Current Medicaid Flexibilities to Address Social Determinants

The Medicaid program provides states with certain flexibilities under current law to address social determinants. Depending on the method used, states can take advantage of certain funding opportunities or use waiver authorities available under section 1905, section 1915, or section 1115, in order to drive innovation in their programs.

The Milbank Memorial Fund, The Reforming States Group, and the NYS Health Foundation funded the development of a comprehensive guide, “Medicaid Coverage of Social Interventions: A Road Map for States,” which helpfully  describes the current opportunities and authorities that states may use to incorporate services addressing social determinants into their Medicaid programs.
CMS requires Medicaid programs to maintain a State Plan, detailing the state’s plan for providing services to low-income residents. Adjustments to the State Plan must be detailed through a State Plan Amendment and approved by CMS. States can also opt to implement certain State Plan Options, optional services available under the Medicaid statute, by pursuing a State Plan Amendment (SPA). Several State Plan Options are available to states that can help to address social determinants:

Express Lane Eligibility

The Express Lane Eligibility state option allows states to rely on findings for criteria including income, household size, or other eligibility factors, from another program designated as an Express Lane Agency (ELA). Allowing states to use data collected from other programs helps to facilitate enrollment in coverage and reduce duplicity among program application and eligibility processes. ELAs may include: SNAP, School Lunch, TANF, Head Start, and WIC

No Wrong Door

No Wrong Door is an interagency coordination effort to streamline access to LTSS options for all populations and payers. Federal matching funds under Medicaid are available for costs incurred by states for administrative activities that directly support efforts to identify and enroll potential eligibles into Medicaid and that directly support the provision of medical services covered under the State Plan, when those activities are performed either directly by the state Medicaid agency or through contract or interagency agreement by another entity.

Case Management and Targeted Case Management State Plan Option

The Case Management state option allows states to use Medicaid to pay for the costs associated with helping beneficiaries gain access to needed medical, social, and educational services, as well as to other services such as housing and transportation. Targeted case management consists of the same services as case management, but states are not obligated to provide it on a statewide basis or to provide it to all groups of Medicaid beneficiaries. However, there are restrictions on these programs: “states must develop a care plan for individuals, meet record-keeping requirements, and ensure that Medicaid is not financing costs more appropriately born by other social programs.”

Health Homes State Plan Option

States have the option to establish Health Homes, which are intended to provide expansive care coordination and management for beneficiaries with intensive needs. The option was created by the ACA and provides 90% match (for the first 8 quarters) to establish Health Homes for beneficiaries with two or more chronic conditions, one chronic condition and at-risk for another, or a serious mental illness. States have flexibility to design Health Homes for their beneficiaries, and are expected to “coordinate and provide access to individual and family supports, including referral to community, social support and recovery services.” Care may be based in primary care or behavioral health providers’ offices, coordinated virtually, or located in other settings that suit beneficiaries’ needs. “Health homes must provide 6 core services: comprehensive care management, care coordination, health promotion, comprehensive transitional care and follow-up, individual and family support, and referral to community and social support services.”In addition, Health Homes effectively integrate services and supports across traditional disciplines of care. For example, New York has required that the Health Homes have a broad-based team to address individuals’ housing or employment needs, while Missouri has integrated behavioral health services within its primary care health homes. As of January 2017, 20 states and the District of Columbia have established Health Homes.

State Plan Option for Home and Community-Based Services

States can use the home and additional needs-based criteria for individual HCBS, establish a new eligibility group for people who get State Plan HCBS.

States may choose to contract with Managed Care Organizations (MCOs) to provide Medicaid services and benefits to certain eligible populations. MCOs must provide all required Medicaid benefits, but may also choose to provide additional benefits, such as social services, in order to reduce the cost and to improve the quality of care. Such services are referred to as value-added services, and may be offered if authorized through the MCO’s contract, however the cost of the services may not be calculated into the capitation rate.States may also use the MCO contracting process to require MCOs to perform certain activities, like using health risk assessments to also assess whole person needs.

