By: Allexa Gardner, Tanesha Mondestin, Nancy Kaneb, and Juliana St Goar

Executive Summary

In an effort to better address the maternal and infant health crisis, states are increasingly seeking to use Medicaid to cover health-related social needs (HRSN) services and supports for pregnant and postpartum individuals and their children, particularly through Medicaid section 1115 demonstrations. Addressing unmet HRSN among these populations can help stabilize coverage, improve their access to care, and complement traditional medical care to promote maternal and child health more broadly.

• Fifteen states have approved (AZ, AR, MA, NC, NJ, NY, OR, WA) or pending (CA, CT, HI, IL, PA, RI, VT) section 1115 requests to cover housing services for pregnant and postpartum individuals or young children who meet specific eligibility criteria.
• Seven states (DE, MA, NC, NJ, NY, OR, WA) have approval to provide nutrition supports for pregnant and postpartum individuals or young children that qualify while four states (HI, IL, NM, PA) have pending proposals to do so.

States have previously used Medicaid to provide housing linkages, like helping individuals complete applications for housing and providing education on tenancy rights and obligations. Similarly, section 1115 demonstrations have allowed states to offer nutrition counseling and education to individuals enrolled in Medicaid. Medicaid funding has also been authorized more recently to be used for housing and items necessary to establish a basic household and provision of meals or grocery items for medically necessary nutritional supports, including Massachusetts and North Carolina in 2018.¹ The allowable services that states were authorized to provide through Medicaid were expanded upon and broadened by the Massachusetts and Oregon section 1115 demonstration extensions in 2022.

The Biden Administration has made supporting state’s efforts to address health-related social needs a priority, approving section 1115 demonstrations targeting HRSN in nine states, in order to fill gaps to promote better health outcomes. Approval of these policies have encompassed explicit conditions and guardrails for implementing HRSN supports to ensure that provision of medical services remains paramount and existing funding for social supports is not supplanted. For example, spending on HRSN services is capped at 3% of total Medicaid spending for each state and states are prohibited from using HRSN funding for certain services or activities (e.g., construction costs, capital investments, coverage for individuals not eligible for Medicaid due to immigration status). More broadly, CMS has established parameters around the populations that may be eligible to receive HRSN supports through Medicaid –  eligibility must be medically appropriate and based on clinical and social risk factor criteria. Additionally, long-standing CMS policy requires that all section 1115 demonstrations must be “budget neutral,” meaning the costs to the federal government will not exceed expected federal Medicaid spending absent the demonstration.

This report examines states’ use of Medicaid section 1115 demonstrations to cover housing, nutrition, and other HRSN services and supports for pregnant and postpartum individuals and young children who are experiencing or at risk of unmet HRSN.

Introduction

A person’s health is influenced by a wide range of variables, including dynamics well beyond direct access to health care services, often called the social determinants of health (SDOH). Social determinants of health describe the societal, non-medical factors affecting health outcomes. Where a person was born, lives, works, and spends time shape the circumstances they may face. These social determinants of health, such as racism, educational access, or variable state and local policy decisions have a significant impact on health outcomes and drive health inequities.

SDOH is sometimes used interchangeably with the term “health-related social needs,” but the concepts differ. Health-related social needs (HRSN) are individual-level social conditions that stem from how a SDOH may impact a given person, which encompass immediate needs that an individual or family may face, such as affordable housing or food security. Unmet social needs have been shown to worsen health outcomes and can increase lapses in health coverage. This can exacerbate unmet health needs, leading to higher downstream medical costs, and perpetuate health inequities.

Figure 1

States and the federal government have been working for years to understand and tackle the root causes of unmet HRSN, which includes a recent surge in policy actions, most notably within the Medicaid program. Medicaid, a jointly-run state and federal health insurance program, offers states significant flexibility in how they operate the program as long as they meet federal minimum standards. The Centers for Medicare & Medicaid Services (CMS) has highlighted the flexibilities that exist within federal rules and requirements that may allow states to use Medicaid to cover certain services aimed at addressing unmet HRSN, when medically appropriate, for specific populations covered by the program.

