As part of the U.S. Department of Health and Human Services’ ongoing efforts to assist states with addressing various health-related social needs (HRSN), as discussed in a State Health Official Letter about addressing Social Determinants of Health (SDOH) released in 2021, the Centers for Medicare & Medicaid Services (CMS) encourages states to help enrollees stay connected to coverage and access needed health care services by addressing unmet HRSN. As described in a CMCS Informational Bulletin released in 2023, states can address HRSN through a variety of Medicaid authorities, including state plan authorities, section 1915 home and community-based services (HCBS) waivers and state plan programs, managed care in lieu of services and settings (ILOSs) and section 1115 demonstrations, as well as Children’s Health Insurance Program (CHIP) Health Service Initiatives (HSIs). CMS has published a framework of services and supports to address HRSN that CMS considers allowable under specific Medicaid and CHIP authorities.
CMS will consider state requests to use section 1115 demonstration flexibilities to cover certain evidence-based services designed to mitigate the negative health impacts of unmet HRSN. Using this demonstration authority allows states to take a more nuanced approach to defining populations of focus for HRSN services than is permitted through other CMS authorities. HRSN services have unique treatment under budget neutrality, and in order to cover HRSN services, states must agree to additional requirements and guardrails, as well as systematic monitoring and robust evaluation.