As of May 15, HOP eligibility has expanded to include NC Medicaid members who are eligible for Tailored Care Management through Vaya Health or Partners Health Management.

Who We Serve

Impact Health supports a robust network of human service organizations (HSOs) that provide housing, transportation, food and/or interpersonal safety services to eligible NC Medicaid members enrolled in the Healthy Opportunities Pilot.

To be eligible for pilot services, individuals must

  • be enrolled in an eligible NC Medicaid health plan,
  • live in one of the state’s three pilot regions, and
  • have a qualifying physical or behavioral health condition +
    a qualifying
    social need or risk factor.  

North Carolina’s 18 westernmost counties, identified in this map, make up one of the three pilot regions. 

WNC map

Pilot Eligibility: Physical/Behavioral Health Criteria.

NC Medicaid members must be enrolled in a managed care or a tailored care management-eligible health plan and meet at least one physical/behavioral health criteria and one social risk factor to be eligible for the Pilot program.

Eligibility CategoryAge

Needs-Based Criteria (at least one, per eligibility category)

Adults 21+
  • 2 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, chronic infectious disease, cancer, autoimmune disorders, chronic liver 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.
  • Former placement in North Carolina’s foster care or kinship placement system.
  • Previously experienced three or more categories of adverse childhood experiences (ACEs)
  • Intellectual or developmental disability (I/DD) and traumatic brain injury (TBI) 
  • Meeting clinical criteria for Tailored Care Management (TCM)
Pregnant Womenn/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
  • Former or current placement in NC’s foster care or kinship placement system 
  • Previously experienced or currently experiencing three or more categories of ACEs
  • Intellectual or developmental disability (I/DD) and traumatic brain injury (TBI) 
  • Meeting clinical criteria for Tailored Care Management (TCM)

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
0-20
  • 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 <5th or >85th percentile for age and gender, developmental delay, cognitive impairment, substance use disorder, behavioral/mental health diagnosis (including a diagnosis under DC: 0-5), attention-deficit/hyperactivity disorder, and learning disorders, chronic infectious disease, cancer, autoimmune disorders, chronic liver disease
  • Experiencing or previously experienced 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)
  • Former placement in NC’s foster care or kinship placement
  • Intellectual or developmental disability (I/DD) and traumatic brain injury (TBI) 
  • Meeting clinical criteria for Tailored Care Management (TCM)
  • Cancer and autoimmune diseases
Pilot Eligibility: Social Risk Factors
Risk Factor Definition
Homelessness and housing insecurity Homelessness, as defined in 42 C.F.R. § 254b(h)(5)(A), or housing insecurity, as defined based on the principles in the questions used to establish housing insecurity in the Accountable Health Communities Health Related Screening Tool or the North Carolina Social Determinants of Health (SDOH) screening tool.1,2</sup
Food insecure As defined by the US Department of Agriculture commissioned report on Food Insecurity in America:3 
  • Low Food Security: reports of reduced quality, variety, or desirability of diet. Little or no indication of reduced food intake. 
  • Very low food security: Reports of multiple indications of disrupted eating patterns and reduced food intake 
Or food insecure as defined based on the principles in the  questions used to establish food insecurity in the North  Carolina Social Determinants of Health (SDOH) screening  tool.4
Transportation insecure Defined based on the principles in the questions used to  establish transportation insecurities in the Accountable  Health Communities Health Related Screening Tool or the  North Carolina SDOH screening tool.5
At risk of, witnessing or experiencing interpersonal violence Defined based on the principles in the questions used to establish interpersonal violence in the Accountable Health Communities Health Related Screening Tool or the North Carolina SDOH screening tool.6

1 The Accountable Health Communities Health-Related Social Needs Screening Tool. Available https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf.

2 North Carolina’s SDOH Screening Questions. Available:
https://www.ncdhhs.gov/about/department initiatives/healthy-opportunities/screening-questions

3 USDA Economic Research Service [Internet]. Washington: USDA Economic Research Service; [updated 2017 Nov 27]. Definitions of Food Insecurity; [updated 2017 Oct 4; cited 2017 Nov 27]. Available from: https://www.ers.usda.gov/topics/food nutrition-assistance/food-security-in-the-us/definitions-of-food-security/

4 North Carolina SDOH Screening Tool. Available: https://www.ncdhhs.gov/about/department-initiatives/healthy opportunities/screening-questions

5 Ibid

6Ibid.

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