States’ and managed care plans’ have the ability to cover services or settings that are substitutes for services or settings covered under the state plan as “in lieu of services and settings” (also known as ILOSs) in accordance with 42 CFR §§ 438.3(e)(2) and 438.16.
State Medicaid Director Letter: Additional Guidance on Use of In Lieu of Services and Settings in Medicaid Managed Care
This guidance addresses an innovative option states may consider employing in Medicaid managed care programs to reduce health disparities and address unmet health-related social needs (HRSNs), such as housing instability and nutrition insecurity, through the use of a service or setting that is provided to an enrollee in lieu of a service or setting (ILOS) covered under the state plan. Further, with this guidance, CMS seeks to clarify an existing option that states can pursue to enhance and expand these efforts through the use of ILOSs.
Coverage of Services and Supports to Address Health-Related Social Needs in Medicaid and CHIP
This guidance discusses opportunities available under Medicaid and CHIP to cover clinically appropriate and evidence-based services and supports that address health-related social needs (HRSN), including ILOSs and Medicaid authorities including the State plan, section 1915(c) waivers and section 1115 demonstrations. This guidance also includes a chart summarizing coverage of HRSN services in Medicaid and CHIP.
Institution for Mental Disease (IMD) Frequently Asked Questions (FAQs)
This document is the second set of published FAQs and addresses common questions related to section 438.6(e) for payments to managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs) for an enrollee that is a patient in an IMD in the Medicaid and Children's Health Insurance Program (CHIP) Managed Care Final Rule.