Leveraging innovative technology,  can potentially support more efficient health care delivery and  improve the quality of and access to care.¹ Tech‑enabled solutions include many different types of services or products such as data-sharing and analysis tools, telehealth solutions, electronic health records, and in-person care delivery models that incorporate technology.² When used strategically, tech solutions can simplify a complicated care system for all stakeholders, including payers, health care providers, community-based organizations (CBOs), and patients.

Drawing on the work of the Medicaid Innovation Collaborative, this brief provides an overview of how tech‑enabled solutions can help states achieve their goals to address health related social needs (HRSN). It also provides examples of how Medicaid agencies can create a policy environment conducive to supporting tech-enabled innovations that address HRSN.

The Medicaid Innovation Collaborative (MIC) convenes Medicaid agencies and health plans to support the adoption of tech-enabled innovations through a multi-state approach. Through this work, MIC aims to promote more equitable and higher quality care for Medicaid enrollees. ³ In its 2023 cohort, MIC worked with state Medicaid agencies from Iowa, Kentucky, and New York and 13 managed care organizations (MCOs) from these states to explore the landscape and support adoption of tech-enabled solutions addressing HRSN. ⁴ MIC, a program of Acumen America, is funded by MolinaCares Foundation, CommonSpirit Health, Hopelab, Schmidt Futures, and The Leona M. and Harry B. Helmsley Charitable Trust.

The Opportunity of Tech-Enabled Solutions to Address HRSN

Technology can be used in many ways to improve health care access and quality of care for Medicaid enrollees.⁸ One area of opportunity for states, MCOs, providers, and CBOs is to use tech-enabled solutions as a tool to identify and address HRSN. Social determinants of health (SDOH) strongly influence health and wellbeing and are a key contributor to longstanding health inequities.⁹ For this reason, identifying and addressing social needs has become a Medicaid priority among state and federal policymakers in recent years.^{10, 11} CBOs, which have a deep knowledge of the populations they serve and provide social service supports, play a critical role in successfully implementing strategies to address HRSN. State approaches to addressing HRSN should be grounded in enhancing CBO capacity to support culturally congruent, patient-centered, and equitable care.^{12, 13}

Tech-enabled solutions are one potential tool to facilitate better coordination across health and social sectors, expand the potential of CBOs to serve Medicaid populations, and/or help fill gaps in local infrastructure or service offerings. Many tech-enabled solutions are available to support HRSN interventions, such as food and nutrition services, transportation, and health care navigation assistance to improve care coordination. The current policy momentum toward addressing HRSN, combined with emerging tech innovations, provides opportunities for states and Medicaid MCOs to partner with tech companies in addressing gaps in care and more comprehensively meeting the needs of Medicaid enrollees. Evaluation and implementation of tech solutions must be informed by community perspectives to ensure that innovations support community-based approaches, are effectively tailored to meeting community member needs, and do not divert funding or add burden to resource-constrained CBOs.^{14, 15}

Examples of Tech Solution Capabilities to Address HRSN

In its 2023 cohort, MIC issued a request for information (RFI) to identify and showcase tech-enabled solutions focused on addressing social needs. This RFI was informed by MIC research to understand the experiences and preferences of Medicaid beneficiaries related to HRSN. Specifically, this research included interviews, focus groups, and a survey of Medicaid beneficiaries and Medicaid eligible individuals.¹⁶ To illustrate how tech solutions can potentially support Medicaid goals, the following section highlights the types of tech-enabled capabilities identified through the MIC tech showcase, including solutions to meet specific social needs, enhance care navigation, and support infrastructure and data. Examples of specific solutions are detailed in Exhibit A.

Solutions to Meet Specific Social Needs

Many tech-enabled solutions seek to address particular social needs. For example, promising solutions identified through MIC focus on addressing food and nutrition and transportation supports. Nutrition and transportation access both have a strong evidence base demonstrating their impact on health outcomes and are a common focus of health care system HRSN interventions.^{17, 18} For nutrition supports, tech-enabled solutions can improve access to healthier food options and nutritional education services and offer Medicaid enrollees flexibility in how they can access foods. These solutions often include home-delivery services for medically tailored meals or groceries and may partner with local organizations, like food banks, that may have existing relationships with the community.¹⁹

While non-emergency medical transportation services are covered by Medicaid,²⁰ these programs often fall short of meeting enrollee needs. For example, challenges often exist with providing on-demand services, accommodating schedule changes, and providing high-quality customer service.²¹ There may also be opportunities to provide non-medical transportation, which is generally not covered by Medicaid, but often necessary for enrollees to access HRSN services. Tech-enabled solutions can connect Medicaid enrollees with a network of transportation providers that provide a variety of options, like rideshares, small buses, or accessible vehicles, to meet a continuum of needs and address region-specific transportation gaps. Such solutions can potentially help support local transportation businesses and leverage public transportation options.

