Elisabeth W Burak: Hi, everyone, there are folks coming in to this webinar, fast and furious. So we might give it just one more minute before we get started.
Elisabeth W Burak: Okay, I think our the entries are starting to slow down, so we'll go ahead and get started today.
Elisabeth W Burak: So good afternoon. My name is Elizabeth Wright Barak. I'm a senior fellow at the Georgetown Center for children and families, and we are pleased to have this webinar today. On using Medicaid section 1115. Demonstrations to support the health related social needs for
Elisabeth W Burak: prenatal to 3 populations. This is a
Elisabeth W Burak: we wanted to do this. Webinar based on a report. We released earlier this summer, and we were really excited to have 2 of our teams here at Ccf. Work together on this. Those of us work working on maternal and early childhood health and also our waiver friends.
Elisabeth W Burak: And we're also grateful to our funders, including Packard Foundation and others, for making this work possible
Elisabeth W Burak: before we get started. A few housekeeping notes we will share out a Pdf of the slides and the recording after after today.
Elisabeth W Burak: And if you have any questions during the course of our presentations, just use the Q&A function. And we're going to try to get to those questions or work to get to those questions at the end of the webinar.
Elisabeth W Burak: so
Elisabeth W Burak: we know especially as our country is dealing with maternal health crisis. And we're increasingly looking for ways to improve
Elisabeth W Burak: the earliest healthy development. We know social circumstances, impact health outcomes.
Elisabeth W Burak: And we've seen a lot more conversation in the policy world about
Elisabeth W Burak: what are the best ways for the health system and the health policy worlds to engage in these social needs.
Elisabeth W Burak: especially for pregnant women and young children who have sort of these unique and time sensitive needs during what is always a very rapid time of change and early development for these families. Just a lot of interest in how best to do this, especially in insurance and in Medicaid. So increasingly States and at the Federal level, Cms have started to think through, I think, in a very
Elisabeth W Burak: thoughtful way. What are the approaches that States can take to do this meaningfully? And so we're going to go through that today in terms of kind of where the Federal and State policies are coming together and waivers and other medicaid pathways for health related social needs.
Elisabeth W Burak: And my colleagues and paper authors are here to kind of delve into those details. So next slide, please.
Elisabeth W Burak: So today, we have Tanisha mondestin right here from Ccf. Is going to talk a little bit about what we're talking about when we say health related social needs.
Elisabeth W Burak: how they relate to social determinants.
Elisabeth W Burak: Leo coel who is also on our waiver team, is going to be talking about just the different pathways in Medicaid for health related social needs.
Elisabeth W Burak: We're thrill nancy Kaneb is gonna talk about sort of what we found and reports what the teams found in terms of what States are doing and how they're approaching it, and some of the different considerations in the waiver sense.
Elisabeth W Burak: Alice and Oris, who we're always thrilled to have from our partner at the center on budget and policy priorities is going to talk about sort of implementation, infrastructure funding and also sort of the guard rails that Federal policy folks at Cms have put around this thinking
Elisabeth W Burak: and then
Elisabeth W Burak: Ali is going to talk a little bit more about some of the implementation considerations for these along with Alison, and then get to some questions so very packed agenda.
Elisabeth W Burak: So I will move it over to Tanisha to get us started. Thanks, Tanisha.
Tanesha Mondestin: Thanks, Elizabeth. So I'm going to start us off with a question. Next slide, please.
Tanesha Mondestin: What exactly are health-related social needs?
Tanesha Mondestin: So health related social needs are often used interchangeably with social determinants of health, but they kind of have a difference. A person's health is influenced by a wide range of variables, including dynamics that are well beyond their direct access to healthcare services. So that's what we usually frame as social determinants of health.
Tanesha Mondestin: And this framework is largely used in the public health sphere, and the centers of disease control and prevention describe social determinant of health as those societal non medical factors that affect health outcomes. So the figure that you see here
Tanesha Mondestin: those
Tanesha Mondestin: social determinants of health as a larger circle, because social determinants of health kind of look at the macro level or big picture
Tanesha Mondestin: when we're looking at nonmedical factors so that can include conditions that people are born in the environments that they grow in work, live in or even aging. So social determins of health are also influenced by the distribution of money, power and resources
Tanesha Mondestin: that are impacted by systemic racism, discrimination, and institutional bias.
Tanesha Mondestin: So, on the other hand, in the figure, we see that health related social needs are in a much smaller circle that is engulfed by social determines of health, and that is because so health related, social needs are more specific. So they look at an issue on a micro or individual level. So these are social conditions that stem from how a social determinant of health may impact a person.
Tanesha Mondestin: So health related social needs refer to the social and economic needs that individuals experience that affect their ability to maintain their health and well-being. So some examples may include housing, instability, interpersonal violence, food, insecurity, employment, lack of transportation, and affordable utilities.
Tanesha Mondestin: So Cms. Highlights, flexibilities that exist within federal regulations and requirements that allow medicaid to cover certain services. Under health related social needs when it is medically appropriate. So
Tanesha Mondestin: when we're looking at
Tanesha Mondestin: prenatal to 3 next slide, please.
Tanesha Mondestin: we have that pregnant and postpartum individuals are a key group to target for health related social needs. So medicaid finances, more than 40% of births in the United States and they provide coverage to approximately 1.4 million postpartum individuals
Tanesha Mondestin: in pregnant individuals are more vulnerable to pregnant pregnancy complications and adverse health outcomes, such as preterm birth, preeclampsia, and low birth weight.
