In December 2022, the Centers for Medicare and Medicaid Services (CMS) announced the Section 1115 Demonstration to expand the tools available to states to address the health-related social needs (or “HRSN”) of their enrollees. Announcing exemption opportunities. In November 2023, CMS released a detailed Medicaid and CHIP HRSN framework with an information bulletin (CIB). CMS defines health-related social needs as an individual's unmet and adverse social circumstances (e.g., housing instability, homelessness, nutritional insecurity) that contribute to poor health and threaten underlying health. defined as the result of social determinants of health (SDOH). CMS will outline federal guardrails and requirements associated with new demonstration opportunities, including spending limits, service delivery requirements, and monitoring and evaluation requirements. CMS believes that expanding the availability of HRSN services will “facilitate insurance coverage and access to care, improve health outcomes, reduce health disparities, and reduce long-term costs for traditional medical services.” It is hoped that this will lead to the creation of more effective alternatives or supplements.” Although health care programs such as Medicaid can play a supporting role, CMS expects the new HRSN efforts to complement, rather than replace, other federal, state, and local social service programs. , emphasizes that they are designed to work together. And the amount of funding allocated to the HRSN program is modest as a share of Medicaid spending in states where waivers have been approved.
This issue's overview identifies states with approved and pending Medicaid 1115 waivers with SDOH-related provisions, summarizes approvals under the new Biden administration's HRSN 1115 framework, and provides information on approved services, who is eligible, and changes to HRSN services. It highlights the key requirements related to financing.
As of February 2024, the Biden Administration has approved eight 1115 demonstrations under the new HRSN Waiver Framework (Figure 1). These exemptions allow evidence-based housing and nutrition services for certain high-need populations. Some approvals are based on previous 1115 waiver initiatives (including California's “CalAIM” transformation). The approval includes coverage for up to six months of rent/temporary housing and utilities, as well as meal assistance for up to three meals a day, a departure from the long-standing prohibition on “room and board” payments in Medicaid. (months) included. Eleven other states have approved 1,115 waivers with SDOH provisions that predate the Biden administration's HRSN framework. These waivers are typically pilot programs that are narrow in scope (services and populations) or target a specific geographic area. For example, in October 2018, CMS approved North Carolina's Healthy Opportunities Pilots, which operate in three geographic regions. Six additional states have SDOH-related 1115 exemptions pending review with CMS.
The remainder of this overview highlights key provisions approved under the new HRSN 1115 framework in eight states (Arizona, Arkansas, California, Massachusetts, New Jersey, New York, Oregon, and Washington).
What HRSN services are covered by states through recently approved 1115 waivers?
Authorized HRSN services include housing assistance, nutritional assistance, and case management, although the specific services provided vary by state demonstration (Appendix Table 1). States can add HRSN services to their benefit packages; I need Managed care plans provide services to enrollees who meet state standards.
- Housing support. All states offer “room and board” services, including housing transition and navigation services, tenant retention services (tenant rights education, eviction prevention, etc.), temporary transition and moving costs, housing repairs, and housing accessibility. Has approval to provide housing support without. Fixed. Some states are approved to provide “room and board” housing assistance, including recuperative care (also known as medical respite) and short-term housing and utility assistance (up to six months). There is. As of February 2024, four states (Arizona, New York, Oregon, and Washington) have received CMS approval to cover up to six months of rent/temporary housing and utilities. Three states (California, New York, and Washington) have approved it to cover recovery care (up to 90 days) and short-term housing after hospitalization (up to 6 months).
- Nutritional support. Approved nutrition services include nutritional counseling, home-delivered meals or food stocking, nutritional prescriptions, and provision of groceries (meal/nutrition support is approved for up to 3 meals a day for up to 6 months) ). Nutrition services are often tailored to health risks or designed to support individuals with specific nutrition-sensitive health conditions (such as diabetes). Two states (Massachusetts and New York) have approved providing additional dietary/nutritional support. home If you have children or are pregnant who are at high risk.
All states also provide HRSN case management, outreach, and education services. Several states have also approved covering transportation to HRSN services (Massachusetts, New York, and Washington). All states have received CMS approval for HRSN infrastructure spending to support the implementation and delivery of HRSN services. Infrastructure investments may include technology. developing business or operating practices; Workforce development. Outreach, education, and stakeholder convening.