Solutions for Navigating and Coordinating Care, Resources, and Services

One of the major barriers to accessing care for Medicaid enrollees is navigating the complicated health care system, community resources, and social support services. Tech-enabled solutions can help Medicaid enrollees understand what resources and services are available to them. These solutions can also help provider organizations extend their whole-person care capacity to better meet individual’s social needs. This could mean offering up-to-date information on community resources or providing guidance on how to access necessary local services. Many tech-enabled solutions can also support and integrate with on-the-ground staff, such as community health workers or navigators, who can offer Medicaid enrollees person-centered and culturally competent assistance with accessing care.

Solutions to Support Infrastructure and Data Tools for Providers, MCOs, CBOs, and States

Medicaid agencies, their MCOs, providers, and CBOs need better tools to identify social needs, track referrals for the Medicaid enrollees they serve, report on outcomes, and coordinate interventions. Tech-enabled solutions can help build the data systems and tools needed to identify, track, and analyze social needs at an individual and population level. Some solutions also allow information to be accessible to the different entities serving Medicaid enrollees, like MCOs, providers, and CBOs, enabling them to easily exchange information and improve coordination and integration of services. For example, solutions may include closed loop referral capabilities, which enable organizations to track and understand the outcomes of social needs referrals.²²

Exhibit A. Tech Solutions to Address HRSN Featured in the 2023 MIC Innovation Showcase

Solutions to Address: Specific Social Needs	Solutions to Address: Care Navigation	Solutions to Address: Infrastructure and Data Tools
Farmbox Rx: Engagement platform partnering with health insurance providers to improve member health outcomes through nutrition and health literacy.	Live Chair: Partners with payers, providers, and other health care entities to ensure that communities can access preventive, social and administrative care resources that focus on HEDIS gap closures and the achievement of broader STARs metrics.	Benefits Data Trust: Partners with a national network of government agencies, health care entities, and other partners, to streamline public benefits systems and directly connect eligible families and individuals to assistance.
Attane Health: Patient-driven digital health company that brings together personalized food selection, tele-nutrition, and the ability to measure outcomes in one platform.	Pair Team: Partners with safety-net primary care providers and act as extension of the clinical staff to provide comprehensive clinical and mental health care while addressing the many social barriers to achieving a high quality of life.	CareAdvisors: Provides a social care management software platform for Medicaid plans to engage hard-to-reach members struggling with social barriers.
Nourished Rx: Digital health and nutrition company that delivers comprehensive and personalized nutrition programs and experience.	Samaritan: Provides members with the financial and social support needed to meet critical SDOH needs, specifically around housing instability, and enable members to take action toward goals.	Ready Computing: Partners with private and public-sector organizations, health systems, health plans, CBOs, and government agencies to deliver insights and solutions from their data to improve patient and resident outcomes and the overall quality of service delivery.
Kaizen Health: Pairs an adaptive and scalable technology platform with a nationwide infrastructure of transportation and delivery partners to serve urban and rural areas for people of all physical and mental abilities.	Waymark: Partners with health plans and primary care providers to deliver technology-enabled, community-based care in neighborhoods across the country.	Unite Us: Cross-sector collaboration software that builds connected communities through shared technology and local boots-on-ground community approach to address whole-person health needs.
	Welfie: Puts community health workers in K-12 schools to provide health education, coordinate care, and address HRSN for children and families enrolled in Medicaid/CHIP.

