N.C. Healthy Opportunities Pilot Platform Integrates Medicaid Eligibility Verification

The North Carolina Department of Health and Human Services’ Healthy Opportunities Pilot (HOP) recently implemented the capability to verify member eligibility within the Unite Us closed-loop referral platform. Care managers can tie Medicaid information to a person’s record to be automatically notified about their Medicaid eligibility status. 

Not only does this help facilitate social care, but also ensures Medicaid members promptly address lapses in coverage, according to Unite Us. The company said it is the first social care technology solution to integrate real-time member eligibility verification with closed-loop referral management via X12 EDI 270/271 transactions.

HOP was established to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety to high-needs Medicaid enrollees.

North Carolina DHHS also is building a statewide coordinated care network (NCCARE360) to electronically connect those with identified needs with community resources – and allow for a feedback loop on the outcome of that connection.

“The Healthy Opportunities Pilot is a first-of-its-kind innovative program that is described as a ‘life changer’ for thousands of North Carolina families,” said Maria Ramirez Perez, associate director for Healthy Opportunities, in a statement. “The success of HOP is a product of collaboration with partners across the healthcare, social support, and technology sectors. The ability to integrate our Medicaid Management Information System (MMIS) with Unite Us has improved our social care reimbursement workflow in verifying Medicaid eligibility. As we were looking for efficiencies and time savings for our system’s care managers, integrating our MMIS was a big win.”

“By leveraging this functionality, we can now allocate HOP’s resources more efficiently and effectively, ensuring that Medicaid members receive the support they urgently need in critical areas such as housing, food security, transportation, interpersonal safety, and toxic stress mitigation. This builds on the existing long-time partnership between HOP and Unite Us, underscoring our commitment to delivering targeted assistance where it matters most and ultimately improving health outcomes and fostering stronger, more resilient communities,” Perez added.

The functionality builds on Unite Us Payments, an integrated capability that enables reimbursement for social care services at scale from within the referral platform, to further streamline the reimbursement process for community-based organizations (CBOs) and providers delivering services. 

Several states rely on the payments solution as a key component of their Medicaid initiatives’ infrastructure, including Oregon, where nine Coordinated Care Organizations are currently using Payments to streamline Medicaid billing for CBOs under their health-related social needs climate benefit program.

“This new integration is a significant milestone in our mission to broaden access to vital social services,” said Raffaelle Breaks, chief product and technology officer at Unite Us, in a statement. “With Unite Us member eligibility verification, we equip care managers with the ability to check for Medicaid eligibility ahead of enrollment, ensuring timely support for beneficiaries and a more efficient workflow for care managers.”