CMS Issues Guidance for Medicaid and CHIP Programs Regarding Social Determinants of Health

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In a letter to state health officials on January 7 (SHO# 21-001), CMS encouraged state Medicaid and CHIP programs to address and support social determinants of health (SDOH) in their programs. This represents an important breakthrough for addressing health disparities which more often affect persons of color and in poverty.

SDOH is a holistic approach to health that focuses not only on the delivery of health care services (the primary orientation of most US government health care programs), but also other factors that affect an individual’s overall health and well-being. As defined by the CDC, SDOH are “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.” Pioneered by British academic Sir Michael Marmot, this approach has wide acceptance in the health research and academic community, but as of yet has not been widely adopted by payors and government programs in the United States.

The classic example of the SDOH approach versus the priorities of more traditional health care finance and reimbursement system is childhood asthma. While existing systems would pay for a variety of health interventions for the child (including repeated emergencies and hospitalizations), the SDOH approach might focus instead on the child’s living conditions, such as remediating mold in their apartment. The goal is produce not only savings for the payor(s), but increased health, which further reduces expenditures.

The January 7 letter is wide-ranging and sets forth numerous examples of the ways that states could implement a focus on SDOH in their programs. Among these are:

  • Housing and tenancy supports;
  • Transportation;
  • Home-delivered meals;
  • Educational or employment services;
  • Increased eligibility and access to home-based services; and
  • 1115 demonstration projects.

It remains to be seen how individual states will implement the SDOH approach as part of their exploration of alternative payment models. Also, the growing role of Medical Legal Partnerships offers an opportunity to address SDOH by offering a legal solution to addressing the identified problems.[1] The full letter can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf.


[1] For more information, see https://medical-legalpartnership.org/ and https://www.txmlpc.org/

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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