Policy Levers Supporting Tech Solutions to Meet Health-Related Social Needs

Given the potential of tech-enabled solutions to address HRSN, states may consider leveraging Medicaid policy to support such innovation. In some cases, Medicaid may be prescriptive requiring managed care or provider adoption of specific tech solutions. More commonly however, Medicaid agencies seek to provide flexibility for MCOs to adopt solutions that align with their populations’ needs and best complement other capabilities. This section outlines four managed care policy levers for supporting and incentivizing HRSN innovation, including through tech-enabled solutions. States do not necessarily need to create new initiatives to support tech solution adoption; rather, states may consider opportunities to refine and adapt existing policy approaches to further advance HRSN work and encourage the use of innovative technologies for that purpose.

Medicaid Levers and Policy Considerations for Addressing HRSN through Tech-Enabled Solutions

Lever 1: Hold MCOs Accountable for HRSN Interventions/Results	Lever 2: Adapt Coverage/Reimbursement Policies for Addressing HRSN
Considerations for states: • What are your state’s specific, short-term goals for addressing HRSN? How can tech be used as a tool to help support these goals and advance health equity? • How can your state measure progress toward these goals? • Is there opportunity to tie HRSN measures/reporting to MCO payment? Example policies: Enhancing MCO contract language, reporting requirements, and performance incentives related to health equity, HRSN, and tech solutions	Considerations for states: • What level of budget flexibility does your state have to finance HRSN interventions? • Which Medicaid financing pathways may be used to support tech-enabled solutions that support HRSN goals? • How can enhanced HRSN financing advance health equity? Which populations should the state focus on supporting? Example policies: Medicaid payment for HRSN interventions, such as through in lieu of services or waivers
Lever 3: Convene Stakeholders to Support Alignment Around HRSN Interventions, Including Tech-Enabled Solutions	Lever 4: Provide Infrastructure Support or Start-Up Funding to Enable MCOs, Providers, or CBOs to Address HRSN
Considerations for states: • How can states best communicate their goals and expectations for HRSN and tech-enabled solutions to MCOs and other relevant stakeholders? • What forums can the state use to convene stakeholders to support alignment and best-practices sharing around HRSN interventions, including tech solutions? Example policies: MCO contract language requiring MCO alignment around HRSN interventions, convening workgroups or other forums to support MCO collaboration	Considerations for states: • What is the level of MCO, provider, and CBO readiness to implement interventions, including tech-enabled solutions? • What material supports or guidance is the state well-positioned to provide to support HRSN efforts? How can such supports be targeted to advance health equity? • How can states provide support or guidance to ensure tech innovations support the work of local CBOs? Example policies: Start-up funding to help providers or CBOs implement new programs, state funding for tech solutions that address infrastructure needs (e.g., enable data collection and sharing), sharing Medicaid data to help stakeholders develop impactful HRSN interventions

Lever 1. Hold MCOs Accountable for HRSN Interventions/ Results

States are increasingly including requirements and measures related to addressing HRSN in managed care contracts. As a starting point, many states focus on setting requirements related to HRSN screening and data collection. As states seek to advance their HRSN work, they may consider how to strengthen such MCO requirements, including by:

• Defining specific state HRSN priorities based in identified needs and health equity impact;
• Requiring or incentivizing MCOs to design or implement interventions addressing identified HRSN (e.g., tying implementation of HRSN interventions to MCO performance incentives, adding contract language specifying how MCOs follow up on positive HRSN screenings);
• Requiring or incentivizing MCOs to collaborate with or financially support CBOs that provide social services (e.g., incentivizing MCOs to invest a portion of their capitated payment or profits in the community); and
• Requiring MCOs to implement quality improvement projects aimed at addressing HRSN (e.g., developing an HRSN-focused performance improvement project).^{23, 24, 25}

Through these strategies, states can encourage MCOs to enhance their approaches to addressing HRSN. One potential way MCOs can meet these requirements is through tech-enabled solutions. For example, in the context of increased state focus on addressing HRSN, many MCOs have already adopted tech solutions supporting member referrals to social services. States interested in ensuring the use of specific types of technologies in addressing HRSN may also consider requiring MCO reporting or adding MCO contractual requirements related to tech-enabled solution adoption specifically.

