DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
 
 
CMCS Informational Bulletin 
 
DATE:   November 16, 2023 
 
FROM:   Daniel Tsai, Deputy Administrator and Director 
    Center for Medicaid and CHIP Services 
 
SUBJECT:   Coverage of Services and Supports to Address Health-Related Social Needs 
in Medicaid and the Childrens Health Insurance Program 
 
This guidance discusses opportunities available under Medicaid and the Childrens Health 
Insurance Program (CHIP) to cover clinically appropriate and evidence-based services and 
supports that address health-related social needs (HRSN).  An individuals HRSN are derived 
from a person-specific assessment of social determinants of health (SDOH),1 and extensive 
research has indicated that SDOH and associated HRSN can account for as much as 50 percent 
of health outcomes.2  While SDOH are broad environmental conditions, HRSN are specific to an 
individual and when unmet, these individual-level adverse social conditions contribute to poor 
health outcomes.  These needs, when unmet, can drive lapses in coverage and access to care, 
higher downstream medical costs, worse health outcomes, and perpetuation of health inequities, 
particularly for children and adults at high risk for poor health outcomes, and individuals in 
historically underserved communities.3   
 
By addressing HRSN, state Medicaid and CHIP program can help their enrollees stay connected 
to coverage and access needed health care services, and supplement  but not supplant  existing 
local, state, and federal supports.  The Centers for Medicare & Medicaid Services (CMS) 
supports states in addressing HRSN through multiple Medicaid and CHIP authorities and 
mechanisms.  These initiatives include coverage of clinically appropriate and evidence-based 
HRSN services and supports; care delivery transformations, including improvements in data 
sharing; and performance measurement to create accountability for HRSN screening and 
connecting to needed supports as part of successful care management. 
 
 
1 WHO defines social determinants of health as the conditions in which people are born, grow, work, live, and age, 
and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include 
economic policies and systems, development agendas, social norms, social policies, and political systems. 
2 https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-
Review.pdf 
3 https://aspe.hhs.gov/reports/building-evidence-base-social-determinants-health-interventions 
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  CMCS Informational Bulletin 
As indicated in a letter to State Health Officials (SHO) on January 7, 2021,4 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 CHIP Health 
Service Initiatives (HSIs).  For example, the housing and nutrition supports provided under 
HCBS authorities have served as an important precedent for helping individuals stay connected 
to coverage and needed care, and in connecting eligible individuals to additional services 
necessary to meet their comprehensive health needs.  Since the publication of the January 2021 
SHO, CMS has issued additional HCBS guidance in a continued effort to improve health equity 
and outcomes for Medicaid beneficiaries by addressing HRSN.5  
 
CMS has also described ways in which state Medicaid and CHIP programs may cover services 
and supports addressing HSRN for specific populations not traditionally eligible for HCBS 
programs.  On January 4, 2023, CMS published a State Medicaid Director Letter (SMDL) that 
describes innovative options states may consider employing in Medicaid managed care programs 
to address HRSN through the use of a service or setting that is provided to an enrollee in lieu of a 
service or setting (known as an in lieu of service or ILOS) covered under the state plan.6,7  In 
2022, CMS also announced a section 1115 demonstration opportunity to support states in 
addressing HRSN,8 and as of November 2023, CMS has approved section 1115 demonstrations 
in seven states that cover certain evidence-based housing and nutritional services designed to 
mitigate the negative health impacts of unmet HRSN.9  Together, these flexibilities and 
accompanying safeguards to protect program and fiscal integrity comprise a framework for 
coverage of HRSN, complementing but not supplanting existing social services, that states can 
use to improve consistent access to needed care, health outcomes, and health equity among 
Medicaid beneficiaries. 
 
Accompanying this Informational Bulletin, CMS has published a framework of services and 
supports to address HRSN that CMS considers allowable under specific Medicaid and CHIP 
authorities.10  This document includes important guidelines to ensure that interventions provided 
under 1115 authority are clinically appropriate, do not supplant existing social services and 
housing assistance, and adhere to statutory authorities and program goals.  All interventions must 
be evidence-based and medically appropriate for the population of focus based on clinical and 
social risk factors.  States have flexibility to propose clinically focused, needs-based criteria to 
define the medically appropriate population, subject to CMS approval.  Examples of populations 
 