Who can access HRSN services?
The populations targeted by HRSN services vary, but in all cases are narrowly defined groups that must meet specific health and social risk criteria (Appendix Table 2). Subject to CMS approval, states have the flexibility to use clinical and social risk criteria to define target populations eligible for HRSN services. HRSN services must be medically appropriate and voluntary for enrollees. Approved populations include individuals who are homeless or at risk of becoming homeless, individuals with severe mental illness (SMI) and/or substance use disorders (SUD), and high-risk pregnant individuals. , high-risk children/youth, and individuals experiencing high-risk conditions. – Risk care transition (e.g., from institutional care, correctional facilities, or child welfare systems). CMS guidance states that housing services, including “room and board,” are provided to populations experiencing specific housing or care transitions (e.g., individuals experiencing homelessness or individuals transitioning from institutions to the community). ).
What are the key CMS requirements related to financing HRSN services under 1115?
Recent CMS changes budget neutrality policy While it could create a wide range of opportunities for countries to advance HRSN initiatives, the guidance also sets funding limits and guardrails. Although not set forth in statute or regulation, a long-standing element of Section 1115's waiver policy is that the waiver must be budget neutral to the federal government (i.e., federal costs under the waiver must be the amount that would have accrued in the state in the absence of the tax). In its approval, CMS indicated that no offsetting savings are required for HRSN expenditures. Additionally, CMS has announced that states may have access to Designated State Health Programs (DSHPs), a policy that was phased out under the Trump administration, potentially freeing up state funds to fund HRSN efforts. Specified that federal matching funds could be accessed for expenditures. Along with policies that expand financing opportunities for HRSNs, CMS has a mandate for states to prioritize coverage and access to basic health care services, rather than replacing existing local, state, and federal social assistance. It also includes fiscal guardrails and requirements aimed at ensuring that HRSN expenditures are supplemented. . The main requirements are:
- CMS limits the amount of Medicaid funding that states can use for HRSN efforts. CMS guidance provides that spending on HRSN services and infrastructure may not exceed 3% of total annual Medicaid spending. HRSN infrastructure cannot exceed 15% of a state's total HRSN spending authority. The exemption includes spending caps (based on the state's projected spending) for HRSN services and infrastructure (Appendix Table 3). States cannot access federal matching funds for expenditures that exceed the cap. In its approval, CMS said the HRSN spending cap “ensures that states test the benefits of HRSN services while maintaining investment in state plan benefits available to enrollees.”
- CMS requires states to meet provider payment rate requirements for core Medicaid services. To maintain and/or improve enrollees' access to quality care, as a condition of approval, each state will maintain base Medicaid payment rates (fee-for-service and managed care) of at least 80% of the Medicare rate for primary care. is required to do so. We provide behavioral health and obstetric services, and we need to increase rates below this level.
- Medicaid-covered HRSN services supplement, not replace, the activities and funding of other federal or state non-Medicaid agencies.. Additionally, CMS guidance outlines that state spending (pre-waiver) on related social services must be maintained or increased.
What should we focus on as the HRSN Waiver moves into implementation?
In the future, the results of the monitoring and evaluation necessary for HRSN efforts will inform future policies regarding whether and how Medicaid is used to address the health-related social needs of enrollees. It may help you decide. States must submit implementation plans and protocols providing operational details for new initiatives to CMS for review and approval. States are also required to submit quarterly and annual monitoring reports to CMS that provide information on HRSN service implementation, HRSN service utilization, and service quality. Finally, states must submit their evaluation strategies to CMS for review and approval. Independent evaluations will ensure that HRSN services effectively address unmet HRSNs, reduce potentially avoidable high-cost services, and/or improve physical and mental health outcomes You need to test whether. States would also be required to report on health equity indicators. Implementation dates vary by state. California began implementing “community assistance” (managed care authorized under 1115 “on behalf of” authorities) in 2022. According to available implementation plans, two states (Arizona and Oregon) plan to start offering HRSN services in 2024, while Massachusetts plans to start offering its HRSN services in 2025. is. Implementation information from remaining states will be announced in the future. Waiver priorities often change from presidential administration to presidential administration, so whether states can continue these efforts could depend on the outcome of the 2024 election.
Appendix table