State Examples

• Hawaii requires health plans to develop an SDOH work plan. Each MCOs’ work plan should be aligned with the statewide SDOH Transformation Plan and “include its own timelines, benchmarks, milestones, and deliverables.”²⁶ In addition to other requirements, plans must describe their strategies for: linking beneficiaries to SDOH supports, providing value-added services to support SDOH, and accommodating SDOH needs of specific target populations.²⁷
• While not focused on HRSN, Arizona requires MCOs to “develop and implement a strategic plan…to engage and educate its membership, as well as improve access to care and services, through telehealth services and web-based applications intended to assist members with self-management of health care needs”.²⁸

Lever 2. Adapt Coverage/Reimbursement Policies for Addressing HRSN

In addition to providing enhanced incentives for plans, it is important that states provide enhanced, sustainable payment for HRSN interventions. Recent policy changes and clarifications by the Centers for Medicare & Medicaid Services (CMS) have provided new opportunities for states to pay for HRSN interventions through Medicaid. There are many potential avenues for Medicaid to finance HRSN programs, two examples include 1115 demonstrations and in-lieu of services (ILOS).^{29, 30} Under 1115 demonstrations, CMS can waive certain Medicaid requirements and provide federal funding for costs not usually covered by Medicaid.³¹ In 2022, CMS announced a new framework for states to provide HRSN-related services through 1115 demonstrations, including opportunities for covering nutrition, housing, and HRSN case management supports.³² CMS outlined permissible areas of HRSN infrastructure funding, including technology. Potential funding opportunities under this guidance include investments in electronic referral systems; shared data platforms; electronic health record modifications or integrations; screening tools and/or case management systems; databases/data warehouses; data analytics and reporting; data protections and privacy; and accounting and billing systems.³³

CMS also recently provided new guidance on Medicaid ILOS, clarifying how states can use this authority to address HRSN.³⁴ ILOS authority allows states to offer medically appropriate and cost-effective substitutes to services usually covered under Medicaid (e.g., offering nutrition supports to avoid hospitalizations). Importantly, ILOS are included in MCO capitation rate development, providing a sustainable way to cover approved services. ³⁵

These types of payment policy changes ensure that MCOs and their networks of providers will have sufficient resources and flexibilities to build new programs, including deploying tech-enabled solutions, to address HRSN. States pursuing HRSN financing may consider if there are opportunities to elevate tech-enabled innovations as approaches MCO partners might include in their implementation strategies. For example, MIC is supporting multiple pilot projects in which tech companies are partnering with MCOs to provide home-delivered groceries along with nutrition education to members with diabetes.³⁶ These types of solutions can potentially be covered by ILOS or 1115 demonstrations for medically supportive food and nutrition services. In designing Medicaid HRSN programs, states may consider supporting tech solutions to enhance beneficiary access and choice in HRSN services, as well as augment local service gaps. To the extent plans and providers have specific coverage or reimbursement questions related to the use of tech-enabled solutions, states can provide clarifying guidance.

State Examples

• California has pre-approved a set of HRSN supports that MCOs may choose to offer as ILOS through its Community Supports program.³⁷ Examples of Community Supports include:
  • Housing services (housing transition navigation services, housing deposits, housing tenancy and sustaining solutions)
  • Environmental accessibility adaptations (home modifications)
  • Medically tailored meals and medically supportive food
  • Environmental asthma trigger remediation³⁸
• Through an 1115 waiver, North Carolina is implementing the Healthy Opportunity Pilots program in three regions of the state to provide services related to housing, transportation, nutrition, and interpersonal safety for Medicaid enrollees with complex health and social needs.^{39, 40} To facilitate access to these services, the state is also supporting adoption of NCCARE360, a statewide technology platform to support data sharing and referrals.⁴¹

Lever 3. Convene Stakeholders to Support Alignment Around HRSN Interventions, Including Tech‑Enabled Solutions

State Medicaid agencies can also consider how to best leverage their role as conveners to advance HRSN goals and support tech-enabled solution adoption. In addition to “hard” levers such as MCO contract requirements, convening and communicating with stakeholders — including MCOs, providers, CBOs, and/or enrollees — is an important “soft” lever to gain buy-in and implement Medicaid strategies. As an example, MIC’s cohort model supported states in convening MCOs to disseminate research on state-specific HRSN challenges, explore promising tech solutions, and design pilot projects.  MIC has found that Medicaid leadership prioritization of tech-enabled solution exploration, along with ongoing communication with MCOs, is important for accelerating MCO uptake of innovations.