Though a variety of different Medicaid populations may be eligible for HRSN services based on state-defined criteria, pregnant and postpartum individuals are a key group states may target with HRSN policies.² Pregnant individuals are more vulnerable to pregnancy complications and adverse outcomes like pre-term birth, preeclampsia, and low birth weight due to unmet social needs or the associated stress. During pregnancy, individuals are recommended to have 14 prenatal visits to help identify and address potential compilations; HRSN can affect the access and ability to attend all recommended appointments throughout pregnancy. Unmet social needs during the 12-month postpartum period have also been associated with higher depression and anxiety rates among pregnant and postpartum people.

Young children may also experience negative effects from unmet social needs that can put them at greater risk of developmental delays, mental health challenges, and poor educational outcomes. From the prenatal period to the preschool years, a children’s brain is developing most rapidly compared to other life stages. Health and development during the early childhood years can be influenced by both positive and negative experiences like maternal nutrition, parental stress, employment status of caregivers, and home environment. Food insecurity among mothers is associated with greater incidences of inpatient hospitalizations and missed immunizations for their children in the first six months of life. Children in households with HRSN may also be more likely to experience social-emotional challenges within the first year of life that may require early intervention, such as inflexibility, difficulty with routines, and irritability. Addressing the social drivers of health, especially during critical early childhood years, can help promote a child’s healthy development and growth.

Medicaid finances more than 40% of births in the United States and provides coverage to approximately 1.4 million postpartum individuals during the year after delivery. Given the important role of Medicaid for pregnant and postpartum individuals and young children, states are increasingly seeking to leverage the program’s flexibilities to address HRSN during this time-sensitive period of family change and rapid brain development during pregnancy and early childhood. This report provides an analysis of state efforts to use Medicaid section 1115 demonstrations to cover HRSN services and supports for pregnant and postpartum individuals and their children, which can help stabilize coverage and improve their access to care.

Opportunities to Address Health-Related Social Needs Through Medicaid

At the end of 2023, the CMS issued guidance on how states can use Medicaid to address unmet HRSN. There are several pathways available for states to do so – home- and community-based service (HCBS) authorities, Health Service Initiatives (HSIs) funded through the Children’s Health Insurance Program (CHIP) administrative dollars, managed care in lieu of services or settings (ILOS), and section 1115 demonstrations.

• HCBS Authorities. Services provided using HCBS authorities, such as those available via section 1915 of the Social Security Act, generally support individuals with disabilities and over the age of 65 that need more intensive supports and who may otherwise require an institutional level of care.
• CHIP Health Service Initiatives. CHIP HSIs must be used to improve the health of low-income children eligible for CHIP and/or Medicaid, but need not directly be tied to their eligibility. States have used CHIP HSIs to implement a range of different policies including cover lead testing and abatement, improve access to vision services, and create programs focused on promoting early childhood development, Wisconsin uses HSI funds to provide some housing-related supports including tenancy and tenancy sustaining supports and transition-related costs like security deposits (up to a capped amount).
• Managed Care “In Lieu of Services or Settings”. ILOS allow states and managed care plans to cover services or settings that are determined to be a medically appropriate substitute for services or settings covered under the state plan. CMS has outlined opportunities to use ILOS to address HRSN, including the parameters states must follow and required oversight activities. These requirements were recently codified in the updated Medicaid managed care regulations.
• Section 1115 demonstrations. Section 1115 demonstrations are experiments or demonstration projects authorized by the Secretary of Health and Human Services that he/she determines promote the objectives of Medicaid.³ These demonstration projects may offer states additional flexibilities for HRSN services or duration of services they can cover, compared to ILOS. States are required to ensure that all approved 1115 demonstrations do not result in greater federal Medicaid spending than would occur without the demonstration, also known as “budget neutrality,” whether the demonstration contains HRSN supports or not.

For the purposes of this paper, we focus on states with approved or proposed section 1115 demonstrations that cover HRSN services.

In general, based on CMS guidance and 1115 approvals to date, states may provide HRSN services through Medicaid 1115 demonstrations for housing, nutrition, and HRSN case management in certain limited circumstances. Specific covered services vary by state, but all services must be targeted to populations based on state- and CMS-determined criteria (see Box 1) within fiscal and beneficiary protection guardrails specified in the standard terms and conditions (STCs) of each state’s demonstration approval. 

