CMS Releases Updated HRSN Framework for Medicaid and CHIP

Manatt Health

On December 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released an updated CMCS Informational Bulletin (CIB) that refines CMS’ descriptions of opportunities for states to cover clinically appropriate and evidence-based services and supports that address health-related social needs (HRSN) in Medicaid and the Children’s Health Insurance Program (CHIP). This ”HRSN Framework” was initially introduced in a prior bulletin and supporting framework, released on November 16, 2023. The December 2024 bulletin supersedes the earlier guidance and updates the framework, reflecting the expanded experience of CMS and the 10 states with approved section 1115 demonstrations for HRSN services (as of November 2024).

The November 2023 bulletin emphasized the impact of unmet HRSN on health outcomes and health equity. It introduced mechanisms for states to provide targeted interventions via Medicaid and CHIP to address these needs, highlighting their importance in reducing health disparities and enhancing access to care. The updated 2024 guidance refines these approaches, clarifying parameters and adding specificity to what HRSN coverage is permissible under CMS authority.

This CIB reiterates Medicaid and CHIP’s existing mechanisms for addressing HRSN, which include state plan authorities, section 1915 home and community-based services (HCBS) authorities, managed care in lieu of services and settings (ILOS), section 1115 demonstrations, and CHIP Health Service Initiatives (HSIs). Key updates to the 2023 CIB include:

1. Expanded Clinical and Social Eligibility Criteria: The CIB includes broader eligible populations, such as postpartum individuals up to 12 months from childbirth, and permits states to modify the HUD definitions of individuals “at risk of” and “experiencing” homelessness, provided the modification identifies a “similar population” and that the state has verified that its housing providers can implement the definitions accurately, subject to CMS approval.

2. Enhanced Clarity on HRSN Housing Interventions without Room and Board: CMS now specifies—with more detail—the allowable goods and services covered under one-time transition and moving costs (e.g., security deposits, application and inspections fees, movers, household items and furniture, etc., excluding clothing) and under medically necessary home remediation services (e.g., air conditioners, heat pumps, heaters, air filters, and generators in emergency/extreme climate situations).

3. Enhanced Clarity on HRSN Housing Interventions with Room and Board: CMS now limits HRSN housing interventions with room and board under section 1115 demonstrations to a global HRSN housing cap of a combined six months per rolling 12-month period. The CIB also clarifies that utilities, when paid separately from rent, are not considered “room.” These interventions are classified into the following categories:
   • Clinically-oriented episodic interventions: This group of short-term housing supports includes caregiver respite, short-term post-transitional housing, short-term pre-procedure housing, and short-term recuperative care (often referred to as medical respite). Apart from caregiver respite, these services include some level of clinical services, supports and monitoring. Individuals may receive these services multiple times over the course of the demonstration, subject to the combined six-month cap per rolling 12-month period noted above.
   • Room and board-only (or rent-only) interventions: Rent-only interventions have an additional limit of six months per household per demonstration period, with limited exceptions for some individuals who need clinically-oriented episodic interventions and are part of a household that received rent. The updated CIB includes clarifications on allowable settings for short-term rental assistance (e.g., apartments, permanent supportive housing, hotels when serving as the individual’s primary residence, transitional and recovery housing, etc.; specifically prohibits congregate settings) and also specifies what additional costs/fees necessary to secure and maintain the unit are permissible (e.g., allows storage fees and renter’s insurance while prohibiting coverage of pet, parking, and brokerage fees).

4. Inclusion of Case Management for all HRSN Interventions: This new service category broadens the previous CIB’s nutrition case management service to include member outreach and education, linkages to other state and federal benefit programs, and coverage of program application fees related to both housing and nutrition needs.

5. State Oversight for Nutrition Interventions: CMS clarifies requirements on eligibility for nutrition services (particularly as it relates to clinical eligibility factors, including pregnancy) and requires states to establish oversight protocols for nutrition interventions. CMS now requires states to ensure, via their provider contracts, that nutrition service providers appropriately tailor food services to individuals’ needs and that medically tailored meals in particular are tailored to the individual’s health risk, nutrition-sensitive health condition, and/or demonstrated outcome improvement.

By refining the HRSN Framework, this bulletin aims to enhance state flexibility while maintaining program integrity, ultimately improving health outcomes and addressing disparities for Medicaid and CHIP beneficiaries.