Tanesha Mondestin: and during pregnancy individuals are recommended to have at least 14 prenatal visits to help identify and address potential complications. Early on during the pregnancy. But if a pregnant person is concerned about
Tanesha Mondestin: housing or food insecurity, they're not going to be worried about attending all of these appointments. So health related social needs, kind of helps to fill in that gap to make sure. That pregnant individuals are able to make these recommended appointments on time.
Tanesha Mondestin: Young children may also be affected by unmet social needs, and that can place them at greater risk of developmental delays, mental health challenges and poor educational outcomes
Tanesha Mondestin: next slide, please.
Tanesha Mondestin: So 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 the home environment.
Tanesha Mondestin: Food, insecurity among mothers is also associated with greater instances of inpatient hospitalizations and miss immunizations for children during their 1st 6 months of life.
Tanesha Mondestin: Children and households with health related social needs may also
Tanesha Mondestin: are also more likely to experience social, emotional challenges within the 1st year of life that may require early intervention, such as inflexibility, difficulty for routines, and irritability. So addressing the social drivers of health, especially during these critical early years, can help promote a child's health.
Tanesha Mondestin: development and growth.
Tanesha Mondestin: So let's take examples with housing supports and nutrition. So 2 health related social needs for categories of prenatal to 3.
Tanesha Mondestin: So homelessness, we know, is a huge crisis in the United States.
Tanesha Mondestin: and, being homeless, can exacerbate those issues for pregnant postpartum and young individuals.
Tanesha Mondestin: and looking at statistics between 2,016 and 2,020, the prevalence of homelessness among pregnant individuals increased by more than 70%,
Tanesha Mondestin: and research links that homelessness during pregnancy can lead to adverse health outcomes such as preterm birth or severe maternal morbidity, and even mortality.
Tanesha Mondestin: So homelessness can even affect individuals throughout the life course. So people who have experienced homelessness as infants are more likely to develop health conditions like upper respiratory infections, developmental disorders.
Tanesha Mondestin: asthma, and this can result in increased health care costs from emergency room department visits or hospitalizations. So, given this evidence linking access to safe stable housing and health, no wonder many States are starting to look at housing supports through section 1115 demonstrations.
Tanesha Mondestin: And when we're looking at nutrition
Tanesha Mondestin: in 2,022, almost 17% of households with children under 6 experience, food, insecurity.
Tanesha Mondestin: And when we're looking at pregnant persons, they need enhanced nutrition to avoid potential adverse health outcomes, such as severe iron deficiency or anemia which can lead to those complications
Tanesha Mondestin: and Federal nutrition programs, such as nap and wig, may not be enough
Tanesha Mondestin: for pregnant persons who are experiencing conditions, such as gestational diabetes. So that is why nutrition is also an important health. Related. Social needs that states are looking into
Tanesha Mondestin: so overall unmade social needs have been shown to worsen health outcomes and can increase lapse in health coverage.
Tanesha Mondestin: This can exacerbate unmet health needs leading to higher downstream medical costs and perpetuate health inequities.
Tanesha Mondestin: So in a nutshell, social determinants of health are broader social conditions that have a direct impact on the more immediate individual and family needs that often show up as health related social needs.
Tanesha Mondestin: This varies that we find when addressing health related. Social needs can be understood as a result of social determinants of health.
Tanesha Mondestin: So now I will pass it off to my colleague, Leo.
Leo Cuello: Thanks, Tanisha. I'm gonna keep the party going. But just before I do, I wanna let you all know that we are working to turn the chat back, on which, for some reason isn't on right now. All the ref resources will be linked at the end of the slide deck and and we'll have that chat rolling soon.
Leo Cuello: But that said next slide, please slide 6
Leo Cuello: So I'm gonna start to talk about how we get this done historically, for various reasons.
Leo Cuello: Medicaid has had a limited ability to address services targeted at Hrsn, and I'll call those Hrsn services. There has been some access to Hrsn services in the context of Hcvs. And there has. There have been some supports through 1115 like where you, you know, sort of put people in touch with housing resources. But Medicaid really hasn't gotten fully into directly supporting housing or providing nutrition.
Leo Cuello: and this has really begun to change under the Biden Administration States are proposing to use Medicaid to help address Hrsn and Cms. Has already issued some approvals.
Leo Cuello: So this is not a drill. It's happening, people, and you'll see from the report that 12 of the 15 States on the housing chart are paying for, or have requested to pay for housing itself. So this is pretty groundbreaking in Medicaid.
Leo Cuello: So, as the Biden Administration has opened the door to accessing Hrs and services, they have signaled 4 major pathways to get to the services 4 ways that States can actually add the services. The 1st is through section 1115, the Key Medicaid authority allowing pilot programs. This is sort of where most of the action has been happening. And thus this is the focus of our recent report. And today's webinar
Leo Cuello: Cms has already approved numerous States to add Hrsn services using section 1115. I'll mention the 3 other pathways and then come back to 1115.
Leo Cuello: The second pathway is managed care in lieu of services also known as Ilos and this, I think, is the second one that is most important to know about for a general audience in terms of the chatter out. There is are a flexibility that States can give to their managed care plans to cover a substitute service some service that is provided in substitute
Leo Cuello: for a traditional State plan service. So, for example, a managed care plan might provide a community-based depression screening in lieu of an office visit screening.
Leo Cuello: Now, what's important here is that the Biden Administration has started interpreting and issued regulations to interpret substitution more broadly to allow States to target Hrsn with their Ilos. So, for example, the State provides nutrition support for a high risk pregnancy, and that substitutes for the hospitalization that might be prevented.