Housing Supports

Housing Instability and Health Outcomes Among Pregnant and Postpartum Individuals and Young Children

Individuals experiencing homelessness, a growing problem in the U.S., have considerable unmet social needs which are only exacerbated for pregnant, postpartum individuals, and young children. Between 2016 and 2020, the prevalence of homelessness among pregnant individuals increased by more than 70% – from 76.1 to 131 per 100,000 deliveries. Unstable housing and/or homelessness is also a concern for babies and toddlers. In 2021-2022, an estimated 360,000-plus infants and toddlers experienced homelessness. Young children under age five also experience greater risk of eviction as well as living in crowded housing.

Research links homelessness during pregnancy with extreme preterm delivery as well as severe maternal morbidity and mortality. Additionally, pregnant individuals who experience homelessness are less likely to have a prenatal visit during the first trimester and to complete a follow-up visit for their newborn with a pediatrician. Infants of individuals experiencing homelessness also have a greater chance of being admitted into the neonatal intensive care unit.

Infants in households experiencing homelessness have very low enrollment rates in early childhood development programs which support school readiness and overall development. Children who experience homelessness at a young age also face longer-term consequences. People who experienced homelessness as infants are more likely to develop health conditions like upper respiratory infections, developmental disorders, and asthma, which can result in increased health care costs from emergency department visits and/or hospitalizations.

Nearly 11 million families in the U.S. spend 50% or more of their income on housing putting them at risk of being insecurely housed. Though the Department of Housing and Urban Development (HUD) Housing Choice Voucher program can help offset the costs of housing for families with low-incomes, there are often long waiting periods to receive assistance through the program. Even for those that may have or are able to obtain stable housing, there may be concerns about the quality of housing that can affect health, such as mold or pest issues, presence of lead paint, or availability of functioning appliances like air conditioning or refrigeration units. Many if not most pregnant and postpartum individuals and their children experiencing or at risk of homelessness qualify for Medicaid services and are likely to either have Medicaid coverage or be uninsured.

Services to Address Unmet Housing Needs

Given the evidence linking access to safe, stable housing and health, more than a dozen states have requested or been approved to provide housing support services through section 1115 demonstrations. States have options on what services they choose to provide within the guidelines laid out by CMS. For example, Arizona covers the full scope of allowable housing services described in Table 1, while New Jersey has selected to provide a more limited set of supports.

States have previously received authority under section 1115 demonstrations to offer pre-tenancy and tenancy sustaining services, like assisting individuals with completing applications for housing and education on tenancy rights and obligations. The Biden Administration’s recent approval of Massachusetts and Oregon’s demonstration extensions, however, marked the first time Medicaid funding was allowed to be used directly for costs needed to secure housing and establish a basic household. The focus of this report’s analysis of state actions to address housing HRSN is on these supports and those that contribute to the direct provision of housing; it does not reflect pre-tenancy and tenancy sustaining services that other states may be providing.⁴

Housing supports CMS has approved range from housing deposits to rent or temporary housing for up to six months. Services are time limited, either as one-time payment/services or provided for a limited period of time. For example, rent or temporary housing supports are only allowed for up to six months. A closer analysis of implementation documents required by CMS provide additional details on allowable services where states’ approaches may start to vary, including more targeted actions for pregnant and postpartum people or young children. For example, Oregon’s “HRSN Services Protocol” identifies cribs as a covered household good under one-time transition and moving costs supports. Table 1 provides more details on the scope of housing supports states offer or have requested to provide.

CMS has set clear guardrails for use of Medicaid funding for HRSN housing supports. Under approved 1115s to date, CMS explicitly prohibits states from using HRSN housing funding for construction costs (i.e., brick and mortar except for allowable home modifications), capital investments, and most room and board.⁵ Additional conditions for HRSN approvals are described in Box 2 below.

Eligibility for housing services (and other HRSN services) is generally based on two factors: (1) social risk criteria and (2) health or clinical needs criteria, as illustrated in Figure 2. All states that have sought to cover housing supports define the social risk criteria as experiencing homelessness, at risk of homelessness, or transitioning out of an emergency shelter, which CMS approvals define based on HUD regulations. In other words, to be eligible for any housing services in any states, an individual must be homeless or at risk of homelessness and meet health needs-based criteria selected by each state.

