Frequently Asked Questions

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Frequently Asked Questions

General Pilot Information

HOP stands for Healthy Opportunities Pilot, a North Carolina Department of Health and Human Services contract. Serving as the Network Lead for Western North Carolina (WNC), Impact Health will support, oversee, and coordinate the work of participating HSOs. The pilot will evaluate health outcomes as well as healthcare costs by using Medicaid funds to pay for services specifically related to food, housing, transportation, interpersonal safety and toxic stress. The HOP will provide a mechanism for payers, providers, and HSOs to develop the tools, infrastructure, and financial means to integrate these essential services into the delivery of healthcare for eligible Medicaid members.

Pilot Entities

Impact Health is serving as the Network Lead for Region 1 in WNC. A Network Lead is an organization responsible for contracting with the Department and Prepaid Health Plans to develop and manage a network of HSOs providing Pilot services to Pilot Participants.

An HSO is a Human Services Organization that has contracted with Network Lead to participate in its network for the purposes of delivering Contracted Pilot Services. Network Lead establishes the network and monitors and oversees its HSOs under the terms of this Agreement.

HSOs must meet the following qualifications: 

  • Operating as a legal entity in North Carolina 
  • Provide social services covered by the Pilot program to Medicaid-eligible individuals residing within the Pilot region high-quality non-medical services to vulnerable, high-risk individuals in the following Priority Domains: housing, transportation, food insecurity, interpersonal violence and toxic stress.  
  • HSOs will enroll in NCTracks

HSOs act as frontline social service providers that contract with the Network Lead to deliver authorized, cost effective, evidence-based Pilot services to Pilot enrollees. Additionally, HSOs participate in the healthcare delivery system, including submitting invoices and receiving reimbursement for more information on the services delivered.

Geographic Service Area

This is the defined service area where your organization (the HSO) provides services. Impact Health was awarded a contract for Region 1 in WNC (highlighted in purple below).

WNC map


Medicaid managed care enrollees in Standard Plans and Behavioral Health I/DD Tailored Plans must live in a Pilot Region and have at least one of the below physical/behavioral health criteria. See below table for more details. 

Eligibility Category Age Physical/Behavioral Health Criteria (at least one, per eligibility category)
Adults 21+
  • Two or more chronic conditions. Chronic conditions that qualify an individual for pilot enrollment include: BMI over 25, blindness, chronic cardiovascular disease, chronic pulmonary disease, congenital anomalies, chronic disease of the alimentary system, substance use disorder, chronic endocrine and cognitive conditions, chronic musculoskeletal conditions, chronic mental illness, chronic neurological disease and chronic renal failure, in accordance with Social Security Act section 1945(h)(2).
  • Repeated incidents of emergency department use (defined as more than four visits per year) or hospital admissions.
Pregnant Women N/A
  • Multifetal gestation
  • Chronic condition likely to complicate pregnancy, including hypertension and mental illness
  • Current or recent (month prior to learning of pregnancy) use of drugs or heavy alcohol
  • Adolescent ≤ 15 years of age
  • Advanced maternal age, ≥ 40 years of age
  • Less than one year since last delivery
  • History of poor birth outcome including: preterm birth, low birth weight, fetal death, neonatal death
Children 0-3
  • Neonatal intensive care unit graduate
  • Neonatal Abstinence Syndrome
  • Prematurity, defined by births that occur at or before 36 completed weeks gestation
  • Low birth weight, defined as weighing less than 2500 grams or 5 pounds 8 ounces upon birth
  • Positive maternal depression screen at an infant well-visit
  • One or more significant uncontrolled chronic conditions or one or more controlled chronic conditions that have a high risk of becoming uncontrolled due to unmet social need, including: asthma, diabetes, underweight or overweight/obesity as defined by having a BMI of 85th percentile for age and gender, developmental delay, cognitive 67 impairment, substance use disorder, behavioral/mental health diagnosis (including a diagnosis under DC: 0-5), attention deficit/hyperactivity disorder, and learning disorders
  • Experiencing three or more categories of adverse childhood experiences (e.g., Psychological, Physical, or Sexual Abuse, or Household dysfunction related to substance abuse, mental illness, parental violence, criminal behavioral in household)
  • Enrolled in North Carolina’s foster care or kinship placement system

