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NYS FAM Research
Resource Guide

Healthy Opportunities Pilots   

This website gives details about how 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.
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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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Lessons Learned Thus Far From North Carolina’s Healthy Opportunities Pilots

This news article from NCIOM shares valuable insights from research conducted by the Margolis Center, Will Bleser, PhD, MSPH, that evaluates and assesses the impact of the Pilot program on health outcomes.

North Carolina Institute of Medicine. (2022, August 15). Lessons Learned Thus Far From North Carolina's Healthy Opportunities Pilots. https://nciom.org/lessons-learned-thus-far-from-north-carolinas-healthy-opportunities-pilots/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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Practical, Timely Lessons for Advancing and Aligning North Carolina's Health Care Transformation Leadership to Address Social Needs

North Carolina's Pilot service delivery was paused on July 1, 2025. This article aims to bring awareness to the challenges that exist for integrated health and social services. Highlighting a need for practical guidance on improved implementation of the Pilots, North Carolina’s broader Medicaid transformation. In doing so, looking at similar initiatives in other states and project deliverables.

Whitaker, R., Huber, K., Van Stekelenburg, B., et al. (2018). Practical, Timely Lessons for Advancing and Aligning North Carolina's Healthcare Transformation Leadership to Address Social Needs. Duke - Margolis Institute for Health Policy. https://healthpolicy.duke.edu/projects/practical-timely-lessons-advancing-and-aligning-north-carolinas-health-care-transformation

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2018-2025

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How North Carolina Is Using Medicaid To Address Social Determinants of Health 

This article addresses the fact that although Medicaid coverage is associated with better health outcomes and lower mortality rates; clinical interventions are not sufficient in tackling health inequities that negatively impact low-income populations in achieving improved health and well-being. North Carolina's Healthy Opportunities Pilot program allows state governments to use Medicaid dollars to address social determinants of health.

Rapfogel, N. Rosenthal, J. (2022, February 3). How North Carolina Is Using Medicaid To Address Social Determinants of Health. Center for American Progress. https://www.americanprogress.org/article/how-north-carolina-is-using-medicaid-to-address-social-determinants-of-health/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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Healthy Opportunities Pilot: Network Lead-HSO Model Contract 

This contract defines the role of the Network Lead and provides information regarding the rights and responsibilities of a network lead of a Healthy Opportunities Pilot program and the agreement between the network lead and the Human Services Organization (HSO). It outlines the terms and conditions, privacy, security, and records access, and lists all contracted Pilot services and descriptions.

NCDHHS. (2021, October). Network Lead-HSO Contract: Healthy Opportunities Pilot-Network Lead-HSO Model Contract. https://www.ncdhhs.gov/network-lead-hso-model-contract/open

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2021

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Healthy Opportunities Pilot: PHP-Network Lead Model Contract  

This contract defines the role of the PHP-Network Lead and provides information regarding the rights and responsibilities of a PHP-Network Lead of a Healthy Opportunities Pilot program and the agreement between the network lead and the Human Services Organization (HSO). It outlines the terms and conditions, privacy, security, and records access, and lists all contracted Pilot services and descriptions.

NCDHHS. (2021, October). PHP-Network Lead Contract: Healthy Opportunities Pilot: PHP-Network Lead-HSO Lead Model Contract. https://www.ncdhhs.gov/php-network-lead-model-contract/open

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2021

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Healthy Opportunities Pilot Fee Schedule and Service Definitions

Updated fee schedule approved by CMS as of July, 2024. This schedule will continue to be updated in the future based on DHHS experience implementing the Pilots and any feedback from CMS.

NCDHHS. (2021, July1). Updated Healthy Opportunities Pilots Fee Schedule. https://www.ncdhhs.gov/healthy-opportunities-pilot-fee-schedule-and-service-definitions/open

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2024

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NCCARE360-third party statewide referral platform

North Carolina's Care360 (NCCARE360) is the first statewide coordinated community care network that electronically connects those with identified needs to community resources and allow for a feedback loop on the outcome of that connection. This solution ensures accountability around services delivered, provides a “no wrong door” approach and closes the loop on every referral made. As of June 2020, NCCARE360 is available in every county in North Carolina.
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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

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Waiver Approval - Reporting Requirements

This letter , addressed to the Deputy Secretary for Medical Assistance, describes and informs the reader of the limitations, scope, extent of demonstrations, and award details that were approved by CMS, in the form of the 1115 Medicaid demonstration project entitled, North Carolina Medicaid Reform Demonstration, during the timeframe of January, 2019, through October, 2024.

