Referral rails aren’t determination records

In March 2026, TPG’s Rise Funds put approximately $250 million into Findhelp, a platform already connected to more than 900,000 verified community program locations and serving over 800 customers across all 50 states.¹

That is a serious commitment to the connective tissue of social care, and it is going to a real problem. Getting a referral to the right community organization, reliably and at scale, is hard infrastructure work that the field genuinely needed.

It is worth asking a companion question: what capital has gone toward the artifact a health plan has to produce when a regulator asks something different: why this member, why this benefit, why in this order, and who decided?

Comparatively little. And the three states furthest down the health-related social needs road each show, in a different way, why that gap is becoming the binding constraint.

North Carolina: the program came back smaller, and now someone has to prioritize

The Healthy Opportunities Pilots were the nation’s first comprehensive test of financing non-medical interventions for high-needs Medicaid enrollees, authorized for up to $650 million in state and federal Medicaid funding over five years.² On June 2, 2026, NCDHHS released evaluation findings showing HOP reduced health care costs by an average of $164 per member per month, based on a Sheps Center study of more than 31,000 enrollees.³

The program had already been suspended since July 1, 2025, after the General Assembly omitted ongoing funding.²

On July 7, 2026, Governor Josh Stein signed a budget appropriating $25 million in nonrecurring funds, $9 million in state dollars matched with $16 million federal, to restart it.⁴ As of late July, NCDHHS had not announced when service delivery resumes.

That is a genuine reprieve. It is also a restart at a fraction of prior scale. HOP had served more than 35,000 people across 33 counties, most of them rural. One participating provider organization has said the shortfall will require narrowing the scope of the 1115 waiver.⁴

Consider what that actually requires. North Carolina must now decide which members are served, for which services, in what priority order, against a budget that cannot cover prior demand.

That is not a referral problem. It is a determination problem, and scarcity is what turns a determination problem into an auditable one. When a program can serve everyone who screens positive, sequencing is a nicety. When it can serve a fraction, every inclusion is a decision that has to be consistent, defensible, and reconstructable.

There is a second clock running. The funds are nonrecurring. The program has to make its case again at the next budget, and the case that fell short in 2025 was not an aggregate one. North Carolina could show a $164 PMPM average. What it could not show, member by member, was who was determined eligible, for what, in what order, and what that specific spend avoided.

An average persuades a researcher. A per-enrollee record persuades an appropriator.

California: the audit arrived, and it stops at the D-SNP line

Closed-Loop Referral requirements went live July 1, 2025, and DHCS began actively monitoring plans for compliance on July 1, 2026.⁵

The obligations are concrete. Managed care plans must respond to a referral inquiry within one business day, and every referral status must be updated at least monthly.⁵ DHCS is also unambiguous that every referral to Enhanced Care Management or Community Supports is an authorization request, which triggers the grievance-and-appeal noticing requirements of APL 21-011, on a split clock: the authorization decision, date and any denial reason go to providers within 24 hours and to members within two business days.⁵

The volume underneath that is not a pilot. More than 528,000 members have accessed Community Supports since launch, with over 798,000 services delivered in the most recent twelve months of validated data.⁶ California has put $1.85 billion through PATH into capacity and infrastructure.⁷ This is, by a distance, the most developed referral apparatus in the country.

Now the detail that matters most to plans serving dual-eligible members. In its CLR guidance, DHCS addresses what a plan should do when a member is denied Enhanced Care Management on eligibility grounds. One suggested next step: notify the member’s D-SNP of the care management need, and confirm the member has received outreach from that D-SNP.⁵

A member’s need crosses two programs, two payers, and two sets of rules, and the available remedy is a notification.

That is not a criticism of the design. It is a boundary that no single state can close on its own. But it means no one owns the record of what was decided, under which authority, or in what order, and the boundary falls precisely where dual-eligible members live.

Illinois: the state is funding the rails and leaving the record to the plans

The Social Health Care Network NOFO, posted June 3, 2026, will award a single statewide lead organization $5–8 million annually under a contract running October 1, 2026 through June 30, 2029.⁸ Illinois intends to separately procure two platforms: the Illinois Community Access Referral Resource System (ICARRS) for closed-loop referrals, and a billing and claims system for community-based organizations.⁸

Three provisions in that document define the whitespace precisely:

• MCOs approve HRSN services against state-established eligibility criteria. The determination sits with the plan.
• HRSN payments are reimbursed to MCOs outside the capitation rate. These are discrete, traceable, auditable transactions, not blended into a PMPM.
• Grant funds may not be used to pay for billing-and-claiming technology or closed-loop referral platforms.

So Illinois is funding network development, capacity building, and referral routing, sensibly, since those are the pieces a state is best placed to standardize. The determination itself, meaning who qualified, under which authority, and sequenced against what the member already receives, sits with the MCO. Unfunded by the grant, and unstandardized. On a compressed clock, too: the awarded network must be under contract with the newly awarded MCOs by December 31, 2026, the same date the current HealthChoice Illinois MCO contracts expire.⁸

The common gap

Prioritization in North Carolina. Compliance in California. Procurement in Illinois. Three different phases, one structural fact:

A closed-loop referral answers what happened to this request, and answers it well. It is not designed to answer who was responsible for paying, in what order, under which authority, and whether the plan can produce that on demand two years from now.

Those are different questions with different regulatory consequences. The second one is the one that gets audited.