Leo Cuello: The 3rd pathway is Hcbs services, and this is the place where there has been the most action, historically kind of going outside of the usual medical services to access Hrsn. Like things.
Leo Cuello: These are for older adults, persons with disabilities and individuals of all ages, with functional impairments
Leo Cuello: given. Most of the new activity is in the 1st 2 topics. This hasn't been the center of attention, but there has been some expansive new guidance from Cms in the past couple of years for Hcbs. And I would expect the Administration to be open
Leo Cuello: to new ideas.
Leo Cuello: The final pathways through chip health services, initiatives. Hsis, hsis allow States to use whatever money is left over from their budget for chip administrative costs up to a 10% cap to fund Hsis and Cms has indicated that this is a funding stream they will consider for funding Hrsn, maybe even housing. But there isn't much action to talk about yet.
Leo Cuello: So it's to be determined. Cms is provided
Leo Cuello: specific guidance with examples of what you can do using each of these 4 authorities. And there's a very helpful chart from Cms. That is the second link here that will allow you to do some comparisons if you want to compare each one. The last thing I want to do on this slide is just some light comparison between the 1115 and Ilos options, which are kind of the shiny big new toys. Here
Leo Cuello: Ilos, as I said, are a managed care authority. So you can't do, Ilos. If you are talking about a strictly fee for service Context
Leo Cuello: 1115 s. Are supposed to be
Leo Cuello: temporary pilot programs. So they have to be reapproved regularly, namely, by different administrations in all likelihood. And they get a lot of political attention. So I think there's an argument that Ilos are a little safer as a long term solution.
Leo Cuello: that has lower administrative effort and may be able to sort of fly under the radar a little better.
Leo Cuello: but 1115 is more flexible, and can be done in combination with other things that may only be doable through 1115,
Leo Cuello: Alison will talk about what might be the biggest advantage of using 1115, the possibility of infrastructure dollars.
Leo Cuello: And finally, you'll want to think about whether there are different state processes to turn on Ilos versus 1115, for example, one may require state legislative authority and the other one doesn't.
Leo Cuello: So the takeaway here is, I can't tell you. One of them is always better. They both have pros and cons, so you'll have to work through that. In the context of your state and what it is you want to do, and we're certainly happy to help anyone think through that.
Leo Cuello: But certainly in many, many cases you're going to end up looking at an 1115. And so I think our report will be your friend there
Leo Cuello: next slide, please.
Leo Cuello: So now we're going to pivot to talking about how eligibility for the Hrsn services works, and I think it's helpful to start by putting yourself in Cms's shoes. Their job is to run a healthcare program right?
Leo Cuello: so
Leo Cuello: they
Leo Cuello: they are focused
Leo Cuello: on
Leo Cuello: paying for healthcare. And they know that paying for some things that may not look like traditional healthcare to many people. Like nutrition.
Leo Cuello: They. We know that that will improve health and actually reduce healthcare budgets and healthcare spending, but they also know that there may be politicians or partisans who attack them for using healthcare dollars to pay for other stuff, and and they don't want to be the lead lead story on the news channel.
Leo Cuello: And so Cms is making this a very controlled and deliberate expansion into Hrsn. It's not Oprah style, right where you get one and you get one. They're not just going to pay for everything for everybody. Instead, they are going to target when there are Hrsn needs that are connected to some kind of clinical need documented clinical need. So to be eligible. People are going to need to have both some kind of social and clinical need.
Leo Cuello: And I love this graphic that our team did with the sweet spot being where the green and the blue overlap.
Leo Cuello: So, for example that needs to be someone who has a social need like they are experiencing homelessness along with a clinical need, like they have a high risk. Pregnancy. So Cms is generally requiring combinations like that.
Leo Cuello: Now I want to say, Cms has said this in guidance, and that's what they've been doing in their approval. So it's been pretty consistent. But this whole enchilada is a work in progress. There are States who have asked for broader coverage that is less targeted, and we don't quite know where the policy is going to settle over the next year or 2
Leo Cuello: next slide, please.
Leo Cuello: So what are examples of social needs? Well, you have homelessness or being at risk of homelessness, individuals who are at risk because of transitions. And this is a lot of possibilities out of a hospital, a shelter, a prison out of the child welfare system, other institutional settings.
Leo Cuello: people experiencing food or financial insecurity.
Leo Cuello: And while those are examples that Cms is explicitly talked about. Your sit state isn't limited to those in terms of suggesting to Cms additional
Leo Cuello: social needs. You want to target cms may be receptive to some kind of compelling idea that's not on the menu
Leo Cuello: they are building and flying this plane at the same time. Here.
Leo Cuello: now.
Leo Cuello: in terms
Leo Cuello: of clinical needs.
Leo Cuello: our examples are
Leo Cuello: high risk pregnancy, including 12 month postpartum children under 6 who are experiencing or at risk or with a history of certain physical health conditions.
Leo Cuello: complex behavioral health needs in general, including sud and chronic physical health needs.
Leo Cuello: And again, you should not think of this as the definitive end of the list. List Cms. Might be open to additional ideas you can suggest
Leo Cuello: so ultimately as your State designs an Hrsn demonstration proposal. It's going to have to set out the matrix of social and clinical needs that will trigger eligibility for services where the State has a more targeted plan.
Leo Cuello: focusing the supports on subpopulations with specific clinical needs. It's more likely to be an easy lift. The broader, more sweeping you get about providing supports to everyone. The more likely Cms is gonna come in and try and narrow it through negotiations with the State. Cms. Is always going to go back to. They're going to be thinking about how is providing this non medical service ultimately connected to health care. That's what they're looking for.
