Medicaid Authorities and Options to Address Social Determinants of Health (SDOH)

Issue Brief
  1. “Office of Disease Prevention and Health Promotion, Healthy People 2020: Social Determinants of Health, Washington D.C.: U.S. Department of Health and Human Services, last modified June 2021, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

    ← Return to text

  2. World Health Organization, “About Social Determinants of Health,” accessed April 25, 2018, http://www.who.int/social_determinants/sdh_definition/en/

    ← Return to text

  3. Office of Disease Prevention and Health Promotion, Healthy People 2020: Social Determinants of Health, Washington D.C.: U.S. Department of Health and Human Services, last modified June 2021, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

    ← Return to text

  4. Federal financial participation is not available to state Medicaid programs for room and board except in certain medical institutions. Federal financial participation is generally available under certain housing-related supports and services that promote health and community integration. These include home accessibility modifications, one-time community transition costs, and housing tenancy supports. These depend on the individual’s disability and/or health status and are not used for generality utilities in the home.

    See: Centers for Medicare & Medicaid Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), Baltimore, MD: Department of Health and Human Services, January 2021, https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf

    ← Return to text

  5. When states provide case management services under the state plan without regard to “statewideness” and “comparability” requirements, the benefit is referred to as “targeted case management.”

    ← Return to text

  6. States can (and have) created more than one Health Home program to target different populations.

    ← Return to text

  7. For SUD health homes approved on or after October 1, 2018, states can receive ten quarters of enhanced federal match.

    ← Return to text

  8. Office of the Assistant Secretary for Planning and Evaluation (ASPE), Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Evaluation of Outcomes of Selected Health Home Programs Annual Report - Year Five, Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2017, https://aspe.hhs.gov/basic-report/evaluation-medicaid-health-home-option-beneficiaries-chronic-conditions-evaluation-outcomes-selected-health-home-programs-annual-report-year-five

    ← Return to text

  9. New York’s DSRIP program expired on March 31, 2020.

    ← Return to text

  10. Texas’ DSRIP program was originally approved from October 2011 through September 2016, but CMS granted extensions through December 2017 and then through September 30, 2021.

    ← Return to text

  11. California’s original DSRIP program was under California’s “Bridge to Reform” Section 1115 waiver.

    ← Return to text

  12. North Carolina Department of Health and Human Services, Healthy Opportunities Pilots, Raleigh, NC: North Carolina Department of Health and Human Services, accessed July 12, 2021, https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/healthy-opportunities-pilots 

    ← Return to text

  13. California Department of Health Care Services, California Advancing and Innovating Medi-Cal, Sacramento, CA: California Department of Health Care Services, last modified July 9, 2021, https://www.dhcs.ca.gov/provgovpart/Pages/CalAIM.aspx

    ← Return to text

  14. CalAIM includes a Section 1115 Demonstration & 1915(b) Waiver.

    ← Return to text

  15. Costs associated with in-lieu-of services may be included in the numerator of the medical loss ratio (MLR) and are taken into account when developing capitation rates.

    ← Return to text

  16. Centers for Medicare & Medicaid Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), Baltimore, MD: Department of Health and Human Services, January 2021, https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf

    ← Return to text

  17. Costs associated with value-added services are included in the numerator of the MLR calculation (either as incurred claims or quality-related activities).

    ← Return to text

  18. If managed care plans implement SDOH activities that meet certain federal requirements (in 45 CFR § 158.150(b) and are not excluded under 45 CFR § 158.150(c)), managed care plans may include the costs associated with these activities in the numerator of the MLR as activities that improve health care quality (under 42 CFR § 438.8(e)(3)).

    ← Return to text

  19. North Carolina indicated selected policies for FY2020 but did not implement MCOs in the state in that year.

    ← Return to text

  20. States can leverage managed care quality requirements in 42 CFR § 438.310 through 438.370, including Quality Strategies, quality assessment and performance improvement (QAPI) requirements, and external quality review to address SDOH within their managed care programs. States can require MCOs to focus on SDOH in their QAPI programs and/or performance improvement projects (PIPs). MCO performance in these QAPI programs and/or PIPs could also be integrated into the payment methodologies for certain managed care payments, such as managed care plan incentive payments. In addition, states can contract with external quality review organizations (EQROs) to conduct optional EQR-related activities, such as calculation of additional performance measures focused on SDOH or to conduct studies to gain a fuller understanding of how SDOH affect health outcomes among their beneficiaries.

