and
- Developing capabilities to participate in the health care delivery system including tracking, reporting and invoicing for Pilot services delivered to Pilot enrollees.
Evaluation
A key component of the Pilots is a comprehensive and rigorous approach to evaluation. In collaboration with the University of North Carolina, Cecil G. Sheps Center for Health Services Research, NCDHHS will:
- Evaluate the effectiveness of the non-medical interventions and the role of the Network Lead in improving health outcomes and reducing healthcare costs for high-risk NC Medicaid Managed Care members.
- Leverage evaluation findings to embed cost-effective interventions that improve health outcomes in the Medicaid program statewide, furthering NCDHHS’ goals for a sustainable Medicaid program.
- Support the sustainability of delivering non-medical services identified as effective through the evaluation, including by strengthening the capabilities of HSOs and partnerships with health care payers and providers.
Resources
Additional Resources
Care Management Trainings
- North Carolina Area Health Education Centers (NC AHEC) Trainings
- For AMH+/CMA/LME Care Manager live trainings and AHEC trainings for Care Management teams who will provide HOP Care Management to Tailored Care Management eligible members, please visit the Tailored Care Management page.
Care Management Resources
- Guidance on Duplicative Medicaid and Healthy Opportunities Pilot Services
- Healthy Opportunities Pilot Member Consent Form - English | Spanish
- Healthy Opportunities Pilot Consent Form Job Aid - English | Spanish
- Healthy Opportunities Pilot Program Guide for LHDs
- Healthy Opportunities Pilots - No Wrong Door Approach to Enrollment
- Healthy Opportunities Pilots Tier 3 AMH Provider Manual (see Appendix G through I)
- Pilot Overview and Care Management Team Roles and Responsibilities
- How Care Managers Can Choose Appropriate Food Services
- PESA Companion Guide
For additional information and support specific to care managers, visit NC Medicaid's Advanced Medical Home webpage.
- Evidence Base Roundtable Series #1 Kickoff
- Evidence Base Roundtable Series #2 SIREN
- Evidence Base Roundtable Series #3 Food and Pilots Evaluation
- Evidence Base Roundtable Series #4 Housing, Transportation and Legal Support
- Evidence Base Roundtable Series #5 Network Lead Pilot Region Overview
- Evidence Base Roundtable Series #6 Intimate Partner Violence
- Hurricane Helene Resources for Human Services Organizations (HSOs)
- Frequently Asked Questions
- Healthy Opportunities Pilots Fact Sheet
- Healthy Opportunities Pilots Continuous Improvement Efforts Year 1 Update Fact Sheet - June 2023
- Healthy Opportunities Pilots: Housing Services Questions and Answers
- Healthy Opportunities Pilots Webinar: Focus on Human Services Organizations
Archive
Stakeholder Feedback Requested
On July 15, 2019, NC released important technical documents for stakeholder feedback related to the Healthy Opportunities Pilots. The documents include:
1. Healthy Opportunities Pilots Service Definitions and Pricing Methodology: A request for feedback on detailed pilot service definitions and pricing information, especially from frontline human service providers. Stakeholder feedback on this document will inform the development of an equitable and transparent fee schedule for Pilot services. DHHS encourages stakeholders to use this template to provide feedback to healthyopportunities@dhhs.nc.gov by 5 p.m. Aug. 2, 2019.
2. Healthy Opportunities Lead Pilot Entity (LPE) Statement Of Interest and Supplementary Guidance: A request for a non-binding Statement of Interest (SOI) to bid from organizations interested in serving in the pilots as an LPE, plus more information about entities that may serve as an LPE. DHHS envisions that LPEs will serve as the essential connection between traditional healthcare and human service organizations and will play a crucial "behind the scenes" role by establishing a network of frontline human service providers to provide pilot services and connect that network to Pre-paid Health Plans. DHHS encourages potential LPE applicants to use this template to submit their SOI to healthyopportunities@dhhs.nc.gov by the updated deadline of 5 p.m. Aug. 12, 2019.