Leo Cuello: And if I could say one last thing about this framework
Leo Cuello: what I've laid out is the general policy, but I think in practice it also ratchets up and down. If you are trying to pay for actual housing right, which can be expensive, which pushes the envelope of what has been allowed. Historically, you're going to have a stricter requirement for targeting precisely and connecting to healthcare. Whereas if you're trying to cover something that looks more like case management or tenancy education, I think Cms. Will have a lower bar
Leo Cuello: likewise, I think maternal or early childhood might get
Leo Cuello: easier targeting a lower bar than some other populations where you have may have to connect and document more clinically, but at the end of the day. It's not yet the case that just being pregnant or just being a child gets you eligible. So you you have to think about the eligibility in combination.
Leo Cuello: and with that I'm going to pass the baton to my colleague, Nancy.
Nancy Kaneb: Next slide, please.
Nancy Kaneb: So in our analysis of these demonstrations, we followed States formats and categorized the services into 3 main categories, housing, nutrition, and other.
Nancy Kaneb: Nearly every state defines its eligibility, criteria slightly differently, and the eligible populations further vary by service, particularly within nutrition, supports
Nancy Kaneb: these conditions for eligibility as well as implementation and access details can be found in approved waivers accompanying protocol documents, and are detailed in our table's notes.
Nancy Kaneb: So housing supports include a range of services, such as rent, application, fees, cost of movers, ventilation, repairs, and more. We sorted these services into 5 main buckets, which is rent and temporary housing utility payments. One time transition, moving costs, fees to secure housing or housing deposits, and medically necessary home goods and modifications.
Nancy Kaneb: both rent and utility. Payments differ in length based on the State.
Nancy Kaneb: but ultimately cannot exceed 6 months.
Nancy Kaneb: We use the term one time. Transition costs to account for states, coverage of initial expenses that arise that are one time, such as security deposits, utilities, activation fees, movers, pest eradication, and more.
Nancy Kaneb: Some states also cover what we call medically necessary home goods or home modifications. In cases where adaptations to the home, like air conditioners, ramps, handrails, and humidifiers are essential to the health and medical treatment of an individual.
Nancy Kaneb: Similarly to housing, we were able to classify. Nutrition supports under 3 categories, which is medically tailored meals, meals or pantry, stocking and
Nancy Kaneb: fruit, vegetable or protein prescriptions, so for medically tailored meals, it's mostly self-explanatory. States generally require individuals undergo an official nutritional assessment to determine a need and develop a medically appropriate nutrition plan before receiving these meals. The second category accounts for a variety of different forms of food provisions, so some states, coordinate grocery deliveries, and pantry stocking, others do meal kits, food vouchers, etc.
Nancy Kaneb: Under Cms guidance. This specific bucket can cover up to 3 meals per day for 6 months, depending on the States. These types of services can be provided through vouchers and prepaid cards or through food deliveries.
Nancy Kaneb: Again, there's variation on who is eligible for what and more specifics on the methods and details can be found in States. Cms. Approved protocol documents, for example, Delaware's model uses, a food box initiative through State funds to provide one box of shelf staples per week for up to 8 weeks of the postpartum period. But that is very different from a lot of the other
Nancy Kaneb: categories that fall under this bucket.
Nancy Kaneb: and lastly, for nutrition, prescription services can be for fruits, vegetables, or protein, just depending on the state and on the needs of the individual.
Nancy Kaneb: And, lastly, the other category of services accounts for support, such as transportation to non-medical services, case management and interpersonal violence programs
Nancy Kaneb: next slide, please.
Nancy Kaneb: So this map shows all States with approved or pending demonstrations. It also shows that the majority of States pursuing health related social needs through 1115 demonstrations are providing both housing and nutrition support to pregnant and postpartum individuals and young children
Nancy Kaneb: of the 12 States, providing both of these supports. 4 also cover transportation and or interpersonal violence programs. Under the 3rd category
Nancy Kaneb: there are 6 States covering solely housing supports and 2 covering solely nutrition supports.
Nancy Kaneb: So over half of the States on this map have approved 1115 demonstrations, including North Carolina, which also has an extension pending with Cms. To expand the eligibility criteria.
Nancy Kaneb: The total comes out to 21 States, including DC. That are providing or seeking to provide health, related social needs for prenatal to 3 populations. Through these 1115 demonstrations.
Nancy Kaneb: This map, along with a housing, nutrition and summary chart are available under our new health related social needs landing page on our website and will be regularly updated as we get States protocol documents and new proposals. Come in, and when you go and look at this map you can scroll over each State, and it will give you all the details on what they are providing and the status of their waiver demonstrations.
Allison Orris: I think I am up next, and we can go to the next slide.
Allison Orris: just to thank you, Ccf. For having me join you. I am going to talk a little bit. About some of the implementation considerations. That States are weighing as they. Con. Consider these new flexibilities. And as Ali's gonna talk a little bit about later implementing these health related social needs, waivers, takes significant energy and investments as states work with community based partners
Allison Orris: to build the capacity to deliver these services.
Allison Orris: And what we've seen is that in 1,115 waivers cms the agency that oversees all of this is willing to help States pay for these investments.
Allison Orris: and over the last year or so has articulated some updated flexibilities and financing policies to make all of this possible we could do a totally different webinar on some of the details. But I just want to give you a flavor about where infrastructure investments have been allowable. And a lot of what Cms and States have negotiated again.