In addition to the above criteria, Medicaid enrollees must have at least 1 Social Risk Factor within the following categories:

Risk Factor Definition
Homelessness and Housing Insecurity
  • Individuals who are homeless: defined as an individual who lacks housing, including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and an individual who is a resident in traditional housing.
  • Individuals who are housing insecure: including individuals who, within the past 12 months, have ever stayed outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else’s home (i.e. couch surfing); are worried about losing their housing; or within the past 12 months have been unable to get utilities (heat, electricity) when it was really needed.
Food Insecurity Patients who are experiencing food insecurity – defined as the disruption of food intake or eating patterns because of lack of money and other resources – including those who:
  • Report reduced quality, variety, or desirability of diet. There may be little or no indication of reduced food intake. This is considered low food security.
  • Report multiple indications of disrupted eating patterns and reduced food intake. This is considered very low food security.
  • Report that within the past 12 months they worried that their food would run out before they got money to buy more.
  • Report that within the past 12 months the food they bought did just not last and they didn’t have money to get more.
Transportation Insecurity Patients for whom, within the past 12 months, a lack of transportation has kept them from medical appointments or from doing things needed for daily living.
At risk of, witnessing, or experiencing interpersonal violence Patients who report that they felt physically or emotionally unsafe where they currently live; within the past 12 months have been hit, slapped, kicked or otherwise physically hurt by anyone; or within the past 12 months have been humiliated or emotionally abused by anyone.

For more specific information on eligibility criteria, please visit the DHHS Healthy Opportunities Pilot RFP, starting on page 160.

Covered Services

Below is a list of the Pilot services in each of the domains. You can also refer to the list of services on the NCDHHS fee schedule.

  • Housing and Navigation Support and Sustaining Services
  • Inspection for Housing Safety and Quality
  • Housing Move-in Support
  • Essential Utility Set-up
  • Home Remediation Services
  • Home Accessibility and Safety Modifications
  • Healthy Home Goods
  • One-time Security Deposit and First Month’s Rent
  • Short-Term Post Hospitalization Housing
  • Food and Nutrition Access Case Management Services
  • Evidence-Based Group Nutrition Class
  • Diabetes Prevention Program (DPP)
  • Fruit and Vegetable Prescription 
  • Healthy Food Box (Delivery and/or Pick-up)
  • Health Meal (Delivery and/or Pick-up)
  • Medically Tailored Home Delivered Meals
  • Reimbursement for Health-Related Public Transportation
  • Reimbursement for Health-Related Private Transportation
  • Reimbursement for Gas Mileage
  • Transportation PMPM Add-on for Case Management
  • Vehicle repairs may be reimbursable
Interpersonal Violence/ Toxic Stress
  • IPV Case Management 
  • Violence Intervention Services
  • Evidence-Based Parenting Curriculum 
  • Home Visiting Services
  • Dyadic Therapy
Cross Domain
  • Holistic High Intensity Enhanced Case Management Services
  • Medical Respite
  • Linkages to Heath-Related Legal Supports

Fee Schedule

These rates are final and are not negotiable. Once published by the CMS, these are the reimbursable rates. Prior to Service Delivery I, no changes will occur to published rates. After Service Delivery I, the Department may update the fee schedule based on the results from the evaluations and increase HOP service payments to a greater value.

Refer to the list of services on the NCDHHS fee schedule.