3. Healthy Opportunities Pilot LPE Statement of Interest Submissions: The compiled list of Statements of Interest (SOIs) will serve as a tool to promote community awareness and collaboration among organizations interested in bidding to serve as an LPE and other organizations (healthcare and human services organizations, among others) in its region. Healthy Opportunities is in the process of developing a request for proposals (RFP) to procure two to four LPEs through a competitive bidding process. DHHS anticipates releasing the LPE RFP in fall 2019 and selecting LPEs in early 2020. As a reminder, the inability to submit an SOI does not preclude entities from submitting an RFP response. Submission of an SOI does not obligate an organization to submit a response to the LPE RFP and will not impact the evaluation of RFP responses. Please continue to check the Healthy Opportunities Website for updates and news.
On Feb. 15, 2019, NC DHHS released a policy paper and RFI on the Healthy Opportunities Pilots. The policy paper describes the preliminary Healthy Opportunities Pilot program design. The RFI and accompanying Cost Worksheets seek feedback on considerations related to Pilot design and implementation. More information about the Healthy Opportunities Pilots can be found in the RFI and the Healthy Opportunities Pilots Frequently Asked Questions (FAQs).
On March 5, 2019, NC DHHS posted an addendum to the RFI: Addendum 1: Department Response to Questions and Revisions to the RFI. This addendum responds to questions received about the RFI and makes some revisions to the RFI regarding submission.
Respondents may respond to the RFI using a Fillable PDF Version of the Healthy Opportunities Pilots RFI. Respondents seeking to submit multiple service description templates can also submit a standalone Fillable PDF of the Healthy Opportunities Pilots RFI Service Description Template and may submit as many services as preferred.
NC DHHS recently hosted two webinars that provided additional information on the policy paper and RFI.
- On March 15, 2019, NCDHHS posted an addendum to the Request for Information (RFI): Addendum 3: Department Response to Questions, answering additional questions received about the RFI.
- On March 13, 2019, NC DHHS posted an addendum to the RFI: Addendum 2: RFI Submission Deadline Extension, extending the deadline for responses to the RFI to 2 p.m. EST on March 20, 2019.
- On March 5, 2019, NC DHHS posted an addendum to the RFI: Addendum 1: Department Response to Questions and Revisions to the RFI. This addendum responds to questions received about the RFI and makes some revisions to the RFI regarding submission.
Healthy Opportunities Network Lead Award
The North Carolina Department of Health and Human Services selected organizations to serve three regions of the state, marking a major milestone towards launching the nation’s first comprehensive program to test evidence-based, non-medical interventions designed to reduce costs and improve the health of Medicaid beneficiaries.
Following a competitive selection process, the following organizations reach three regions, two in eastern North Carolina and one in western North Carolina.
- Access East, Inc.: Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin, Northampton, Pitt
- Community Care of the Lower Cape Fear: Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender
- Dogwood Health Trust: Avery, Buncombe, Burke, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Yancey
The Pilots operate within the NC Medicaid Managed Care program and are an important part of fulfilling the Department’s commitment to buying health, not just health care. The Healthy Opportunities Pilots is a groundbreaking program that began in spring 2022 to cover the cost of approved services related to housing, food, transportation, interpersonal safety and toxic stress that directly impact people’s health outcomes and health care costs.
Learn more about the Healthy Opportunities Pilots and the Healthy Opportunities Network Lead (formerly referred to as Lead Pilot Entity, or LPE) contract awards in the May 27 press release.
Procurement of Network Leads (formerly known as Lead Pilot Entities)
On Nov. 5, 2019, the North Carolina Department of Health and Human Services (DHHS) released a Request for Proposals (RFP) for the Healthy Opportunities Pilots implemented as a part of Medicaid managed care.
The RFP selected Lead Pilot Entities (LPEs) through a competitive procurement process and entered into contracts with LPEs to operate elements of the Healthy Opportunities Pilot program. LPEs contract directly with other organizations to build a network of Human Services Organizations to deliver Pilot services in their geographic area.
The deadline to submit proposals was Feb. 14, 2020, at 2 p.m. The Department received proposals from nine Offerors. Please see the list of Healthy Opportunities Lead Pilot Entity Offerors for a list of organizations that submitted a proposal.
The RFP and all related information is available on the Requests for Proposals (RFPs) and Requests for Information (RFIs) page under REQUEST FOR PROPOSAL FOR HEALTHY OPPORTUNITIES LEAD PILOT ENTITY.
Lead Pilot Entities Request for Proposals Fact Sheet - Nov. 5, 2019.
This page was last modified on 10/30/2024