Allison Orris: is an attempt to make it possible for community based social services, providers who may not typically interact with the Medicaid program to meet Medicaid or managed care requirements or requirements under the waiver
Allison Orris: that relate to the delivery of these services. So this slide highlights, allowable categories of infrastructure investments. And to just give you a few example of the broad categories. That you can see on the slide if we take tech technology, things like developing shared data platforms.
Allison Orris: case management systems, data reporting one of the things that I'll talk about in a minute is that these waivers have evaluation and monitoring components so ensuring that providers of health related social needs services, are able to report their data to the State or to the managed care entity that they might be contracting with
Allison Orris: accounting and billing systems.
Allison Orris: Or if we're thinking about some of the business and operational practices thinking about, you know, the resources needed just to develop internal policies and workflows to do things like developing cultural competency training, so that providers are ready to work with people with unique social needs. Trauma informed
Allison Orris: training are examples of things that States have used infrastructure funding to support and then just basic outreach education, stakeholder convening efforts can also be supported by
Allison Orris: by infrastructure development funding. One thing to mention is that that funding is limited. So Cms is being flexible. But they have set a limit that infrastructure spending cannot exceed 15% of states. Total health related social needs spending. Remember that number because I'm gonna talk in a minute about other health related social needs spending limits.
Allison Orris: But Cms is setting that total amount as a limit. And then they're also being very clear that there are certain things that cannot be considered as infrastructure consistent with longstanding Medicaid law. Construction costs, capital investments or general workforce costs sort of unrelated to the Medicaid population are not supportable by this new infrastructure funding.
Allison Orris: But let's go to the next slide.
Allison Orris: and I want to talk a little bit more generally. You know, we've talked so far about flexibility. So now, moving to some of the flexibility, some of the ways that Cms is putting guardrails around that flexibility. You know, there Cms is looking and has put conditions to ensure that spending on health related social needs, supports.
Allison Orris: beneficiaries, health. Right? We wanna make sure that there's money going to support these needs, but also helping to connect people to more sustainable resources, such as long term rental assistance, without supplanting existing funding sources, that the State may already have in place. To support housing to support nutrition. So this is not Medicaid
Allison Orris: sort of taking over or replacing state spending, but really helping to kind of fill gaps and to fill temporary needs that the Medicaid population might be experiencing, as the Medicaid program helps to improve access to healthcare.
Allison Orris: And I think you know one of the things that you'll see if you take a closer look at the paper that Ali dropped into the chat that my colleagues and I wrote almost a year ago, is that I think these guardrails reflect an attempt to balance Medicaid's ability to respond to unmet social needs while remaining consistent with some important principles. Such as as I said, ensuring that Medicaid continues to perform
Allison Orris: its primary function of providing people with access to clinical healthcare services. The more standard medical services that we think about when we think about Medicaid ensuring that Medicaid investments are evidence-based and medically appropriate, that gets back to some of the targeting that Leo was talking about.
Allison Orris: There's also some considerations and conditions, I should say, in these waivers that really focus on some of these investments being time limited. So Medicaid is not going to pay for rent forever. But there are time limits of 6 months on rent, on nutrition services, so that again, Medicaid is kind of helping to fill gaps, and can can connect people to services that can sustain their health
Allison Orris: over the longer term, and I think that that really goes to the sort of approach that Medicaid can't address all of the underlying issues in our social services system and in our, you know country that lead to some of these health unmet health, related social needs, but can be used to fill important gaps.
Allison Orris: And so one of the ways that we are seeing this unfold is that Cms is working with States to establish a baseline level of State funding for social services
Allison Orris: related to the
Allison Orris: demonstration, and then is requiring States to maintain that spending over the course of the demonstration, so that medicaid isn't substituting for existing, spending, but is lifting kind of all boats is how I think about it. And then I talked about the cap on infrastructure spending. But that infrastructure spending cap sort of sits below a cap that Cms has imposed on health, related social needs.
Allison Orris: services, and infrastructure at 3% of a State's total computable Medicaid spending so Cms and the State negotiate how much money is kind of flowing through the waiver. 3% of that can be used for health related social needs and infrastructure. And then of that 3%, there's that limit on infrastructure spending within that
Allison Orris: and there's a few other guardrails in place that we've talked about already things like beneficiary choice. You can't make a person have a service instead of a medical service, for example. People have access to appeals if a service is denied and we also have a real commitment to use community based providers to be providing these services
Allison Orris: but one condition that I think is really important to mention in the context of this webinar is that Cms is also
Allison Orris: asking states whose health related social needs. Spending meets a certain level to track and increase the share of Medicaid enrollees who are enrolled in programs that address other social needs like Snap, like Wic and Tanf. So really trying to be intentional about tracking data and improving participation in other programs that also meet these needs.
Allison Orris: Let's go to the next slide.
Allison Orris: The last guardrail that I'm going to talk about is for States that meet a certain standard of health related social needs. Spending Cms is requiring those States to review provider rates, medicaid reimbursement rates that are given to providers in a couple of areas in an effort to ensure that spending on health related social needs
Allison Orris: is not only not diminishing Medicaid access by sort of shifting resources within the State but also making sure that the State is continuing to invest in promoting access to the standard kind of Medicaid medical services that we see. So states that are making significant investments here have to review their provider rates and
Allison Orris: primary care. Obstetrics, care and care for mental health and substance, use disorders, and for
Allison Orris: depending on what the State finds. The
Allison Orris: Cms is requiring the State to ensure that if payments are not already at at least 80% of what medicare rates pay in those 3 areas the State has to commit to by year 3 of the demonstration, increasing rates by 2 percentage points in the category with the lowest rates.