Invoicing & Payments

After the service is delivered by the HSO, the HSO transmits their invoice to Impact Health (the Network Lead). Impact Health reviews the invoices for completeness and sends validated invoices to the health plan for payment. From there, HSOs are paid directly (either via check or direct deposit) from the health plans. Once the invoice is authorized, a remittance is sent with payment so that the HSOs can reconcile what services have been paid vs. those pending. The health plan then sends authorized encounter data to DHHS for tracking purposes.


NCCARE360 is a statewide network that unites healthcare and human services organizations with a shared technology that enables a coordinated, community-oriented, person-centered approach for delivering care in North Carolina. It will be a key tool for HSOs in our Healthy Opportunities Pilot because it helps providers electronically connect those with identified needs to community resources and allow for feedback and follow-up. This ensures accountability for services delivered, provides a “no wrong door” approach, closes the loop on every referral made and reports outcomes of that connection. NCCARE360 is available in all 100 counties across North Carolina.

Your organization will accept/decline referrals from care managers within the system. Additionally, after your service delivery is completed, you will update the status to indicate that the service was either completed or not. You will also communicate with care managers through this system for any additional information requested.

Yes, all HSOs participating in the Pilot Program must have a functional use and understanding of NCCARE360. Serving as an essential communication platform, NCCARE360 will allow for referrals, reports on service deliveries, and related outcomes for Pilot services to be shared seamlessly.

To join NCCARE360, please fill out the form on the registration page.

NCCARE360 has training videos for some of the functions that the system provides. If you are contracted with the network, training opportunities will also be available.

Application Process

If your organization previously submitted an LOI or has been in contact with Impact Health regarding submission, you should have received an invitation via JotForm to apply. You can request an invitation by emailing [email protected]

This round of applications will consist of two phases to choose from:

Phase 1: Organizations that are ready to apply and can meet a short deadline.

Application submission window closed June 3, 2022
Target launch date: Summer 2022

Phase 2: Organizations that are almost ready, but need a little bit more time to complete the application.

Application deadline to Impact Health: July 14, 2022
Target launch date: Fall 2022

Evaluation Criteria

The application review process is approximately 2-3 weeks, from initial review for completeness, Readiness Reviews, and Application Committee Review. For a more detailed timeline, please review the timeline below.

Each HSO is scored related to the following areas:

1. Diversity & Equity Up to 5 points
2. Services Up to 15 points
3. Geographic Reach Up to 5 points
4. Capacity Up to 15 points
5. Clients Up to 15 points
6. Staffing Up to 5 points
7. Community & Partner Relationships Up to 5 points
8. Technical Capacity Up to 5 points
9. Budget Up to 5 points
10. Additional questions focused on unique population or under-represented area(s) served N/A

Scoring: There is a maximum score of 75. If an organization scores below 15 points, the application will be put on hold and a staff member from Impact Health will reach out regarding your application. 


  • A copy of the executed Network Lead-HSO Model Contract will be delivered to the signatory for your organization via email once both parties have signed. 
  • To review the model contract prior to generation, please refer to this example contract.
  • For organizations that subcontract out portions of service delivery, further discussions will be had about the subcontractor’s potential role in your delivery of service method. Please note that all use of subcontractors must be approved by Impact Health prior to Pilot Service Delivery authorization.

Capacity Building Funds

Please refer to the HSO Network application. This will also be evaluated during the Readiness Reviews. As a reminder, only contracted HSOs are eligible to apply for capacity building funds.

  • Pilot Capacity Building funds can be utilized in the following categories only:
    • Operationalizing day-to-day Pilot-related responsibilities 
    • Developing necessary infrastructure/systems 
    • Pilot service delivery enhancements  
    • Participation in learning collaboratives 
    • Participation in Pilot Program Evaluation activities

Who can I contact with questions?

For general questions & information contact:

Laurie Stradley, DrPH
Executive Director
[email protected]

Amanda Bauman
Director of Programs
[email protected]

Rachel Walker
Community Engagement Manager
[email protected]

Punam Medina
Community Engagement Manager
p.[email protected]

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