    See: Centers for Medicare & Medicaid Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), Baltimore, MD: Department of Health and Human Services, January 2021, https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf

    ← Return to text

  21. Diana Crumley et al., “Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations,” Center for Health Care Strategies (December 2018), https://www.communityplans.net/wp-content/uploads/2018/12/Addressing-Social-Determinants-of-Health-via-Contracts-and-1115-Demonstrations.pdf

    ← Return to text

  22. Ibid.

    ← Return to text

  23. MassHealth Managed Care Entity Bulletin 36, Community Support Program for Homeless Individuals Residing in Department of Housing and Community Development-Funded New Temporary Shelters, Boston, MA: Commonwealth of Massachusetts Executive Office of Health and Human Services, Office of Medicaid: July 2020, https://www.mass.gov/doc/managed-care-entity-bulletin-36-community-support-program-for-homeless-individuals-residing-0/download

    ← Return to text

  24. Centers for Medicare & Medicaid Services, Integrated Care Models, Baltimore, MD: Department of Health and Human Services, July 2012, https://www.medicaid.gov/federal-policy-guidance/downloads/SMD-12-001.pdf

    Centers for Medicare & Medicaid Services, Integrated Care Models, Baltimore, MD: Department of Health and Human Services, July 2012, https://www.medicaid.gov/federal-policy-guidance/downloads/smd-12-002.pdf

    ← Return to text

  25. Centers for Medicare & Medicaid Services, Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH), Baltimore, MD: Department of Health and Human Services, January 2021, https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf

    ← Return to text

  26. Elinor Higgins, “Q&A: How Rhode Island Tackles Social Determinants of Health through its Accountable Entity Models,” National Academy for State Health Policy (November 2018), https://www.nashp.org/qa-how-rhode-island-tackles-social-determinants-of-health-through-its-accountable-entity-model/

    ← Return to text

  27. Rhode Island Executive Office of Health and Human Services, Rhode Island Prioritizes Social Determinants of Health with Statewide Rollout, Cranston, RI: Rhode Island Executive Office of Health and Human Services, accessed July 12, 2021, https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-06/Unite%20Us%20RI%20Community%20Partner%20Email.pdf

    ← Return to text

  28. Ibid.

    ← Return to text

  29. Rhode Island’s Accountable Entity model is part of the state’s Section 1115 waiver.

    ← Return to text

  30. Kathleen Gifford et al., “A View A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020,” KFF (October 2019), https://www.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/

    ← Return to text

  31. The Commonwealth Fund, “Review of Evidence for Health-Related Social Needs Interviews,” accessed July 12, 2021, https://www.commonwealthfund.org/sites/default/files/2019-07/COMBINED-ROI-EVIDENCE-REVIEW-7-1-19.pdf

    ← Return to text

  32. Emilie Courtin et al., “Can Social Policies Improve Health? A Systematic Review and Meta-Analysis of 38 Randomized Trials,” The Milbank Quarterly 98 (June 2020), https://www.milbank.org/quarterly/articles/can-social-policies-improve-health-a-systematic-review-and-meta%E2%80%90analysis-of-38-randomized-trials/

    ← Return to text

  33. Hannah L Crook et al., How Are Payment Reforms Addressing Social Determinants of Health? Policy Implications and Next Steps,” Milbank Memorial Fund (February 2021), https://healthpolicy.duke.edu/sites/default/files/2021-02/How%20Are%20Payment%20Reforms%20Addressing%20Social%20Determinants%20of%20Health.pdf

    ← Return to text

  34. Lauren M. Gottlieb, Holly Wing, and Nancy E. Adler, “A Systematic Review of Interventions on Patients' Social and Economic Needs,” American Journal of Preventative Medicine 53 no. 5 (July 2017): 719-729, https://pubmed.ncbi.nlm.nih.gov/28688725/

    ← Return to text

The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.