States use a variety of strategies for convening and communicating with MCOs and other stakeholders to support policy development and program implementation. For example, Medicaid agencies often have standing meetings with MCOs to communicate policy guidance, oversee implementation of quality improvement programs, support implementation of care delivery initiatives, and/or troubleshoot program challenges. Medicaid agencies may also implement MCO or multi-stakeholder workgroups (e.g., composed of MCOs, providers, and enrollees) focused on specific care delivery initiative or quality improvement topics. 

States seeking to support adoption of tech-enabled innovations to address HRSN may consider what existing or new forums they may use to:

1. Communicate HRSN and tech-innovation priorities;
2. Support planning and implementation of tech-enabled solutions;
3. Disseminate lessons and best practices related to tech-innovation; and/or
4. Monitor how MCOs are using tech-enabled solutions to address HRSN priorities.

As part of this work, states may consider how to support collaboration across MCOs. Strategy alignment across plans, whether in terms of prioritizing specific HRSN for intervention or incentivizing adoption of the same tech solutions, may enhance impact. This may be particularly true for HRSN that are often impacted by geographic factors (e.g., local social service capacity, public transportation availability, etc.).

State Examples

• As part of its ILOS contracting guidance to MCOs, California encourages MCOs within the same county to collaborate in developing their approach to providing ILOS (e.g., services offered, provider network, and policies and procedures for service delivery).
• As part of MIC, Iowa Medicaid leadership set and clearly communicated expectations that MCOs explore opportunities for tech-enabled innovation. This helped spur collaboration across MCOs in implementing an MIC-funded pilot of a solution aimed at expanding transportation access. Outside of MIC, Iowa has also developed a regular communication and quality oversight process to support collaboration. For example, the state meets monthly with all MCOs to discuss quality strategies and address operational issues. As a part of this, MCOs regularly share their approaches for addressing HRSN with the state and their peer MCOs.

Lever 4. Provide Infrastructure Support or Start-Up Funding to Enable MCO, Provider, or CBO Uptake of Solutions

Finally, states may consider what type of infrastructure supports stakeholders need to implement HRSN interventions, including tech-enabled solutions. New, ongoing funding streams (as described under Lever 2) may not cover start-up costs of developing new data capabilities, developing new cross-sector collaborations, or implementing new workflows. States may consider providing start-up funding for new initiatives or pilot programs. For example, MIC, with support from The Leona M. and Harry B. Helmsley Charitable Trust and other Acumen America funding partners, is providing funding for pilot projects implemented by tech companies in partnership with health plans to assess the impact of tech-enabled solutions that address HRSN on care for populations with chronic conditions.⁴² States could consider offering similar funding to support testing or evaluation of innovative approaches to addressing HRSN.

States can also directly provide non-monetary supports, such as data reports, to help stakeholders develop HRSN approaches or technical assistance to support stakeholders in developing these approaches. As previously described, in some cases, tech-enabled solutions offer the infrastructure support needed to identify and address HRSN. States may consider directly supporting such solutions to enhance capacity for cross-sector data sharing and collaboration. For example, states are increasingly supporting implementation of community resource and referral platforms to enable HRSN screening, provide directories of local HRSN resources, and facilitate referrals to CBOs.⁴³

As part of this work, states may particularly consider how to support capacity building for CBOs addressing social needs. Many tech-enabled solutions, such as community resource directory and referral platforms, require close collaboration with and buy-in from CBOs to coordinate care or provide social services. At the same time, CBOs often have limited resources to expand services or implement new initiatives.⁴⁴ In addressing HRSN, including through tech solutions, it is important to consider how to support and extend the reach of CBOs and not add burden to or supplant existing local organizations. For example, states could give CBOs enhanced funding to build their capacity to coordinate with health systems and payers. States could also support development of CBO networks — groups of CBOs supported by a lead entity — to enable more efficient cross-sector coordination and provide administrative and infrastructure support to smaller, less well-resourced CBOs.⁴⁵

