Using a Community Care Hub Model to Address Health Related Social Needs in Medicaid

May 30, 2024 |  By Sarabeth Zemel

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At least nine states have received approval from CMS to pay for health-related social needs (HRSN) interventions through Medicaid through 1115 waivers, including housing supports, nutrition supports and case management. Up until Fall 2023, however, there was limited guidance explaining the agency’s parameters on this policy. In an effort to clarify the coverage options for housing and nutrition services under Medicaid, CMS released new guidance in November 2023 emphasizing the significance of addressing HRSNs. This includes a comprehensive list of 15 HRSN services that CMS considers approvable, spanning housing, home environment, and nutrition domains, along with the authorities, including through both 1115 waivers and Medicaid managed care contracting, under which each service may be authorized. 

Community Care Hubs 

In conjunction with the CMS guidance, the Biden Administration also released a playbook on addressing social determinants of health and a “Call to Action” document urging the health care and social services sectors to bridge the silos that currently exist and work together to address HRSNs. Through these resources, the Administration provides support for using a community care hub model to link the health care system to the human or social services system and the community-based organizations (CBOs) that provide those social services. Hubs coordinate the administrative functions for CBOs, so CBOs can do what they do best: focus on delivering services.  

Community care hubs are not a new model. The U.S. Administration for Community Living, with support from the Centers for Disease Control and Prevention has supported a hub model for evidence-based interventions, and CMS has also supported hub development through its Accountable Health Communities model. The Partnership to Align Social Care is a multi-sector effort seeking to promote health and social delivery system transformation, which strongly supports the development of community care hubs

North Carolina’s 1115 waiver, approved in 2018, was the first 1115 waiver state to utilize the hub approach through its Healthy Opportunity Pilots which are being tested in three areas of the state. While the evidence is still limited, North Carolina’s approach shows promise and the state is currently seeking to renew its waiver and expand it statewide. 

New York is Next State to Get 1115 Waiver Approval 

New York State is one of the latest states to receive approval for Medicaid payment for HRSNs through an 1115 waiver and plans to take the hub model statewide. In January 2024, New York State announced a funding opportunity for entities to lead Social Care Networks (SCNs) across its nine regions, aiming to coordinate social care service delivery of services approved through the waiver. The SCNs are critical to the state’s effort and will seek to build robust regional networks of CBOs for effective HRSN screening and service delivery. Eligible lead entities, required to be 501(c)(3) nonprofits with relevant experience, will play a pivotal role in addressing housing, food and transportation needs regionally, reflecting a scalable model for integrating social care into healthcare delivery. SCNs will create and support a network of CBOs with the capacity to: 

  • screen all Medicaid members for HRSNs,  
  • coordinate social care services for the populations eligible under the waiver,  
  • contract with MCOs and become a Medicaid provider to facilitate payments for social care services delivered by the network CBOs,  
  • conduct data and technology management to ensure data sharing and reporting with the network.  

Another Approach: CalAIM 

Other states have taken a different approach. When California first launched its Medicaid transformation initiative, CalAIM, through a combination of 1115 waiver and managed care contracting authority, the state did not use a centralized entity to organize the CBOs providing HRSN services. In CalAIM, Medi-Cal managed care plans (MCPs) can choose to offer up to 14 different social services to eligible Medi-Cal enrollees through its Community Supports program. In the over two years since Community Supports have launched across the state, many CBOs have struggled to become Medi-Cal providers and take on the required administrative functions, such as billing and claims.  

CBO Challenges in a Medicaid-funded Model 

A recent Health Affairs blog acknowledged these challenges for CBOs when moving from a revenue model based on grant funding to Medicaid’s model of reimbursement after delivering services, particularly around cash flow. While the new HRSN 1115 waiver framework can typically offer infrastructure and capacity building funding for CBOs to take advantage of, states using non-1115 waiver authorities, like Medicaid managed care contracting, may not offer these opportunities. But in New York, the state is also taking a different approach: the infrastructure funds unlocked through the state’s 1115 waiver amendment will build the Social Care Networks that will serve as regional network hubs for the CBOs and take on many critical functions that CBOs might otherwise struggle with, including billing. 

Although CalAIM did not include network hubs as part of its model, at least one of the MCPs participating in the initiative has moved in that direction. At the beginning of 2024, Kaiser Permanente adopted this approach and now has three Network Lead Entities that contract with smaller community-based providers to provide ECM, CS and Community Health Worker services under CalAIM. 

Eyes on New York 

Will New York State succeed with their SCN model? As an added pressure, the state will only have about three years to implement before it must renew its 1115 waiver and show CMS some results in the evaluation that must accompany the renewal. Given this accelerated timeframe, the SCN model seems to best set CBOs up for success in implementing and delivering HRSN services quickly. 

Transform Health is a nationally certified women and minority led health care consulting firm. Reach out to us today if you would like to work together. Contact Heather Bates, COO, and VP of Stakeholder Engagement at heather@transformhc.com. We would love to hear from you!