Allison Orris: So this is sort of a long term investment in monitoring and ensuring that investing in one area is not only not weakening access to regular Medicaid services, but also can help push States to make ongoing investments in access through provider rates.
Allison Orris: So with that, I'll turn it to
Allison Orris: our next
Allison Orris: speaker.
Allie Gardner: Yes, and that is me.
Allie Gardner: alright. Next slide, please.
Allie Gardner: So before we kind of get into big picture, what does this mean for advocates, implementation, all of those things I did want to address. A new benefit. That I know has gotten a lot of attention, as of late which are States using medicaid to provide diapers for infants.
Allie Gardner: Historically, diapers have only been able to be covered by medicaid for children.
Allie Gardner: typically, no children under age of 2 have been able to receive diapers. And they're typically any children who do receive where medicaid covers diapers is for incontinence reasons, however. In May, Cms. Approved 2 States alone. 15 demonstrations, one in Delaware and one in Tennessee, that provide diapers to children or to infants within their 1st 2 years of life.
Allie Gardner: Delaware provides diapers as part of a postpartum box. Nancy talked about the nutrition portion of that postpartum box where they receive weekly shelf staple items, but then they also receive a weekly supply of diapers and wipes. For the 1st 12 weeks. Postpartum.
Allie Gardner: Tennessee's benefit is a lot more expansive in that it
Allie Gardner: any child under 2 is eligible to receive up to 100 diapers per month, or up to 200 diapers every 60 days. One key difference here is Delaware actually already had this program in place to provide these postpartum boxes up to 8 weeks postpartum using State only dollars. So they received Cms approval to really scale up this demonstration, but already had the infrastructure in place and had already been implementing this program.
Allie Gardner: And so, where this is set, we separated this from the other benefits we talked about. Is that Cms has not explicitly defined diapers as a health related social, that chart that we put in the chat that Cm. Where Cms. Laid out all the different types of health related social needs, it would consider approving through the different pathways. Diapers aren't on there and frankly based on as Leo talked about some of the medical appropriateness and the clinical clinical need definition.
Allie Gardner: These. Both of these approvals are a lot more broad in terms of eligibility. Criteria for diapers. But there is a health related. Social needs, implication, particularly for parental mental health.
Allie Gardner: Due to diaper need. When parents don't have enough diapers for their children. We know that that's a stressor and can affect post part, especially postpartum depression.
Allie Gardner: And so we are thinking about this in a health related social needs context, but did want to give the disclaimer that that it may not be as direct of a health related social need as Cms is considering it.
Allie Gardner: And it is because of this it is unclear whether States can provide diapers through those other pathways that Leo talked about earlier. But it is definitely something that other States are or some States are exploring
Allie Gardner: one key thing. Again, I know this is a hot topic right now that as you as advocates, or as anybody in their state is considering is, there is a real need to leverage existing networks like diaper banks, as well as additional touch points for new parents like snap and wic offices and pediatricians to help distribute diapers. The way Tennessee's benefit operates is, people have to go to the pharmacy to get their diaper supply.
Allie Gardner: and there is an increasing increasing
Allie Gardner: prominence of a pharmacy deserts. So we want to make sure that if these these benefits diaper benefits are approved, that that means that anybody eligible has access and that access to a pharmacy is not prohibiting somebody from being able to access those diapers. So just some considerations there. Next slide, please.
Allie Gardner: And I, potentially am going to be a Debbie Downer before we go into questions. But I do think that implementation with any 1115 waivers. But especially as we talk about these health related social needs. Demonstrations
Allie Gardner: is so so important. These policies have the potential to make real change and help the upstream effects of health. But they're only going to be as successful as the implementation of the policies. And one piece to really hammer home here is that Outreach will be one of the most important factors in ensuring eligible populations receive
Allie Gardner: the services that they should get as Leo and Alison both talked about leo talked about all the different the Venn diagram of who is eligible? And there's a lot of different pieces there. So understand? So having people understand.
Allie Gardner: hey, you fit in that middle of the Venn diagram is going to be really important, which means that the infrastructure funding that Alison talked about and outreach being a piece of that really needs to be utilized, and Ma and the infrastructure funding maximized in those outreach efforts.
Allie Gardner: That also means that the state and groups should help connect with community partners outside of Medicaid. This is a key thing that Cms has been emphasizing in terms of leveraging connections with local and State housing authorities snap in wic offices things like that. But it really may. It may fall to outside groups beyond the State to help facilitate those connections and make sure that everybody's moving in the same way.
Allie Gardner: And additionally, there, in some States, or with some services. There may be documentation requirements that people have to have meaning like they need their doctor to sign off on a medical need. They need to have proof of medical need to get any of the housing or nutrition services, and understanding what those requirements are at before you go out and do outreach
Allie Gardner: are is going to be really important when you're when going out into the community to make sure the people eligible for those services have are able to get all their ducks in a row to get the services that they should
Allie Gardner: and another key piece. And when we're thinking about implementation is oversight, oversight of 1115 s. Is always important.
Allie Gardner: But it's really going to be important here with that infrastructure funding based on how state the standard terms and conditions of the 1115 approvals. How those are written, a lot of that infrastructure funding that Alison talked about is going
Allie Gardner: to be distributed through the Mcos. So the Mcos are going to be responsible for doing applications for community based providers or people who develop systems and distributing the infrastructure funding accordingly. And
Allie Gardner: you know our colleague Andy does a lot of work on Mco. Transparency and oversight, and I think this is going to be a really important piece to make sure that infrastructure funding is going to the organizations that need it as well as being used to develop a community based provider network of these services that are not traditionally part of the Medicaid network.