State Examples

• Under its proposed 1115 waiver, New York seeks to invest in coordinated, regional networks of CBOs to more effectively address HRSN. Goals of these investments include supporting CBOs to create “IT and business processes infrastructure, and adopt interoperable standards for a social care data exchange.” Among other capabilities, these CBO networks would be responsible for “coordinating a regional uniform referral system and network.” In addition to direct CBO investments, the state seeks to support a statewide data-sharing system that will include HRSN data.⁴⁶
• Arizona implemented a statewide HRSN referral system to support more efficient referral processes and track referral outcomes. The effort is a collaboration between Arizona Medicaid, Arizona’s health information exchange, Unite Us, and Arizona 2‑1‑1.⁴⁷ CBOs may be eligible for incentive payments for reaching system participation milestones and financial assistance to offset the cost of participation.⁴⁸

Conclusion

Tech-enabled solutions are one of many strategies Medicaid agencies may consider leveraging to address HRSN. Tech companies have increasingly developed solutions to support HRSN identification and interventions, such as care navigation solutions, data-sharing platforms, and solutions administering HRSN supports such as food and transportation. To capitalize on these opportunities, states can consider a wide variety of Medicaid policy options to encourage MCO implementation of HRSN interventions and support the adoption of tech-enabled solutions to address HRSN. Developing partnerships across Medicaid agencies, MCOs, CBOs, and tech companies can help ensure that Medicaid beneficiaries benefit from tech innovations that hold promise for making care more accessible, efficient, and patient-centered.