Figure 2. Factors Determining Eligibility for HRSN Services

In some states, pregnancy or being within the postpartum period or under age six have been proposed as a qualifying clinical need to be eligible for HRSN services. To date though, a subset of these populations are eligible in most states based on having or being at risk of developing certain conditions (e.g., malnutrition, low birth weight, or high-risk pregnancy), or on other clinical factors, such as an identified mental health condition. The health needs criteria for which pregnant and postpartum people and young children may indirectly or more explicitly qualify are detailed in Table 1.

Nutrition Supports

Food Insecurity Among Pregnant and Postpartum Mothers and Young Children

Lack of adequate or available food, known as food insecurity, is an unfortunately common occurrence with serious health consequences, especially for young children and individuals who are pregnant or in their postpartum period. Almost 17% of households with children under six experienced food insecurity in 2022 (a significant increase from 12.9% in 2021). Pregnant people require enhanced nutrition to avoid potential adverse maternal and infant health outcomes. For example, severe iron deficiency, or anemia, can lead to serious pregnancy complications and increased risk of an infant with low birth weight. Accessing necessary nutrition to support a healthy pregnancy may be difficult for those experiencing food insecurity.

Food insecurity during the postpartum period can result in increased parental stress and maternal depression which affects both the mother and baby. Maternal depression rates are higher among families with low-incomes, where food insecurity is a more prevalent issue. Both maternal depression and food insecurity can affect a young child’s development. Infants and toddlers of parents with untreated depression are at risk of cognitive and social-emotional developmental delays as early as infancy. Similarly, research has found household food insecurity to be associated with poor early child development among young children.

While federal programs exist to help increase food security especially for children and pregnant people (e.g., Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)), these supports may not be sufficient to meet the nutritional needs of this population. For example, a pregnant individual with or at risk for gestational diabetes requires substantially more fresh fruits and vegetables and/or protein and fewer shelf-stable products that may be higher in sugar. Though some of these grocery items may be available through other benefits, these programs may not be enough to support medically necessary nutritional needs throughout the entire month, especially with rising food costs.

Services to Address Inadequate Nutrition

Eleven states have sought to provide nutrition services that can help address food insecurity and other HRSN through section 1115 demonstrations. Similar to the housing supports, the specific mix of nutrition supports offered or proposed vary across states. CMS has identified five types of nutrition supports that are considered allowable: (1) food/nutrition case management; (2) nutrition counseling; (3) home delivered meals or pantry restocking; (4) nutrition prescriptions like fruit and vegetable boxes; and (5) grocery provisions.

Some of these services are meant to educate and improve nutrition skills, like nutrition counseling that provides guidance on selecting healthy foods and healthy meal preparations. Other services directly provide meals or groceries to eligible individuals; these direct services tend to be more targeted to specific populations or health conditions. Massachusetts and New York also received federal approval to cover cooking supplies, including pots and pans and refrigerators necessary for preparing nutritious meals.⁶

States must establish need-based eligibility criteria to ensure the supports are medically appropriate for the individuals receiving them, as with HRSN housing supports. However, eligibility criteria for nutrition services are generally easier to meet for pregnant and postpartum people and their children. In fact, CMS guidance on HRSN services specifically mentions children and pregnant individuals as groups that may receive home delivered meals or pantry stocking services. Several states, like New Jersey, will cover certain nutrition services for pregnant people at risk for or diagnosed with diabetes, who are at greater risk of compilations if nutritional guidelines are not carefully followed. Hawaii seeks to ensure all postpartum individuals up to twelve months after delivery may access covered nutrition supports such as fruit/nutrition prescriptions and pantry restocking as proposed in its HRSN request to CMS.

Direct provision of meals or groceries are limited to up to three meals per day for up to six months under CMS guidance. However, some states, such as New York, include allowances for services to continue if an individual is determined to still meet the eligibility criteria. Table 2 provides further details on key nutrition supports states provide or are seeking to provide and identifies how pregnant and postpartum people or young children may be eligible to receive these supports. As with housing services, specific eligibility may vary by service.