Allie Gardner: And additionally, as we think about the prenatal to 3 population. One thing that's clear, based on our tracking is while there is a few states that have focused on pregnant and postpartum individuals as well as young children. They aren't a key focus, despite their high the consequ, the significant consequences of having unmet health related social needs.
Allie Gardner: So as you are, if your State has not yet sought a waiver, or is thinking about it, defining the pregnancy and postpartum period more explicitly as part of a qualifying criteria is really important.
Allie Gardner: But if your State has already gotten a Cms approval. The game's not lost. Since, you know. Nancy mentioned a lot of the details of State's approvals are being flushed out in subsequent protocol documents
Allie Gardner: which comes through negotiations with the State and Cms. And a lot of States are seeking stakeholder fee, stakeholder, feedback, following initial 1115 approval. But before submitting those protocol documents to Cms, so there are opportunities to more explicitly call out these key populations, as eligible for help the Hrs and services.
Allie Gardner: and
Allie Gardner: there's a number of reasons why implementation is a successful implementation is so important. But as Leo alluded to 11, one key piece of 1115 s. Is their experiments, their pilots. And because of the evaluation requirement for 1115 s. We have an opportunity to learn something here.
Allie Gardner: So by having successful implementation, we can get better evidence. And about the links between addressing health related social needs
Allie Gardner: and improving health outcomes, or just generally getting more evidence on what those links are. So if the implementation isn't successful, then not only do people not get the services that they should be eligible for, but also we don't. It's not going to help our understanding about all of these different pieces. And again, the up the effects of addressing upstream needs that affect health.
Allie Gardner: So next slide, please.
Allie Gardner: Like Elizabeth mentioned at the top, we will be providing a Pdf of these slides. So all of the links that we've been putting in the chat, and we've mentioned will be available here. But with that I will pass it over to Nancy to kick us off for QA.
Nancy Kaneb: All right. So thank you. Everyone for using the chat. If there were any questions you had throughout the presentation or that weren't answered in the chat. Please send them to the Qa. Box. And
Nancy Kaneb: with that we will get started on questions. So we have one question.
Nancy Kaneb: that discusses.
Nancy Kaneb: Climate remediation support similar to Oregon's 1115 waiver in California. There was a bill that could have done this, but it died in appropriations. So the question is, do you know how Oregon identified and provided evidence that climate supports like A/C air purifiers, etc, can benefit so many enrollees across populations of focus.
Allie Gardner: That's a great question, and I can hopefully make it a little easy. In that. Those protocol documents that I mentioned Oregon was the 1st one that we saw.
Allie Gardner: and I'll put it in the the chat. But if you look on page 12 of the Oregon Protocol document, there is a section specifically on all of these climate. Related devices that Cms has allowed the State to cover, and each of those pieces so air conditioners, they lay out that that is, for people who are
Allie Gardner: at a health risk due to significant due to significant heat or refrigerator units for individuals. Who have certain medical needs based on medication. So that protocol document lays out, I think, what you're alluding to in terms of what the justification is for those climate related needs.
Allison Orris: And Ali, could I just jump in? Because the question was from California and it as as we were talking one thing that I realized I didn't say in talking about infrastructure. And California is a great example. Some states have been, be been creative and used an 1115 for infrastructure, and used their managed care in lieu of services
Allison Orris: for their health related social needs. California did a little bit of both, because there are certain things that couldn't be provided through an 11 through in lieu of services. So just, you know, really, every state is different. And this idea of using infrastructure. Is. I think it's important to understand that 1115 is kind of right now, the only vehicle for the infrastructure
Allison Orris: funding. But that doesn't mean that all of the health related social needs have to come through the waiver, which makes it all a little bit more complicated. But California is a good example of kind of thinking about the most sustainable authorities, and trying to weave them together.
Nancy Kaneb: And another question we have is, Do you have a sense of how often Cms approves renewals of 1115 waivers for health related social needs like how strong the evidence has to be from the State in its monitoring and evaluation, that these efforts are worthwhile to continue.
Allie Gardner: Well, these are new, so I don't think we've there hasn't been a state
Allie Gardner: quite yet that has had to go through the renewal process, and I'll say quite yet, because North Carolina and Massachusetts both received approval under the Trump Administration for some of the more direct pieces rather than just the pretenancy supports and education. And those are have gone through renewal through the Biden administration. North Carolina's extension request of this health related social needs is still pending Massachusetts was approved.
Allie Gardner: But because of Covid, a lot of the implementation of those Hrsn pieces was delayed, and so I think in general, with 1115 s. In terms of evidence, requirements, and things.
Allie Gardner: The Cms. Has been more willing to let demonstrations proceed just because of Co. The difficulties of collecting data during Covid, and the delays in general implementation were so significant. But I'll pass it to Leo or Alison. If you guys have other thoughts.
Leo Cuello: You know, I I second you. I think it's it's early to get into the what does the renewal of these things look like when we're we're just at the point right now of seeing how they're actually stood up and and what types of information states are gonna collect to start to evaluate this. But clearly Cms. Will eventually be looking at that at renewal times.
Leo Cuello: at renewal time. I I don't think that in the early years Cms is going to be as rig as rigid because they're still trying to figure out
Leo Cuello: how all this works right? So I don't. I don't think we're going to very quickly get to the point where Cms is immediately putting the kibosh on these things.