1. L. Suennen, M. Ingraham, and H. Wagner. Technology Innovation in Medicaid: What to Expect in the Next Decade. California Health Care Foundation and Manatt Health. February 2021. Available at: https://www.chcf.org/publication/technology-innovation-medicaid-what-expect-next-decade/.
2. K. Brykman. Supporting Technology-Enabled Innovation in Medicaid Managed Care to Improve Quality and Equity: State Considerations. Center for Health Care Strategies. August 2022. Available at: https://www.chcs.org/media/Supporting-Technology-Enabled-Innovation-in-Medicaid-Managed-Care-to-Improve-Quality-and-Equity_082422.pdf.
3. Medicaid Innovation Collaborative. “Our Work.” Available at: https://www.medicaidcollaborative.org/ourwork.
4. Medicaid Innovation Collaborative. “2023 Cohort: Social Determinants of Health.” See Participating States and Health Plans. Available at: https://www.medicaidcollaborative.org/2023-cohort-sdoh./
5. S. Seervai and L. Gustafsson. Technology Could Transform Care for People on Medicaid. The Commonwealth Fund. December 18, 2018. Available at: https://www.commonwealthfund.org/publications/2018/dec/technology-could-transform-care-people-medicaid.
6. L. Suennen, M. Ingraham, and H. Wagner, op. cit.
7. Medicaid Innovation Collaborative. “2023 Cohort: Social Determinants of Health.” See Research Insights. Available at: https://www.medicaidcollaborative.org/2023-cohort-sdoh.
8. S. Seervai and L. Gustafsson, op. cit.
9. Healthy People 2030. “Social Determinants of Health.” Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health.
10. K. Gifford, A. Lashbrook, S. Barth, M. Nardone E. Hinton, M. Guth et al. States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address Long-Standing Issues -Executive Summary. KFF, October 2021. Available at: https://files.kff.org/attachment/Executive-Summary-States-Respond-to-COVID-19-Challenges.pdf.
11. Centers for Medicare and Medicaid Services. “Health Related Social Needs.” Available at: https://www.medicaid.gov/health-related-social-needs/index.html.
12. D. Crumley, R. Houston, and A. Bank. Incorporating Community-Based Organizations in Medicaid Efforts to Address Health-Related Social Needs: Key State Considerations. Center for Health Care Strategies, April 2023. Available at: https://www.chcs.org/media/Incorporating-Community-Based-Organizations-in-Medicaid-Efforts-to-Address-Health-Related-Social-Needs_050523-1.pdf.
13. USAging, Aging and Disability Business Institute, Partnership to Align Social Care, and Camden Coalition. Resource Guide- Partnerships with Community-based Organizations: Opportunities for Health Plans to Create Value. Available at: https://www.partnership2asc.org/wp-content/uploads/2023/06/FINAL-Opportunities-for-Health-Plans-to-Create-Value-June-2023.pdf.
14. A. Rogers and S. Thomas. CBO Marginalization: A Byproduct of Inequitable, Technology-Forward SDOH Interventions. Health Leads. April 21, 2022. Available at: https://healthleadsusa.org/communications-center/blog/cbo-marginalization-a-byproduct-of-inequitable-technology-forward-sdoh-interventions/.
15. S.N. McKinlay. The Risks and Rewards of Digital Health Technology In Racial Health Equity. Health Leads. March 29, 2022. Available at: https://healthleadsusa.org/communications-center/blog/the-risks-and-rewards-of-digital-health-technology-in-racial-health-equity/.
16. Medicaid Innovation Collaborative. “2023 Cohort: Social Determinants of Health.” See Research Insights. Available at: https://www.medicaidcollaborative.org/2023-cohort-sdoh.
17. A. Whitman, N. De Lew, A. Chappel, V. Aysola, R. Zuckerman, and Benjamin D. Sommers. Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts. Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, April 1, 2022. Available at: https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf.
18. D. McCarthy, C. Lewis, C. Horstman, A. Bryan, and T. Shah. Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update. The Commonwealth Fund. Available at: https://www.commonwealthfund.org/sites/default/files/2022-09/ROI_calculator_evidence_review_2022_update_Sept_2022.pdf.
19. Medicaid Innovation Collaborative. “Medicaid Innovation Collaborative Social Determinants of Health Innovation Showcase”. 2023. Available at: https://www.medicaidcollaborative.org/_files/ugd/b1096e_d1b6a70e25d64e4c84bc4a98b08c66f9.pdf.
20. Medicaid and CHIP Payment and Access Commission. “Non-emergency medical transportation.” Available at: https://www.macpac.gov/subtopic/non-emergency-medical-transportation/.
21. A. Ganuza and R. Davis. Disruptive Innovation in Medicaid Non-Emergency Transportation. Center for Health Care Strategies, February 2017. Available at: https://www.chcs.org/media/NEMT-Issue-Brief-022317.pdf.
22. American College of Physicians. “Closing-the-Loop.” Transforming Clinical Practice Initiative. Available at: https://www.cms.gov/priorities/innovation/files/x/tcpi-san-pp-loop.pdf.
23. D. Crumley and A. Bank. Financing Approaches to Address Social Determinants of Health via Medicaid Managed Care: A 12-State Review. Center for Health Care Strategies, February 2023. Available at: https://www.chcs.org/resource/financing-approaches-to-address-social-determinants-of-health-via-medicaid-managed-care-a-twelve-state-review/.
24. Bailit Health. “Addressing Health-Related Social Needs Through Medicaid Managed Care.” State Health and Value Strategies and Health Foundation of South Florida, October 2022. Available at: https://www.shvs.org/wp-content/uploads/2022/11/Addressing-HRSN-Through-Medicaid-Managed-Care_October-2022.pdf.
25. D. Crumley, J. Lloyd, M. Pucciarello, and B. Stapelfeld. Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations. Association for Community Affiliated Plans and Center for Health Care Strategies, December 2018. Available at: https://www.chcs.org/media/Addressing-SDOH-Medicaid-Contracts-1115-Demonstrations-121118.pdf.
