NC Medicaid Waiver 1115

Background on the 1115 Waiver:

The State of North Carolina transitioned the Medicaid and NC Health Choice programs from fee-for-service models to managed care. The transition to managed care is paired with initiatives to:

(a) support and enhance the capabilities of Medicaid providers;

(b) strengthen access to care for beneficiaries; and

(c) improve health through evidence-based, health-related interventions spearheaded by public–private regional pilot programs (also known as “Healthy Opportunities Pilots”).

(d) Expand coverage of SUD services to include residential services furnished in IMDs, both for short-term residents with a SUD diagnosis and as part of a comprehensive strategy, will decrease long-term opioid use, increase the utilization of medication-assisted treatment (MAT), and result in improved care quality and outcomes for patients with SUD.

NC received approval of a 1115 demonstration waiver to implement these initiatives and complete the transition to managed care.

HOP: The Healthy Opportunities Pilot (HOP) is part of the NC 1115 Waiver. HOP aims to test evidence-based, non-medical interventions for their direct impact on NC Medicaid beneficiaries’ health outcomes and healthcare costs, with the purpose of incorporating findings into the Medicaid program. The overall goal of HOP is to promote health equity by building a well-coordinated system for qualifying Medicaid beneficiaries.

Background on the Evaluation:

Federal law requires 1115 demonstration projects be evaluated by an external, independent entity. North Carolina selected the Sheps Center to perform the required evaluation components:

(a) An evaluation of the transition to managed care and the Substance Use Disorder (SUD) Program

(b) An evaluation of the Healthy Opportunities Pilots “HOP”