Medicaid Coverage of Social Interventions: A Road Map for States

Bachrach D, Guyer J, Levin A
Publication Year: 2016
Patient Need Addressed: Behavioral health, Care Coordination/Management, Financial insecurity, Food insecurity, Homelessness/housing, Patient satisfaction/engagement
Population Focus: Medicaid beneficiaries
Intervention Type: Service redesign, Staff design and care management
Type of Literature: Grey

Extensive research demonstrates the impact of social factors—such as income, access to food and housing, and employment status—on the health and health outcomes of Americans, particularly lower-income populations. These findings are not lost on federal and state officials who seek to provide Medicaid beneficiaries with quality, cost-effective care. In developing strategies to address both the medical and social determinants of health, states face several challenges, including, primarily, how to provide a revenue stream to cover the cost of the social services. After all, Medicaid is first and foremost a health insurance program. Nonetheless, under some circumstances, Medicaid is available to cover the costs of social service interventions linked to the health of Medicaid enrollees.
Faced with mounting evidence about these social factors, state Medicaid agencies are looking for ways to integrate social interventions into their coverage, payment, and delivery models. As federal and state Medicaid officials look to improve health outcomes and to do it cost effectively, they must decide how far to go in tackling social issues, recognizing that Medicaid is not a social services program, and that there are limits on how it can be used.
This issue brief was prepared at the request of the Milbank Memorial Fund’s Reforming States Group (RSG), with support from the New York State Health Foundation, to help policymakers better understand Medicaid coverage for social interventions. Supported by the Fund since 1992, the RSG is a bipartisan group of state executive and legislative leaders who, with a small group of international colleagues, meet annually to share information, develop professional networks, and commission joint projects.

Insights Results

Overview of article

  • The 4 specific areas of social support services that are covered in this report are: 1) Linkages to social service programs that can offer help with food assistance, rent, child-care costs, heating bills, and other major household expenses; 2) Stable housing provided through services that help people find and remain in homes (e.g., assistance locating a home, making home repairs, and training in navigating relationships with landlords or other tenants); 3) Employment and job stability, including ways to help people prepare to enter the job market or to find and keep a job; and 4) Peer and community supports addressed by care coordinators who offer support and assistance in navigating the system, as well as by peer support specialists who come from a beneficiary’s community or who have had similar experiences and can offer counseling, advice, and other support

Key takeaways/implications

  • In general, there are 3 routes to covering services in Medicaid that help to address social factors that affect health: 1) State plan amendments (SPAs); 2) 1115 waivers; and 3) Managed care and alternative payment models (APMs)
  • SPAs are typically the simplest for states to secure funding for a service and can be used when the Medicaid statute directly allows for coverage of a particular service or activity. SPA-based options include: case management/targeted case management (allows states to use Medicaid to pay for the costs associated with helping beneficiaries gain access to needed medical, social and educational services), preventive and rehabilitative services (e.g., use community health workers), habilitation services, Health Home services (provides expansive care coordination and management for beneficiaries with intensive needs
  • Section 1115 demonstration program waivers and home and community-based services waivers are the 2 most common Medicaid-related waivers
  • State examples of waiver use: 1) Oregon’s 1115 demonstration waiver required the creation of Coordinated Care Organizations (CCOs), which in turn were required to train at least 300 community health workers across the state. The goal has already been reached, reflecting that CCOs have found significant value in using community health workers to connect beneficiaries to social services. Often residing in the same areas as the beneficiaries that they serve, the workers use this first-hand knowledge of the community to connect beneficiaries to social support services; 2) Colorado has established regional organizations, known as Regional Care Collaborative Organizations (RCCOs) that are charged with coordinating and improving care for the majority of Medicaid beneficiaries in the state. RCCO responsibilities include helping beneficiaries navigate their various appointments and medication reconciliation, as well as referring beneficiaries to social service programs and working with local agencies to address food deserts and other community issues; 3) In 2015, Michigan updated its Medicaid managed care contract to require MCOs to use community health workers or peer specialists to serve enrollees with significant behavioral health issues or complex physical comorbidities; 4) Maine first implemented a Health Home in 2013 targeting beneficiaries statewide with a variety of chronic illnesses. Primary care practices are the foundation of the Health Home provider teams and provide basic care coordination, case management, and family supports for enrolled beneficiaries; 5) California covers targeted case management in specific counties for Medicaid beneficiaries deemed to be in jeopardy of negative health or psychosocial outcomes
  • Medicaid options for supporting housing services: 1) Support transition services that help a beneficiary transitioning from institutional living or homelessness find and secure appropriate community-based housing; 2) Support sustaining services that advance a beneficiary’s ability to maintain a sustainable housing situation; 3) Support housing-related collaborative activities include working with state and local partners to advocate for and develop additional housing resources
  • Housing support services at state level: 1) Louisiana is currently providing supportive housing services to individuals with physical or developmental disabilities, serious mental illness, or who are in treatment or recovery from a substance use disorder through the Permanent Supportive Housing (PSH) Program; 2) Oregon is providing housing supports through its 1115 waiver; and 3) Texas requires its Medicaid managed care organizations participating in its STAR+PLUS program to pay for minor home modifications for beneficiaries to ensure the safety, security, and accessibility of the home
  • Medicaid options for supporting employment services: 1) Support prevocational services prepare people who would otherwise not work with the skills they need to find and keep a job; and 2) Advance supported employment services assist individuals who otherwise could not work in obtaining and maintaining employment in a community setting
  • Medicaid support for employment services at the state level: 1) In Maryland, habilitation services are provided through the state’s HCBS waiver, called the Community Pathways Waiver, to children and adults with developmental disabilities. The waiver covers 19 services, including “employment discovery and customization” and “supported employment”
  • In addition, peer support services are provided in the community by people who have themselves experienced an illness and can be covered under a number of different authorities. Most states choose to cover them as a state plan “rehabilitative service” under Section 1905(a)(13) or integrate them into their Health Homes or 1115 waivers. Examples include 1) Georgia provides peer support to enrollees with serious mental illness under the rehabilitative services option; 2) When Kansas established Health Homes, it included peer support specialists as required members of the provider teams serving beneficiaries with serious mental illness; 3) New York chose to add “peer specialists” to its standard list of authorized care team members in the state’s Health Home program
  • Under managed care and APMs, state Medicaid agencies pay managed care organizations a capitated rate to cover a defined set of services. MCOs can cover social services not included in the contract in 2 ways: 1) In lieu of services; and 2) Value-added services