Nov, 17, 2023

CMS Releases Information Bulletin on Coverage of Services and Supports to Address Health-Related Social Needs in Medicaid

Manatt Health

On November 16, the Centers for Medicare and Medicaid Services (CMS) issued a new Informational Bulletin and accompanying framework which together detail Medicaid coverage options for services that address the health-related social needs (HRSN) of Medicaid enrollees. The new guidance reiterates the importance of addressing HRSNs to improve access to care and health outcomes, and summarizes (and in some cases updates) multiple previous sources of CMS guidance on how HRSN services may be covered in Medicaid, including guidance on in lieu of services authority (ILOS) and on HRSN coverage in section 1115 waivers.

Overall, the new CMS guidance does the following:

  • Lists 15 HRSN services that CMS will approve in Medicaid, which primarily focus on housing and housing-related supports as well as food and nutrition services.
  • Indicates which Medicaid authorities may be used to authorize each HRSN service, including: ILOS, section 1115 waivers, home and community-based service (HCBS) authorities, and Children’s Health Insurance Program (CHIP) health services initiatives (HSIs).
  • Identifies limitations and guardrails that apply to each service and Medicaid authority, including limitations on the duration of services, the populations that can receive services, cost and spending limitations, and enrollee protections.

The guidance retains state flexibility to select between available Medicaid authorities for each approvable service, but is silent on whether states can propose to cover HRSN services that are not on this list of approvable services. States, when covering HRSN services, must generally propose “clinically focused, needs-based criteria” to determine which enrollees may be eligible for HRSN services. Notably, the guidance reiterates that CMS will only approve HRSN services that cover costs of “room and board” under 1115 demonstrations, and that those services must generally be limited in both duration and to certain high need populations. For example, utility assistance and short-term housing may only be provided for six months and once per demonstration period, while nutrition supports that provide three meals per day are limited to six months, but may be renewed for additional six-month periods if the enrollee continues to meet eligibility criteria. There are no durational limits on services that do not constitute “room and board,” which includes nutrition services of less than three meal per day.

The Informational Bulletin comes alongside the release of a White House playbook on addressing social determinants of health (synonymous with HRSN), and a call to action from the U.S. Department of Health and Human Services on addressing HRSN.