Leo Cuello: That's my instinct.
Nancy Kaneb: Okay. And now we will get to 2 questions from the chat. The 1st one is there, clarity on whether or not Medicaid funds could be used to fund direct cash programs.
Leo Cuello: So I would say, there's not clarity on that.
Leo Cuello: There's
Leo Cuello: that hasn't been suggested or pursued to my knowledge anywhere. I I think
Leo Cuello: that that one is going to be challenging for 2 reasons. The 1st reason is, Cms is following the evidence bases here. Right? There is a well established evidence basis around how not paying for housing leads to an explosion in healthcare costs right? Same with nutrition. So I think the income questions
Leo Cuello: just don't have that evidence basis. And so I think Cms would be hesitant to move without having that clear evidence basis to justify the act. And then, you know, of course. Second
Leo Cuello: I think that would get kind of the highest level of public scrutiny. And so that, too, would be something that Cms would be quite worried about. So I you know, I think, for that 1 first.st The first.st The thing that has to lead
Leo Cuello: here is the the evidence, basis, and maybe there is one, and I'm not aware of it. But but you know, that's that's something that needs to get out there first.st
Allison Orris: And I would also add, you know, when you think about the limits on spending and the principles that I talked about about, you know.
Allison Orris: I think in general Cms. Is mindful about the budget consequences of all of this, and so trying to sort of stay within a 3% cap. If we were moving to income seems hard, and I think it's also important to remember that unlike some of the health insurance that you know we're familiar with in general and Medicaid. Money isn't changing hands with enrollees. So the whole
Allison Orris: idea of paying, you know people directly versus providing them with a medical service is a really different paradigm shift, and certainly there have been examples and managed care of gift cards as health incentives. But that, I think, is kind of as far as as I think.
Allison Orris: It will be easy for Cms to go in their current sort of legal framework.
Nancy Kaneb: There was a question expressing frustration, just that.
Nancy Kaneb: Yes, this is a service that is given to an individual, sometimes a parent or a young kid, but that this affects the entire family structure, particularly the mom or dad and the infant. So there's not a big, clear attempt to link that with individual family data. So wondering if there's any infrastructure or anything anyone can add, discussing that as a group.
Leo Cuello: Right. So I I took that question to be about thinking about the family unit or the mom baby dyad
Leo Cuello: as opposed to say, a child in isolation. I'm not aware of any state specifically working on this for these kind of Hrsn. 1115 s. I think it's a a very interesting idea that States and Cms. Could think about. I don't think there's anything in principle that would prevent Cms from thinking about social needs or interventions
Leo Cuello: at the family level. But I do think ultimately to use the child's Medicaid to pay for the targeted family intervention. I think Cms is going to want some kind of connection that comes back to the child's
Leo Cuello: clinical
Leo Cuello: care and the child's needs. So I don't necessarily think those 2 things are in conflict. So I I don't think what that's impossible. But I don't think that
Leo Cuello: Cms will quite feel like it can justify using the child's Medicaid to address family level clinical needs that don't come back to the child within a clear and documentable way, which is kind of the standard they've set out here it might be a different
Leo Cuello: scenario, and and easier to do, more feasible if both the mom and the child were in a medicaid subpopulation. Status like, say both were that, like the family was experiencing homelessness. Then I think you could get into a very interesting space there more easily.
Allie Gardner: Yeah. And I'll just add on some of the nutrition supports.
Allie Gardner: See the again, the standard terms and conditions that outline. What States are allowed to do when the services are targeted at high risk pregnancies or postpartum individuals when someone's had a high risk pregnancy.
Allie Gardner: a number of States have, been able to get approval, where, if the the mother is eligible for services based on that criteria, everyone, the chat children in the household are also eligible for those nutrition supports, and they can receive additional nutrition supports for the household. So I do think.
Allie Gardner: kind of the reverse of what was said in the chat is somewhat true. But it is again more targeted. It's not just thinking about the entire family. It's thinking about new moms and and children in the household.
Nancy Kaneb: And with time in mind, there's 2 remaining questions. It looks like
Nancy Kaneb: Alison might be touching on the Federal match one. If you want to share anything with that.
Allison Orris: I was just starting to type. There's no increased Federal match for these services. So that is a good question. And then in response to Barbara's question about Mco oversight and distribution of the infrastructure funds, I will say I am most familiar with how California has set up their infrastructure funding. And in that state, the there's a grant program, and a relationship with
Allison Orris: manage care. So I I think that is a very specific question about what has been approved, how our services being delivered? Are they being delivered through managed care? But I think you know, and happy, Barbara, to talk offline if you've got a specific question. But States have flexibility to do this in different ways. They just need to sort of have criteria
Allison Orris: for the infrastructure spending so that it's not a free for all. But that, too, is an in is a, you know, barrier to entry for some States.
Allie Gardner: And I'll just put in a final plug. In that. A lot of that.
Allie Gardner: It's like everything in Medicaid. You've seen one Medicaid program. You've seen one Medicaid program. And so each of these approvals is very different. And so, looking specifically at the protocol documents as it relate, there, that's what Cms is doing. A lot of batches of right now is the infrastructure protocol. And that's really where you can see how that those infrastructure funding dollars are being passed through, whether it's through the Mco. Or whether the State is going to have a more heavy hand, and and facilitating that.
Nancy Kaneb: All right. It looks like we are out of time.
Nancy Kaneb: Thank you. Everyone for listening, and for your questions there will be a recording, and a Pdf. Of this entire presentation posted
Nancy Kaneb: and thank you to all the panelists who shared.