CMS Outlines Medicaid Social Determinants of Health Flexibilities

CMS has released a new roadmap outlining how states can improve social determinants of health and reinforce their value-based care approach using Medicaid flexibilities.

“The new guidance describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH and supports states with designing programs, benefits, and services that can more effectively improve population health and reduce the cost of caring for our nation’s most vulnerable and high-risk populations,” explained the press release.

CMS emphasized that the roadmap’s goal is to flip the common healthcare trends by supporting lower spending with more positive outcomes. Value-based care arrangements and social determinants of health strategies are key to reversing trends of high spending with poor outcomes.

“The evidence is clear: social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s wellbeing,” said CMS Administrator Seema Verma.

“Unfortunately, our fee-for-service system inherently limits the doctor-patient relationship to what can be accomplished inside the four walls of a clinician’s office. Today’s letter to state health officials highlights strategies by which states can promote a value-based system that fosters treatment of the whole person and lowers healthcare costs. Patients are more than a bundle of medical diagnoses, and it’s time our healthcare system treated them as such.”

The roadmap is designed to make state health officials aware of the federal support and flexibilities available to advance Medicaid social determinants of health programs. However, private payers may also benefit from the lessons that Medicaid provides on social determinants of health.

The roadmap divides Medicaid programs’ social determinants of health flexibilities into several categories: housing-related services and supports, non-medical transportation, home-delivered meals, educational services, employment, community integration and social supports, and case management.

Under housing, Medicaid programs can receive federal financial support for home accessibility modifications, making a house more livable for a Medicaid beneficiary through alterations such as wheelchair ramps, shower accommodations, and more.

Federal funding is also available to support one-time community transitions as Medicaid beneficiaries shift from a provider-operated group setting—such as a homeless shelter—to a community-based private home. The federal government can cover certain necessities in this situation such as utility activation fees and essential household items.

Housing and tenancy support is also available to help a beneficiary move into housing and continue her tenancy.

Under non-medical transportation, beneficiaries who use Medicaid-funded home and community-based services (HCBS) may receive non-medical transportation to destinations such as the grocery store or the individual’s workplace.

Access to healthy food is a major social determinant of health issue, not only due to shortages of food options in certain regions but also because beneficiaries may find it difficult to prepare food on their own. For HCBS beneficiaries with medical limitations or other barriers to making food, Medicaid programs can help with home-delivered meals.

Educational support is available for children with disabilities who may be eligible for an individualized education plan or individualized family service plan, depending on their age. Medicaid covers any Medicaid provider services in these plans.

Employment is important for well-being. Certain methods of incentivizing employment through Medicaid—specifically through work requirements that can lead to loss of coverage—are controversial, but there are other federally-financed options available to states.

For example, states can offer enhanced benefits to incentivize work or community engagement under section 1115. Also, beneficiaries with disabilities can receive intensive on-going support through Medicaid’s HCBS in order to keep their employment. CMS stressed that employment solutions often must be individualized.

Some options are available to individuals who are not eligible for Medicaid but who need access to employment support. Individuals can pay into Medicaid in order to gain access to certain programs. Payment is on a sliding scale.

Community integration is also a key social determinant of health. Medicaid beneficiaries can receive support through Medicaid-provided instructions about public transportation, companion services, and other solutions through HCBS.

For many of the above scenarios, case management is critical to coordinating beneficiaries’ social determinants of health plan. Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries can receive case management services to help them access solutions both within Medicaid and outside of their Medicaid program.

Other options to advance value-based care and social determinant of health awareness under Medicaid include implementing integrated care models, CHIP Health Services Initiatives, obtaining federal funding for administrative procedures, Medicare Savings Programs, and the Money Follows the Person demonstration.

There are a few avenues that states can pursue to tap into these federal flexibilities. They can use a Section 1905(a) state plan authority, HCBS option, section 1115 demonstration, Section 1945 health homes, managed care programs, or the Program of All-inclusive Care for the Elderly (PACE). The roadmap provides more specific guidance on engaging in these alternatives.