26. Med-QUEST Division, Hawaii Department of Human Services. “Request for Proposals: QUEST Integration (QI) Managed Care to Cover Medicaid and Other Eligible Individuals.” RFP-MQD-2021-008. December 8, 2020. Available at: https://medquest.hawaii.gov/content/dam/formsanddocuments/resources/QIRFPSC2.pdf.
27. Ibid.
28. Arizona Health Care Cost Containment System. “AHCCCS Medical Policy Manual- 920: Quality Management/Performance Improvement Program Administrative Requirements.” April 27, 2021. Available at: https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/900/920.pdf.
29. D. Crumley and A. Bank. Financing Approaches to Address Social Determinants of Health via Medicaid Managed Care: A 12-State Review, op. cit.
30. Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services. “Opportunities in Medicaid and CHIP to Address Social Determinants of Health.” SHO# 21-001. January 7, 2021. Available at: https://www.medicaid.gov/sites/default/files/2022-01/sho21001_0.pdf.
31. Medicaid and CHIP Payment and Access Commission. “Section 1115 research and demonstration waivers.”Available at: https://www.macpac.gov/subtopic/section-1115-research-and-demonstration-waivers/#:~:text=Under%20Section%201115%2C%20the%20HHS,the%20goals%20of%20the%20program.
32. enters for Medicare and Medicaid Services. “Health Related Social Needs.”, op. cit.
33. For example, see special terms and conditions 9.3 here: Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services. “Oregon Health Plan”. Demonstration Approval for 1115 waiver. Number 11-W-00415/10. April 20,2023. Available at: https://www.medicaid.gov/sites/default/files/2023-04/or-health-plan-ca-04202023.pdf.
34. Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services. “Additional Guidance on Use of In Lieu of Services and Settings in Medicaid Managed Care.” SMD #: 23-001. January 4, 2023. Available at: https://www.medicaid.gov/sites/default/files/2023-01/smd23001.pdf.
35. S. Dunbar. “In-Lieu-Of Services and Value-Added Benefits.” Medicaid and CHIP Payment and Access Commission. December 8, 2022. Available at: https://www.macpac.gov/wp-content/uploads/2022/12/07_In-Lieu-Of-Services-and-Value-Added-Benefits.pdf.
36. Medicaid Innovation Collaborative. “2023 Cohort: Social Determinants of Health.” See SDOH Innovation Pilot Program. Available at: https://www.medicaidcollaborative.org/2023-cohort-sdoh.
37. California Department of Health Care Services. “Enhanced Care Management and Community Supports.” Available at: https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Home.aspx.
38. California Department of Health Care Services. “Medi-Cal Community Supports, or In Lieu of Services (ILOS), Policy Guide.” July 2023. Available at: https://www.dhcs.ca.gov/Documents/MCQMD/DHCS-Community-Supports-Policy-Guide.pdf.
39. Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services. “CMS Approval – Attachment G Healthy Opportunities Pilot Eligibility and Services.” North Carolina Medicaid Reform Demonstration. October 20, 2023. Available at: https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82766.
40. North Carolina Department of Health and Human Services. “Healthy Opportunities Pilots.” Available at: https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/healthy-opportunities-pilots.
41. A. Van Vleet and J. Ludlam. “A First Look: Highlights From North Carolina’s Healthy Opportunities Pilots.” Manatt Health. April 27, 2023. Available at: https://www.manatt.com/insights/newsletters/health-highlights/a-first-look-highlights-from-north-carolinas-heal.
42. Specifically, MIC is supporting pilot projects with a focus on supporting individuals with insulin-requiring diabetes as a test case.
43. For example, North Carolina, Rhode Island, and Arizona have supported implementation of community resource and referral platforms: North Carolina Department of Health and Human Services. “NCCARE360.” Available at: https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/nccare360; Rhode Island Executive Office of Health and Human Services. “Rhode Island Prioritizes Social Determinants of Health with Statewide Rollout.” Available at: https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-06/Unite%20Us%20RI%20Community%20Partner%20Email.pdf; Contexture. “Contexture Announces Unite Us as New Technology Partner for Arizona’s Social Determinants of Health Referral System.” October 24, 2022. Available at: https://contexture.org/unite-us-partner-sdoh-system/.
44. D. Crumley, R. Houston, and A. Bank. Incorporating Community-Based Organizations in Medicaid Efforts to Address Health-Related Social Needs: Key State Considerations, op. cit.
45. A. Spencer, A. Bank, and D. Crumley. Early Approaches to Community-Based Organization Networks and Community Care Hubs to Address the Non-Medical Drivers of Health in Texas. Episcopal Health Foundation, Center for Health Care Strategies, Treaty Oak Strategies. 2023. Available at: https://www.chcs.org/media/Early-Approaches-to-Community-Based-Organization-Networks-and-Community-Care-Hubs-to-Address-the-Non-Medical-Drivers-of-Health-in-Texas.pdf.
46. New York Department of Health. “Pending Application – Health Equity Reform Amendment Application.” New York Medicaid Redesign Team. September 15, 2022. Available at: https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82656.
47. Contexture. “Contexture Announces Unite Us as New Technology Partner for Arizona’s Social Determinants of Health Referral System.”, op. cit.
48. Contexture. “Arizona Community-Based Organizations Can Earn $10K through CommunityCares Program.” January 12, 2023. Available at: https://contexture.org/arizona-community-based-organizations-can-earn-10k-through-communitycares-program.