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State Plan Options

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