Other HRSN Policies

Transportation to Non-Medical Services

Federal Medicaid law requires states to provide transportation to and from medical appointments through the non-emergency medical transportation (NEMT) benefit. Some states have extended or are seeking CMS approval to extend transportation benefits to provide transportation (public, private, or both) to covered HRSN services through 1115 demonstrations. For example, North Carolina currently offers reimbursement for public or private transportation to HRSN supports for eligible individuals.⁷

Case Management

States already have the ability to provide case management services to adults through state plan authority and as a required service for children under the Early and Periodic Screening, Diagnostic, and Treatment benefit. States increasingly include case management as a key component for specific populations prioritized by proposed or existing section 1115 demonstrations. Pennsylvania seeks CMS approval to use case management to help connect pregnant people and young children and other priority groups with HRSN services, such as connections to housing specialists. More than a dozen states are requesting demonstration project approval to provide case management services to justice-involved populations as part of a targeted set of allowable services covered in the 90 days prior to release from carceral settings; many of these states plan to connect individuals to HRSN supports as they transition back into the community as part of the case management benefit. Some states, like Connecticut, identify pregnancy or being within twelve months postpartum as a qualifying eligibility criterion for the pre-release benefits.

Interpersonal Violence Programs

Interpersonal violence (IPV) and toxic stress have been shown to contribute to adverse health outcomes for pregnant individuals and their infants. Illinois, New Jersey, and North Carolina are seeking or have been approved under 1115 waivers to provide IPV and prevention supports as part of the HRSN services offered through Medicaid. In New Jersey, part of the state’s Home Visiting Pilot program includes education and screening for domestic and intimate partner violence. North Carolina’s Healthy Opportunities Pilot (HOP) program is currently approved to provide IPV supports including legal assistance, but implementation has been delayed.

Diapers and Changing Supplies

States are also beginning to explore the provision of diapers as a new HRSN support in Medicaid. Currently, diapers are covered through Medicaid almost exclusively for individuals age three and above in cases where the supplies are considered medically necessary.⁸ Diaper need has been associated with maternal depression and increased parental stress, which can have adverse effects on children’s physical, behavioral, and emotional development, and diaper-related illnesses can occur from delayed diaper changes.

Two states have sought to address this HRSN by providing diapers to families of young children enrolled in Medicaid. CMS recently approved Tennessee’s request to provide a monthly supply of diapers to all children under age two with Medicaid coverage, noting the health benefits to both infants and their parents. Delaware has also received approval to cover diapers for a smaller subset of infants in Medicaid, building on an existing state-funded program that provides postpartum individuals enrolled in Medicaid with a weekly supply of diapers and changing supplies, for up to eight weeks postpartum. Through its demonstration, the state will expand its program to 12 weeks postpartum.

Implementation Funding for HRSN Services

Most states are requesting additional federal funding in their section 1115 applications to invest in “infrastructure” needed to ensure approved HRSN services are available and utilized by eligible individuals. As defined in approvals, HRSN infrastructure funding is to be used by states to develop systems and partnerships that support implementation of HRSN services. This funding may be used for technology (e.g., electronic referral systems, screening tools and/or case management systems); development of business or operational practices like developing policies for referral management and trauma-informed practices; workforce development (e.g., cultural competency training); and outreach, education, and stakeholder convening.⁹

Outreach will be critical to ensuring that eligible populations receive available HRSN services. Eligibility criteria for HRSN services creates an additional layer of complexity beyond basic Medicaid eligibility rules. Ensuring pregnant and postpartum people and their children who meet qualifying criteria understand and receive HRSN services will require more nuanced, targeted, and sustained outreach.

Infrastructure funding for outreach may cover one-time opportunities like community-based outreach events, training for community-based health workers, and learning collaboratives for stakeholders, along with ongoing activities like education and and the provision of outreach materials and their translation into languages other than English. Regardless of how infrastructure funding is used for outreach, the scope of HRSN services provided and the proportion of infrastructure dollars devoted to outreach will help determine the ultimate success of a state’s efforts to connect eligible individuals to services. In Oregon and Washington, two of the three states with approved infrastructure protocols, outreach spending constitutes 15% of total infrastructure spending; in New Jersey, which has fewer HRSN services, 10% of infrastructure funds has been directed to outreach based on the state’s approved protocol. In states where eligibility for HRSN supports differ by service, outreach and education efforts will need to be carefully targeted.

