Access East Healthy Opportunities Pilot

Eligibility & Requirements

Check the eligibility and requirements below

To be eligible…

for the Healthy Opportunities Pilot Program, you must have Medicaid and be a Medicaid Managed Care Member. Contact Member Services on the back of your insurance card for an assessment.

When contacting Member Services, tell them you are interested in receiving services through the Healthy Opportunities Pilot Program. You can use the chart below to access the correct number for your Prepaid Health Plan.

AmeriHealth Caritas

(855) 375-8811

Healthy Blue

(844) 594-5070

Trillium Health Resources

(877) 685-2415

United Healthcare

(800) 349-1855

Wellcare of NC

(866) 799-5318

Requirements

You must meet all 3 of the following requirements for the Access East Healthy Opportunities Pilot Program*

You must live in one of the following regions

Beaufort

Bertie

Chowan

Edgecombe

Halifax

Hertford

Martin

Northampton

Pitt

You must have at least one social risk factor

Homelessness or 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.

Food Insecurity

As defined by the US Department of Agriculture commissioned report on Food Insecurity in America:

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.

As defined by the US Department of Agriculture commissioned report on Food Insecurity in America:

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.

As defined by the US Department of Agriculture commissioned report on Food Insecurity in America:

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.

Transportation Insecurity

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.

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.

You must have at least one physical or behavioral health condition

Adults (Age 21+)

2 or more chronic conditions. Chronic conditions that qualify an individual for pilot enrollment include:
- Autoimmune disorders
- BMI over 25
- Blindness
- Cancer
- Chronic cardiovascular disease
- Chronic disease of the alimentary system
- Chronic endocrine
- Chronic infectious disease
- Chronic liver disease
- Chronic mental illness
- Chronic musculoskeletal conditions
- Chronic neurological disease
- Chronic pulmonary disease
- Chronic renal failure
- Cognitive conditions
- Congenital anomalies
- Intellectual or developmental disability (I/DD)
- Substance use disorder
- Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
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)

2 or more chronic conditions. Chronic conditions that qualify an individual for pilot enrollment include:
- Autoimmune disorders
- BMI over 25
- Blindness
- Cancer
- Chronic cardiovascular disease
- Chronic disease of the alimentary system
- Chronic endocrine
- Chronic infectious disease
- Chronic liver disease
- Chronic mental illness
- Chronic musculoskeletal conditions
- Chronic neurological disease
- Chronic pulmonary disease
- Chronic renal failure
- Cognitive conditions
- Congenital anomalies
- Intellectual or developmental disability (I/DD)
- Substance use disorder
- Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
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)

2 or more chronic conditions. Chronic conditions that qualify an individual for pilot enrollment include:
- Autoimmune disorders
- BMI over 25
- Blindness
- Cancer
- Chronic cardiovascular disease
- Chronic disease of the alimentary system
- Chronic endocrine
- Chronic infectious disease
- Chronic liver disease
- Chronic mental illness
- Chronic musculoskeletal conditions
- Chronic neurological disease
- Chronic pulmonary disease
- Chronic renal failure
- Cognitive conditions
- Congenital anomalies
- Intellectual or developmental disability (I/DD)
- Substance use disorder
- Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
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)

Pregnant Women

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 adverse childhood experiences (ACEs)
Intellectual or developmental disability (I/DD)
Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management,
North Carolina’s Health Home benefit (SPA 22-0024)

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 adverse childhood experiences (ACEs)
Intellectual or developmental disability (I/DD)
Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management,
North Carolina’s Health Home benefit (SPA 22-0024)

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 adverse childhood experiences (ACEs)
Intellectual or developmental disability (I/DD)
Traumatic brain injury (TBI)
Meets the clinical eligibility criteria for Tailored Care Management,
North Carolina’s Health Home benefit (SPA 22-0024)

Children (Age 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

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

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

Children (Age 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
- Attention-deficit/hyperactivity disorder
- Autoimmune diseases
- Behavioral/mental health diagnosis (including a diagnosis under DC: 0-5)
- Cancer
- Cognitive impairment
- Developmental delay
- Diabetes
- Intellectual or developmental disability (I/DD)
- Learning disorders
- Substance use disorder
- Traumatic brain injury (TBI)
- Underweight or overweight/obesity as defined by having a BMI of <5th or
  >85th percentile for age and gender
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
Experiencing or previously experienced three or more categories of adverse
childhood experiences (ACEs) (e.g. Psychological, Physical, or Sexual Abuse, or Household dysfunction related to substance abuse, mental illness, parental violence, criminal behavioral in household)
Enrolled or formerly enrolled in North Carolina’s foster care or kinship placement
system

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
- Attention-deficit/hyperactivity disorder
- Autoimmune diseases
- Behavioral/mental health diagnosis (including a diagnosis under DC: 0-5)
- Cancer
- Cognitive impairment
- Developmental delay
- Diabetes
- Intellectual or developmental disability (I/DD)
- Learning disorders
- Substance use disorder
- Traumatic brain injury (TBI)
- Underweight or overweight/obesity as defined by having a BMI of <5th or
  >85th percentile for age and gender
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
Experiencing or previously experienced three or more categories of adverse
childhood experiences (ACEs) (e.g. Psychological, Physical, or Sexual Abuse, or Household dysfunction related to substance abuse, mental illness, parental violence, criminal behavioral in household)
Enrolled or formerly enrolled in North Carolina’s foster care or kinship placement
system

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
- Attention-deficit/hyperactivity disorder
- Autoimmune diseases
- Behavioral/mental health diagnosis (including a diagnosis under DC: 0-5)
- Cancer
- Cognitive impairment
- Developmental delay
- Diabetes
- Intellectual or developmental disability (I/DD)
- Learning disorders
- Substance use disorder
- Traumatic brain injury (TBI)
- Underweight or overweight/obesity as defined by having a BMI of <5th or
  >85th percentile for age and gender
Meets the clinical eligibility criteria for Tailored Care Management, North Carolina’s Health Home benefit (SPA 22-0024)
Experiencing or previously experienced three or more categories of adverse
childhood experiences (ACEs) (e.g. Psychological, Physical, or Sexual Abuse, or Household dysfunction related to substance abuse, mental illness, parental violence, criminal behavioral in household)
Enrolled or formerly enrolled in North Carolina’s foster care or kinship placement
system

*Requirements may change and it could affect your eligibility. Speak to your Prepaid Health Plan Provider for the most recent eligibility requirements.

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