Addressing Health-Related Social Needs through 1115 Demonstrations

June 01, 2023 | Madison Hluchan

Similar to ASTHO’s Strategic Plan, the federal Centers for Medicare & Medicaid Services (CMS) prioritizes health equity. CMS seeks to advance federal flexibilities to address health-related social needs (HRSN)—a person’s unmet, adverse social conditions that contribute to poor health. Research highlights how unmet HRSN, such as access to housing and food insecurity, correlate with poor health outcomes and higher health care spending. By addressing HRSN in §1115 demonstrations, states can improve coverage, access, and equity across Medicaid beneficiaries, and use Medicaid funding as a lever for sustainable public health funding.

In January 2021, CMS released a framework that guides states on allowable HRSN services, service delivery, and related requirements, which are often a result of their community’s underlying Social Determinants of Health (SDOH). The framework encourages states to leverage the authority under section 1115 of the Social Security Act to address unmet HRSN and adverse health implications. These priorities directly align with identified health equity strategies mapped out in ASTHO’s 2022 Environmental Scan as efforts that can support community-based, person-centered systems of care to achieve public health goals and elevate population health improvements.

Core domains of HRSN services deemed allowable within 1115 waiver demonstrations include (1) housing-related services and supports, (2) nutrition supports, and (3) HRSN case management. CMS also approves services outside of these domains (e.g., transportation services, one-time community transition costs) on a case-by-case basis.

Innovative State Demonstrations to Address HRSNs

HRSN interventions were at the forefront of recently approved and renewed amendments to section 1115 demonstrations in Arizona, Arkansas, Massachusetts, and Oregon in fall 2022. Three additional waivers are currently pending approval in Delaware, Maine, and Montana as of April 2023.

The Arizona Health Care Cost Containment System (AHCCCS) waiver included the provision of the H20 program to provide specified evidence based HRSN services to individuals with a specific clinical or social risk who are experiencing homelessness or who are at risk of homelessness. These services included:

1. Housing supports including post-transition rent/temporary housing-up to six months, pre-tenancy and tenancy sustaining services, transitional housing navigation services, one-time transition and moving costs, housing deposits, and medically necessary home accessibility modifications and remediation services.
2. Case management including education and outreach, as well as linkages to other benefit programs, program application assistance, and program application fees.

The Arkansas Health and Opportunity for Me (ARHOME) program was given the authority to cover certain HRSN services for subsets of Life360 HOME beneficiaries, including women with high-risk pregnancies, adult clients with mental illness or substance abuse issues in rural areas, and targeted groups of young adults at risk of long-term poverty and poor health outcomes. Covered services for beneficiaries with certain clinical and social risk factors include:

1. Housing supports including pre-tenancy and tenancy sustaining services, housing transition navigation services, one-time transition and moving costs, and housing deposits.
2. Nutrition counseling and education as well as healthy meal preparation.
3. Case management including education and outreach as well as linkages to other benefit programs, program application assistance, and program application fees.

Massachusetts’ Medicaid and CHIP program, MassHealth, allows certain ACO-enrolled members up to age 64 with at least one identified health needs-based criteria and one risk factor to access HRSN services through their Flexible Services Program. HRSN services are also available to those in a Specialized Supports Program-members who are either (1) experiencing homelessness, (2) justice-involved living in the community, or (3) facing eviction related to their behavioral health condition. The allowable HRSN services vary by program but include the following:

1. Housing supports including pre-tenancy and tenancy sustaining services, transitional housing navigation services, one-time transition and moving costs, housing deposits, medically necessary devices to maintain healthy temperatures/clean air, and medically necessary home accessibility modifications.
2. Nutrition counseling and education, home delivered meals for up to six months, medically tailored meal prescriptions for up to six months, and cooking supplies.
3. Case management including education and outreach, as well as linkages to other benefit programs, program application assistance, and program application fees.
4. Transportation services to and from HRSN services for tenancy and nutrition supports.

Oregon made a number of changes to its Oregon Health Plan through their recently approved waiver that include addressing HRSN services for those experiencing major life transitions. These groups include youth with special health care needs (YSHCN), adults and youth discharged from Institution for Mental Diseases (IMDs), adults and youth released from incarceration, youth involved in the child welfare system, people transitioning from Medicaid-only to dual eligibility status, people who are homeless or at risk of becoming homeless, and people with high-risk clinical needs residing in regions experiencing extreme weather events. Eligible HRSN services for these groups include:

1. Housing supports including post-transition rent/temporary housing for up to six months, utility assistance, pre-tenancy and tenancy sustaining service, transitional housing navigation services, one-time transition and moving costs, housing deposits, medically necessary devices to maintain healthy temperatures/ clean air, and medically necessary home accessibility modifications.
2. Nutrition counseling and education, medically tailored meals for up to six months, fruit and vegetable prescriptions for up to six months, and pantry stocking.
3. Case management including education and outreach, as well as linkages to other benefit programs, program application assistance, and program application fees.

Implications for Medicaid/Public Health Partnerships

Section 1115 waivers provide states with the opportunity to develop and further cross-agency partnerships to best accommodate and support marginalized, under-resourced communities served by the health care safety-net system. Public health can serve not only as a service provider for certain HRSN services during implementation, similar to what is being conducted through North Carolina’s Healthy Opportunities Pilot implemented in 2021, but also guide demonstration project design.

ASTHO has interviewed public health and Medicaid agencies from Oregon, Arkansas, and Massachusetts about their recently approved waivers. A common theme emerged: public health as an expert advisor on health equity and population health when considering programmatic approaches.

A MassHealth official commented: “The Massachusetts Department of Public Health has been an important thought partner when thinking through the importance of health equity. Their perspective has carried through our whole waiver design process and helped to elevate the importance of health equity in what we submitted to CMS and ultimately had approved by them.”

Public health can also influence the implementation of HRSN services through their connection to community-based organizations (CBOs), as referenced by an Oregon Health Authority official: “In the implementation phase of the waiver process we are beginning to engage public health, specifically around their expertise with CBOs. During the COVD-19 pandemic, public health engaged with many CBOs to help with testing and vaccination efforts, and we know that many of these same folks are doing work in housing and nutrition services. So, as we begin to implement these services from the waiver, these connections from public health become really important.”

For states considering §1115 waivers to address HRSN, public health expertise can be an asset for Medicaid agencies to leverage and strengthen their development and implementation of programmatic offerings. Collaborative efforts to address HRSN such as those within §1115 demonstrations can move the needle towards achieving health equity for under-resourced and marginalized populations through targeted programs for Medicaid beneficiaries.