Conclusion

Leveraging Medicaid to address families’ health-related social needs has the potential to improve health outcomes for pregnant and postpartum parents who lack key social resources that are vital to accessing medical care and influencing long-term health both for parent and child. Unmet HRSN can affect an individual’s health and well-being during significant periods like pregnancy and early childhood. Now that most states have adopted the option to extend postpartum coverage to twelve months, there is an opportunity for states to explore policies that focus on the upstream factors that affect maternal mortality and morbidity and can support improved maternal and child health. In combination with other policies such as extended postpartum coverage and multi-year continuous eligibility for young children, services that target important social needs like housing and nutrition can help promote coverage and access to care in early childhood and throughout pregnancy and the postpartum period.

Recent actions by states to provide HRSN supports and services are a promising step to remove barriers to coverage and care to populations at greater risk of negative health outcomes. However, the impact of these new policies hinges on the extent to which states target these services to pregnant and postpartum individuals and young children as well as how successful states are in implementing the policies. States that broadly define eligibility to include postpartum/pregnant individuals or young children but do not explicitly call out those groups as eligible will need to do more outreach to ensure these individuals receive HRSN services. Outreach and cross-sectional partnerships will be critical to the success of states’ HRSN approaches.

Lastly, the newly codified regulations on “In Lieu of Services” (ILOS) offer states an alternative pathway for using Medicaid to address HRSN. Moving forward, more states may begin to pursue providing HRSN supports through ILOS rather than through the time-limited and more arduous section 1115 demonstration project process. Providing HRSN services through Medicaid is not a comprehensive nor stand-alone fix to the unmet social needs of low-income pregnant and postpartum individuals or their children. However, states’ pursuit of section 1115 demonstrations to cover HRSN services signifies positive, important progress in recognizing and addressing the many factors that contribute to families’ success.

Acknowledgments: The authors would like to thank Elisabeth Wright Burak and Hannah Green for their significant contributions to conceptualizing and finalizing this report. The authors would also like to thank Joan Alker, Leo Cuello, Anne Dwyer, and Catherine Hope for their review and helpful feedback.

Appendix

---

Endnotes

¹ In October 2018, the Trump Administration approved Massachusetts's “Flexible Services Program” protocol and North Carolina’s “Medicaid Reform Demonstration” which allowed both states to provide more direct housing and nutrition supports to certain high-risk populations. See the MassHealth “Flexible Services Protocol” Approval, available here and the North Carolina 1115 demonstration approval, available here.

² With focus nationally and in states on “maternal” health, this paper uses the term “mother” to distinguish covered individuals following their pregnancy. We aim to use more inclusive terms when able in recognition that not all individuals who become pregnant and give birth identify as women. Georgetown CCF also uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth.

³ States submit applications for section 1115 demonstrations to CMS for approval, which must include a research hypothesis the state plans to test and a proposed evaluation. Applications are considered “pending” until CMS takes action to approve or deny a proposal.

⁴ In addition to the services outlined in Table 1, states may provide other pre-tenancy and tenancy sustaining supports. Pre-tenancy services are defined as services that assist individuals with locating and obtaining housing options, and providing education about their tenancy rights and responsibilities. Tenancy sustaining services include connecting individuals with social services or services that can assist in applications to obtain sources of income, assisting with lease and housing subsidy renewals, and directing individuals to legal assistance as needed. States like Massachusetts and Hawaii were previously authorized to provide these services, which are still largely included in the states’ approved demonstrations or pending proposals.

⁵ CMS guidance defines “room” as “hotel or shelter-type expenses including all property related costs” and defies “board” as “three meals a day or other full nutritional regimen.” With its recent 1115 amendment approval in Massachusetts, CMS has broadened the definition of allowable “room and board” to include certain short-term post transition temporary housing.

⁶ Cooking supplies are only allowed when not available to an individual through other programs.

⁷ In North Carolina, transportation needs must be documented in an individual’s care plan in order to receive services.

⁸ Any exceptions for children under age three to receive diapers are when determined to be medically necessary. Full details can be found here.

⁹ Once CMS approves such infrastructure funding, states must seek subsequent CMS approval on a protocol document detailing use of funds and the providers eligible to receive funding (additional oversight and data on the infrastructure funding is required in other demonstration documents like the evaluation of the demonstration).