CMS Offers to Support More State Medicaid Programs with SDOH | Healthcare Innovation
Several states have begun to integrate social determinant of health services into their state Medicaid programs through section 1115 demonstration projects. Now the Centers for Medicare & Medicaid Services is offering a new 1115 demonstration opportunity to support states in addressing health-related social needs (HRSN).
In 2022, CMS issued 1115 waiver approvals to Arizona, Arkansas, Massachusetts, and Oregon, which have begun to integrate SDOH services into their state Medicaid programs through these authorities.
On Dec. 6 and Dec. 12, CMS hosted calls to explore these new opportunities with other Medicaid program leaders, and to explain the guardrails around the program. HRSN services in 1115 programs can include housing supports, nutrition supports, and case management. The service must be medically appropriate, as determined using state-defined clinical and social risk factors . Beneficiaries must be able to opt out at any time. The services must be integrated with existing social services (e.g., HUD services, SNAP, etc.)
Integration with state/local housing agencies
Services and supports that can assist with obtaining and maintaining housing are a top need identified by housing and homeless services agencies. Partnerships with state and local housing agencies are essential to success in implementation of allowable housing supports under Medicaid programs. State and local housing agencies can play three roles:
• Coordinating the provision of rental assistance or affordable housing to beneficiaries who are receiving tenancy sustaining services;
• Serving as providers of housing navigation, pre-tenancy, and tenancy sustaining services to eligible beneficiaries;
• Administering short-term housing assistance or one-time transition and moving costs on behalf of a state Medicaid agency.
Medicaid-covered affordable housing supports should supplement, but not substitute existing housing funds. Ideally, Medicaid-covered housing supports should work seamlessly with available housing resources and programs
The expenditures cannot exceed 3 percent of state’s annual total Medicaid spend , and infrastructure costs cannot exceed 15 percent of total HRSN spend . Also, state spending on related social services pre-1115 must be maintained or increased. State Medicaid reimbursement rates for primary care, behavioral health, and OB/GYN must be at least 80 percent of Medicare rates.
CMS said it may consider services beyond those in the HRSN 1115 framework on a case-by- case basis. Other HRSN services may require different treatment for budget neutrality calculations.
Similar to other 1115 demonstration authorities, HRSN services are subject to systematic monitoring and robust evaluation processes. In order to help identify key quality and equity gaps in state Medicaid programs, states must submit reporting to CMS on HRSN service implementation, including progress made and any challenges experienced; HRSN service utilization; quality of services; and health outcomes for individuals receiving HRSN services.