4 https://www.medicaid.gov/sites/default/files/2022-01/sho21001_0.pdf 
5 https://www.medicaid.gov/sites/default/files/2022-04/mfp-supplemental-services-notice.pdf 
6 Additional Guidance on Use of In Lieu of Services and Settings in Medicaid Managed Care. 
https://www.medicaid.gov/sites/default/files/2023-01/smd23001.pdf.  
7 ILOSs are authorized in accordance with 42 CFR  438.3(e)(2). 
8 https://www.medicaid.gov/sites/default/files/2023-01/addrss-hlth-soc-needs-1115-demo-all-st-call-12062022.pdf. 
9 See examples: https://www.medicaid.gov/sites/default/files/2022-06/ca-calaim-ext-appvl-12292021.pdf 
https://www.medicaid.gov/sites/default/files/2022-09/or-health-plan-09282022-ca.pdf 
https://www.medicaid.gov/sites/default/files/2022-09/ma-masshealth-ca1.pdf 
https://www.medicaid.gov/sites/default/files/2022-10/az-hccc-ca-10142022.pdf 
https://www.medicaid.gov/sites/default/files/2022-11/ar-arhome-ca-11012022_0.pdf 
https://www.medicaid.gov/sites/default/files/2023-03/nj-1115-cms-exten-demnstr-aprvl-03302023.pdf 
https://www.medicaid.gov/sites/default/files/2023-06/wa-medicaid-transformation-ca-06302023.pdf 
10 https://www.medicaid.gov/health-related-social-needs/downloads/hrsn-coverage-table.pdf 
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  CMCS Informational Bulletin 
that could be served across Medicaid authorities include children and pregnant individuals 
identified as high risk, individuals who are or are at risk of becoming homeless, individuals with 
serious mental illness and/or substance use disorder, and individuals experiencing high-risk care 
transitions.11  Medicaid-covered services and supports to address HRSN will not supplant the 
work or funding of another federal or state non-Medicaid agency, and must be complementary to 
existing social services such as those provided by the U.S. Department of Housing and Urban 
Development and the U.S. Department of Agriculture Supplemental Nutrition Assistance 
Program.  These services will be the choice of the enrollee; enrollees can opt out anytime; and 
provision of these services does not absolve the state or managed care plan of its responsibility to 
provide coverage for other medically necessary services.   
 
There are also other requirements and limitations, including fiscal limitations, in the provision of 
Medicaid-covered HRSN services as an ILOS, which are further delineated in the framework and 
separate guidance on provision of ILOSs.  Additionally, for section 1115 demonstrations, these 
requirements include that expenditures on HRSN services cannot exceed 3 percent of the states 
total computable Medicaid spending, infrastructure costs cannot exceed 15 percent of total 
HRSN spending, and state spending on related social services must be maintained or increased 
(as compared to state spending prior to approval of section 1115 demonstration).  Further, as a 
condition of approval for HRSN services and related infrastructure under section 1115 
demonstrations, states have been and will be required to ensure provider payment rates in 
primary care, obstetrics care, and care for mental health and substance use disorders meet 
minimum thresholds, or commit to improving those payment rates.  This condition of approval 
reflects that connections to care can only be successful if beneficiaries have timely access to 
health care providers. Research shows that increasing Medicaid payments to providers improves 
beneficiaries access to health care services and the quality of care received.12  Further, states 
must adhere to systematic monitoring and robust evaluation requirements, including performance 
reporting on quality and health equity measures.13  
 
The flexibilities allowed under the HRSN framework provide state Medicaid and CHIP programs 
with the opportunity for innovation and new mechanisms to achieve these goals.  For additional 
information about this Bulletin or technical assistance, please contact your state lead or section 
1115 demonstration project officer. 
  
 
11 Examples of high-risk care transitions include transitions from emergency shelters, carceral settings, foster care 
settings, and hospitals or nursing homes for people with disabilities and older adults. 
12 Polsky, D., Richards, M. Basseyn, S., et al. Appointment Availability after Increases in Medicaid Payments for 
Primary Care. The New England Journal of Medicine; 2015; https://www.nejm.org/doi/10.1056/NEJMsa1413299; 
Decker, S. L., Medicaid Physician Fees and the Quality of Medical Care of Medicaid Patients in the USA. Review 
of Economics in the Household; 2007; https://link.springer.com/article/10.1007/s11150-007-9000-7. 
13 https://www.medicaid.gov/sites/default/files/2023-01/addrss-hlth-soc-needs-1115-demo-all-st-call-12062022.pdf  
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