Welcome To The Healthy Opportunity Pilot

 NC Medicaid Managed Care members must meet at least one physical/behavioral health criteria and one social risk factor to be eligible for the Pilot program. 

• 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)

• 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)

• 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 <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