In 2018, 16 states required and 10 states encouraged MCOs to screen enrollees for social needs and provide referrals to social services. In a 2017 survey, a majority of the Medicaid managed care plans were working to address social determinants of health. 77% of plans reported connecting members with housing services, 73% reported connecting with nutrition services and 51% reported connecting with education services.

Example: Michigan

The Michigan Department of Health and Human Services (DHHS) incorporated the collection and use of data on social determinants of health as a responsibility of its Medicaid health plans in the 2016 contract. Plans must “develop a multi-year plan to incorporate social determinants of health into their process for analyzing data to support population health management.” DHHS also requires contractors to develop a “core set of social determinants of health” as part of their provider performance measure reports

Section 1115 Demonstration Waivers

  • Section 1115 of the Social Security Act provides states with the authority to request a waiver from any of the requirements under section 1902 of the Social Security Act, which governs the Medicaid program, as long as it promotes the objectives of the Medicaid program. States must apply to the Secretary of HHS for approval of such waivers, which are intended to serve as demonstration projects and will be evaluated by HHS over the course of the demonstration. There are general criteria CMS uses to determine whether Medicaid/CHIP program objectives are met. These include whether the demonstration will:
    • Increase access to, stabilize, and strengthen providers and provider networks available to serve Medicaid and low income populations in the state;
    • Improve health outcomes for Medicaid and other low income populations in the state;
    • Increase the efficiency and quality of care for Medicaid and other low income populations through initiatives to transform service delivery networks; and
    • Maintain budget neutrality.
  • States are increasingly using section 1115 waiver demonstrations to test new approaches that include connecting people to social services and, to some extent, allow for flexible funding of social services that directly affect health.However, states may only use pay for medical services, limiting the breadth of potentially innovative approaches to address social determinants. For example, CMS released guidance in 2015 outlining how states may fund certain supportive housing services, but specifically notes the funding limitations
  • States have also used section 1115 demonstration waivers to implement large-scale delivery system reform initiatives, known as Delivery System Reform Incentive Payment (DSRIP) programs. Funding available through DSRIP has been used to support infrastructure development and/or care innovation and redesign among hospitals and other providers. States have also used such payments to support efforts to address social determinants of health.

Examples of State Use of 1115s

Washington State – Accountable Communities of Health

Washington State established nine regional Accountable Communities of Health (ACHs), which are multi-sector coalitions that aim to improve the health of their regions by integrating health and other community services. ACHs are composed of managed care organizations, providers, and community organizations, and are tasked with assessing community population health needs and integrating service delivery and accountability. In January 2017, CMS approved an extension of Washington’s section 1115 waiver, which aims to, among other things, implement population health strategies that improve health equity and provide targeted services that address the needs of the state’s aging populations and address key determinants of health.

Oregon – Coordinated Care Organizations

Oregon established Coordinated Care Organizations (CCOs), local networks of payers, providers, and community organizations that are paid a fixed rate by the state to provide physical, mental and oral healthcare to beneficiaries. The CCOs are held accountable for healthcare outcomes, and are strongly encouraged to use alternative services and interventions focused on improving population health by targeting social determinants of health, however such so-called coordinated services are not considered state plan services and must be paid for from CCO’s savings. The CCOs use individual patient care plans to identify and connect beneficiaries to necessary health-related supportive services. The state does reimburse the CCOs for community health workers, personal health navigators, or peer support specialists.

California – Whole Person Care Pilots

As part of its Medi-Cal 2020 DSRIP Waiver, California is implementing Whole Person Care (WPC) Pilots. The 18 pilots are supported by $3 billion in funding over five years and are generally led by a county government, in collaboration with health plans, providers and other entities. Pilots are required to target certain high-need Medicaid beneficiaries through care coordination, wrap-around services, and housing support interventions. While the pilots represent a hugely ambitious strategy to address social determinants, the state is again limited by current funding and programmatic constraints. In fact, to get around CMS’ limitation on funding non-medically necessary housing services, the state established flexible housing pools, where pilot funding may be braided with external housing and housing support funding

New York –Medicaid Redesign Team

New York also received approval for a DSRIP waiver, which is “intended to reduce avoidable hospital use by 25 percent through transforming the New York State health care system into a financially viable, high performing system.” Under the model, Medicaid providers and community based organizations formed integrated delivery networks, known as Performing Provider Systems (PPSs), that are responsible for a range of projects including building care management and population health infrastructure, enhancing disease management program, and improving population health.

