North Carolina Medicaid Undergoes Big Changes

Raleigh -- North Carolina's Medicaid program is about to see some important changes starting July 1, 2025. These include ending a special pilot program and wrapping up some temporary rules for another service.

 These shifts are happening because of decisions made by the state's government, specifically the Republican majority in the North Carolina General Assembly.

Popular Health Program to End Due to Budget Choices by Lawmakers

The Healthy Opportunities Pilot (HOP) program is set to close its doors on July 1, 2025. This was a unique program in North Carolina that used federal Medicaid money to help people with things not directly related to medical care, but that greatly impact their health. For example, it helped people get healthy food, find stable housing, and arrange transportation to appointments. Since it started in 2022, HOP has helped about 30,000 low-income people across the state, including many in Western North Carolina.

The main goal of the Healthy Opportunities Pilot was to show that helping people with basic needs like food and housing could actually improve their health and even save money in healthcare costs. A study published in a medical journal called JAMA found that the program led to fewer emergency room visits and shorter hospital stays, and also saved public money each year for the people it served.

But now, the HOP program is ending because of choices made during the state's budget process. The Republican Party holds the most seats in both the North Carolina House of Representatives (71 out of 120 seats) and the North Carolina Senate (30 out of 50 seats). This means they control how the state's money is spent. Their proposed budgets for the next few years do not include any money to keep the HOP program going. Without state funds, the program can't continue, even though it uses federal money too.

Republican lawmakers have said that the state budget is tight this year and that they need more proof that the program's benefits are worth the cost. Even so, the North Carolina Department of Health and Human Services (NCDHHS), which runs Medicaid, told its partners in early June 2025 to get ready for the program to shut down because the state legislature didn't provide funding.

The end of the HOP program is expected to have a big impact on health efforts in communities, especially in Western North Carolina. The program worked with over 60 local groups to provide essential support to people who needed it. Losing this funding means these groups might struggle to keep offering food, housing, and transportation help. This could lead to more health problems for low-income residents in the region.

Temporary Medicaid Rules for People with Disabilities Are Expiring

Also, starting July 1, 2025, some temporary changes to the NC Innovations Waiver will end. This waiver helps people with intellectual and developmental disabilities get services they need at home or in their communities. These temporary changes were put in place by the federal government (CMS) in September 2024 because of Hurricane Helene, to help people stay safe in their homes during and after the storm.

When these temporary rules expire, the program will go back to its normal procedures. This means:

No more extensions for checking if someone still qualifies for care.
Required assessments to measure how much support someone needs will start again.
Care plans won't be approved for past services anymore.
All required signatures will be needed on care plans again.
People will need to receive more than one service each month to stay in the program.
Care managers will go back to meeting face-to-face with people each month or quarter.
Special payments to providers for emergency situations will no longer be available.
Changes to certain day support services will require a new care plan or approval.
These changes simply mean the program is returning to its regular operations now that the emergency needs from the hurricane have passed.

How North Carolina's Medicaid System Has Evolved

These specific adjustments are part of a larger overhaul of North Carolina's Medicaid system. The state decided to switch to a "Managed Care" system back in 2015 (under a law called House Bill 372, signed on September 23, 2015). Under this system, most people on Medicaid get their healthcare through private health plans instead of directly from the state. Most of this switch happened on July 1, 2021. For people with serious mental health issues, substance use disorders, or intellectual/developmental disabilities, special "Tailored Plans" began on December 1, 2022. On top of that, North Carolina also expanded Medicaid coverage on December 1, 2023, allowing more low-income adults to get health insurance.

The Republican-controlled General Assembly directly decides how the state's Medicaid program is funded and what policies it follows through its two-year budget process. The decision to end the HOP program is a clear example of this influence.

WNCTimes

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