Why this is sharpest for duals

For a dual-eligible member, a single need, whether transportation, a meal or a home modification, may be payable under Medicaid HRSN, Medicare non-emergency transportation, or a Medicare Advantage supplemental benefit. Which one pays, and in what sequence, is not an operational preference. It is a compliance determination.

On the Medicare side, plans offering special supplemental benefits for the chronically ill must have written policies for determining enrollee eligibility, must document those determinations, and must make that documentation available to CMS on request.⁹ Records supporting those determinations sit inside a ten-year retention and audit-access obligation.¹⁰ On the Medicaid side, states are now actively monitoring referral loop closure. Neither system produces a version-stamped, tamper-evident record of the sequencing decision across both.

That is the referral to nowhere. Not a member who never got a call, but a member who got called by two entities, was served by neither because each reasonably assumed the other owned it, and left behind no artifact showing who decided what.

Jake Rothstein, co-founder and CEO of the housing platform Upside, named the pattern from the delivery side: “most solutions stop at the referral.”¹¹ He is describing services. The same sentence describes the infrastructure underneath them.

What the next dollar should buy

Directories and navigator layers are necessary, and the good ones keep getting better. They are not the missing piece. The missing piece is the determination record itself: payer-neutral, per-enrollee, version-stamped, sequencing-aware, and producible on demand to a state Medicaid agency or to CMS.

The supply side of social care is now well capitalized and, in several markets, genuinely adequate. The proof side has drawn comparatively little. North Carolina is the live case, not a post-mortem: a program that worked, went dark, came back at a fraction, and must now prioritize and re-argue for itself using a record layer it never had reason to build.

Buying social care got easier in 2026. Proving you delivered it, to the right member, in the right order, on the right authority, is the part still waiting to be built.

Anchor is a payer-neutral system of record for supplemental benefit determination and sequencing in the D-SNP market. We are the custodian of the determination, not its author.

References

1. TPG Partners with Findhelp to Expand Access to Essential Services for Underserved Populations. TPG, March 2, 2026. Approximately $250 million investment; 900,000+ verified community program locations; 800+ customers in all 50 states. Platform-scale figures are company-reported.
2. Healthy Opportunities Pilots. NCDHHS program page. Up to $650 million in state and federal Medicaid funding over five years; operations suspended after July 1, 2025 when the General Assembly did not provide additional funding. CMS separately authorized the pilots through December 2029.
3. Healthy Opportunities Pilots Lead to Healthier Outcomes and Reduce NC Medicaid Costs. NCDHHS, June 2, 2026. Average reduction of $164 per member per month, net of service and administrative costs, from a Cecil G. Sheps Center study of more than 31,000 enrollees (March 15, 2022–November 30, 2024). NCDHHS notes the underlying summative evaluation results are preliminary and have not been approved by CMS. See also the evaluation report.
4. Budget allocates $9M state plus $16M federal for Medicaid non-medical services. WLOS, July 2026. Restart funding split; prior service volume; statement from the chief operating officer of ABCCM, a participating human services organization, on narrowing waiver scope. Budget signed July 7, 2026; see also NC Health News.
5. Closed-Loop Referral (CLR) Frequently Asked Questions. California DHCS. CLR requirements effective July 1, 2025; active compliance monitoring beginning July 1, 2026; one-business-day inquiry response; monthly status updates; ECM and Community Supports referrals treated as authorization requests triggering APL 21-011 noticing; D-SNP notification as a suggested step following an ECM eligibility denial. APL 21-011 is DHCS’s Grievance and Appeal Requirements and Notice templates guidance.
6. Annual Report on In Lieu of Services and Settings (ILOS). California DHCS, June 2026: over 798,000 services utilized in the last twelve months of the reporting period. The 528,000+ figure for members who have accessed Community Supports since launch is from the DHCS release New Data Reinforce California’s Commitment to Whole-Person Medi-Cal Care, June 26, 2026. DHCS labels utilization data preliminary and subject to revision.
7. Providing Access and Transforming Health (PATH). California DHCS. Five-year, $1.85 billion capacity and infrastructure initiative.
8. Social Health Care Network Program NOFO # 3997-20-26-SHCN. Illinois HFS, posted June 3, 2026. Single award, $5–8 million annually, term October 1, 2026–June 30, 2029; ICARRS and billing/claims platform procurement; MCO approval of HRSN services against state eligibility criteria; HRSN payments outside the capitation rate; billing-and-claiming technology and closed-loop referral platforms listed as unallowable expenses; grantee obligation to contract with newly awarded MCOs by December 31, 2026. Applications closed July 20, 2026.
9. 42 CFR § 422.102. Supplemental benefits. Paragraph (f)(4) requires written policies for determining enrollee eligibility for special supplemental benefits for the chronically ill, documentation of those determinations, availability of that documentation to CMS on request, public listing of the written policies and objective criteria, and maintenance of those standards without modification for the full coverage year.
10. 42 CFR § 422.504. Contract provisions. Paragraph (d) requires books, records and documentation to be maintained for 10 years; paragraph (e) sets out HHS and Comptroller General inspection and audit rights for the current contract period and 10 prior periods; paragraphs (i)(2) and (i)(4) extend those obligations to first tier, downstream and related entities and require written arrangements specifying and monitoring delegated activities.
11. Upside Lands $20M Series A to Solve the U.S. Housing Crisis for Healthcare. PR Newswire, June 25, 2026. Quotation from Jake Rothstein, co-founder and chief executive officer.