Section 1915(c) – HCBS Waivers

In addition to the State Plan Option for Home and Community-based Services, Section 1915(c) provides waiver authority for states to waive certain Medicaid program requirements – including state wideness, comparability of services, and income and resource rules applicable in the community – in order to meet the needs of people who prefer to get long-term care services and supports in their home or community, rather than an institutional setting. The waiver authorizes coverage of a range of medical and nonmedical services to address long-term care needs in a home and community-based setting, including many of the housing-related, habilitation, peer support, and care management services that are needed to address social, emotional, and economic issues.Nearly all states and DC offer services through HCBS waivers. States can operate as many HCBS Waivers as they want – currently there are more than 300 active nationwide.

Accountable Health Communities Model

  • The Accountable Health Communities demonstration program was authorized under section 1115A of the ACA, and is implemented by the Center for Medicare and Medicaid Innovation (CMMI). The model aims to test whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral and community navigation services will impact health care costs and reduce health care utilization. However, CMS has clarified that funds for this model support the infrastructure and staffing needs of the bridge organizations, and do not pay directly or indirectly for any community services (such as housing, food, etc.). The model provides funding to entities across the U.S. the support the following:
    • Screening of community-dwelling beneficiaries to identify unmet health-related social needs
    • Referral of community-dwelling beneficiaries to increase awareness of community services
    • Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
    • Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.
  • The Assistance Track provides community service navigation services to assist high-risk beneficiaries with accessing services. The Alignment Track encourages partner alignment to ensure that community services are available and responsive to the needs of beneficiaries. The Assistance and Alignment tracks began on May 1 2017 with a five-year performance period. There are currently 32 organizations participating in the model
  • NASHP has developed an issue brief describing the efforts in several states to implement the Accountable Health Communities model.
  • In January 2018, CMS released a Health-Related Social Needs Screening Tool as part of the Accountable Health Communities model, in order to test whether “finding and dealing with the health-related social needs of Medicare and Medicaid beneficiaries has any effect on their total health care costs and makes their health outcomes better.”

State Innovation Models (SIMs)

  • The State Innovation Models (SIM) are authorized under section 1115A of the ACA and are implemented by CMMI. CMMI partners with states to help to advance state-based multi-payer health care payment and delivery system reform models. CMMI provides federal grants to states, under cooperative agreements, to design and test innovative, state-based multi-payer healthcare delivery and payment systems.Through two rounds of funding, SIM has supported model “test” awardees and model “design” awardees by providing funding, learning tools, and expert technical assistance. Several states received funding for integration of health and social services through SIM models. For example:
    • Arkansas received $42M for a model based on PCMH and additional Health Homes to coordinate medical, community, and social support services for individuals with complex or special needs.
    • Maine received $44M, part of which is funding the development of Certified Community Partners, which are community-based organizations with expertise in delivering care to members with behavioral health, long-term support services, and social service needs.
    • Minnesota received $45M for the creation of Accountable Communities for Health that integrate medical care with behavioral health services, public health, long-term care, social services, and other forms of care.

Medicaid Innovation Accelerator Program (IAP)

In 2014, CMS launched the Medicaid Innovation Accelerator Program (IAP) with the goal of improving health and health care for Medicaid beneficiaries by supporting states’ ongoing efforts related to payment and delivery system reforms. It is intended to help state Medicaid programs build capacity in key program and functional areas by offering targeted technical support, tool development, and cross-state learning opportunities.IAP has four priority program areas: substance use disorders, beneficiaries with complex care needs and high costs, community integration through LTSS, and physical/mental health integration. Through the IAP, CMS offers program support to states to support housing-related services and partnerships as well as improvements in quality and outcomes in community-based LTSS program. IAP works with other relevant agencies on planning and coordination of program support in order to help promote partnerships between state Medicaid agencies, state housing finance agencies, public housing agencies, state and local services agencies, and providers.