North Carolina Plans to Expand Medicaid SDOH Pilot Statewide

April 5, 2024
Independent evaluation shows the state is spending about $85 less in medical costs per Healthy Opportunities Pilots beneficiary per month

After two years of experimentation with addressing people’s social needs with services like food, housing, and transportation through Medicaid, the North Carolina Department of Health and Human Services (NCDHHS) is planning to expand the services statewide.

More than 288,000 services have been delivered and more than 20,000 NC Medicaid beneficiaries have enrolled across 33 predominantly rural counties in North Carolina as part of the Healthy Opportunities Pilots since the program began providing services two years ago. 

The Centers for Medicare and Medicaid Services (CMS) approved the Healthy Opportunities Pilots in 2018 as part of the state’s waiver to transition to Medicaid managed care. Also, North Carolina expanded who can get Medicaid starting Dec. 1, 2023. Enrollment has surpassed 400,000 in the expansion program’s first four months.

North Carolina says that preliminary research from the program’s independent evaluation shows the state is spending about $85 less in medical costs per Healthy Opportunities Pilots beneficiary per month. 

Those findings also show participants avoided a significant number of emergency department visits, and research shows participants have a reduced risk of food insecurity, housing instability and lack of access to transportation. Further, the findings showed that the longer a person was enrolled in the pilots the greater reduction of risk.

"The Healthy Opportunity Pilots are having a tremendous impact on the lives of thousands of people in North Carolina by removing barriers for people, particularly in rural areas, to services that are critical to whole-person health," said State Health Director and NCDHHS Chief Medical Officer Elizabeth Cuervo Tilson, M.D., M.P.H., in a statement. "This collaborative effort is also investing in the economy of our local communities, which also promotes health.”

NCDHHS used the example of one member to describe how the program works. A single mother had been staying at a local shelter with her children but needed life-saving surgery. Her children couldn’t remain in the shelter without her, which left her in an impossible position. Mom had secured an emergency housing voucher, but it wasn’t enough to cover rent in the county where she would be receiving treatment.

Through the Healthy Opportunities Pilots, her care managers were able to help her transfer her housing voucher and secure income-based housing near the hospital. They also helped her access financial support for her security deposit and utility setup fees — all services that are covered for the Healthy Opportunities Pilots participants.

Now, mom is able to focus on her health, schedule needed medical care, and keep her family together under one roof with help from her friends and the Healthy Opportunities Pilots.

Encouraged by early success of the program, NCDHHS renewed a federal 1115 waiver in October 2023, which included a request to allow expansion of Healthy Opportunities services statewide. NCDHHS anticipates working in collaboration with federal partners to expand the program and ensure more people in North Carolina receive these services.

Right now, the Healthy Opportunities Pilots services are available to qualifying NC Medicaid Managed Care Standard Plan beneficiaries who live in a Pilot region and meet at least one qualifying physical or behavioral health criteria and one qualifying social risk factor. The program looks forward to further extending access to these services later this year for Medicaid Direct beneficiaries who are eligible for tailored care management in the Pilot regions.

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