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.