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2018

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Evaluation  

This article outlines the Healthy Opportunities Pilots (HOP) program and how, through an extension granted, NC Medicaid is authorized to implement HOP via an 1115 waiver. It provides information on background, pilot regions, pilot services, eligibility criteria, including key pilot entities and evaluation.
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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

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Evaluation Design Approval 

This document outlines the CMS approved NC evaluation design and the sections and tables provided in this letter detail the quantitative measures to be used to test each hypothesis, the source or custodian of each measure, the sample or population to which the measure is relevant, and the proposed data sources. This document also reiterates that it is well known that medical care is only responsible for a fraction of a person's health and that factors like social determinants of health and the environment are also considerable drivers. An increased emphasis on a whole person orientation will improve beneficiary outcomes.

Centers for Medicare and Medicaid Services (CMS). (2020, January 14). State Demonstrations Group letter to Mr. Dave Richard of the North Carolina Department of Health and Human Services. DHHS. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/Medicaid-Reform/nc-medicaid-reform-demo-eval-des-appvl-01152020.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2020

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A Landscape Analysis of Medically Supportive Food and Nutrition Interventions in California

This report looks at the existing assets of California related to Medically Supportive Food and Nutrition (MSF&N) programs and next steps needed to secure the benefits of expanding MSF&N with funding and capacity-building support through CalAIM. To support the transition of MSF&N interventions from pilot to permanent in California the UCSF Center for Vulnerable Populations, Harvard Law School’s Center for Health Law and Policy Innovation, the Food as Medicine Collaborative, and SPUR, worked together to survey 145 organizations in California. These efforts brought forward the need to identify all currently operating MSF&N programs and understand the most common barriers to scaling.

Ettman, K., Tong, J. , et al. (2021, October). Integrating Food into Health Care: A Landscape Analysis of Medically Supportive Food and Nutrition Intervention in California. SPUR, Food as Medicine Collaborative, Center for Vulnerable Populations: Zuckerberg San Francisco General Hospital. https://www.spur.org/sites/default/files/2021-11/SPUR_Integrating_Food_Into_Healthcare.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2021

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Building Partnerships to Advance Nutrition in California’s CalAIM Waiver

This article highlights a newly released case study series illuminating efforts in California to expand access to and coverage of nutrition interventions and other social services for Medicaid enrollees. California calls the services provided by its five-year Medicaid waiver, California Advancing and Innovating Medi-Cal (CalAIM), launched in 2022, Community Supports.

Center for Health Law and Policy Innovation. (2023, January 31). Harvard Health Law Lab Case Studies Pinpoint Early Successes, Challenges of California's Innovative Medicaid Program. Harvard Law School - Health Law & Policy, News. https://chlpi.org/news-and-events/news-and-commentary/news/harvard-health-law-lab-case-studies-pinpoint-early-successes-challenges-of-californias-innovative-medicaid-program/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2023

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Equity in CalAIM: How to Identify the Patients Who Will Benefit Most   

This report offers insights into California's CalAIM initiative and the efforts made to transform the state’s Medi-Cal program with a focus on equity and whole-person care. Enrollees with complex needs are receiving care management and supportive services through the Department of Health Care Services (DHCS) enlisted managed care plans. The links provided in this report address the unintended consequences of using utilization data to identify patients who would benefit from comprehensive services.

Davis, R., Kelly, L., Hamblin, A. (2023, May 10). Equity in CalAIM: How to Identify Patients Who Will Benefit Most. California Health Care Foundation. https://www.chcf.org/resource/equity-calaim-how-identify-who-will-benefit-most/#related-links-and-downloads

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2023

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Community Supports: Select Service Definition Updates (2025)

California's Department of Health Care Services has released an Action Plan committed to improvements to standardization and access among Members to ECM and Community Supports services. In this document, DHCS provides for each service definition a summary of the rationale for each set of refinements and the finalized, updated service definition. This document does not contain updates to the service definitions for the Housing Trio.

California Department of Health Care Services (DHCS). (2025, February). Community Supports: Select Service Definitions Updates. https://www.dhcs.ca.gov/Documents/MCQMD/Community-Supports-February-2025-Service-Definition-Updates.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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