CMS Updates Guidance to Health-Related Social Needs Framework
On March 4, 2025, the Centers for Medicare and Medicaid Services (CMS) retracted specific Health-Related Social Needs (HRSN) guidance provided by the previous administration. In particular, CMS rescinded guidance defining various service definitions and parameters for state requests for approval to cover HRSN under Medicaid via waivers and other authorities. This article revisits the rescinded guidance and provides insight into how states with HRSN waivers and waivers in progress can move forward in light of this change.
Background
Since 2021, CMS has progressively built upon efforts to create opportunities for states to support Medicaid enrollees with broader needs that can significantly affect their ability to stay healthy. These social determinates of health (SDOH) -related supports have focused on increasing availability to:
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- Nutritious food
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- Housing and utility support
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- Employment and job support
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- Transportation
In 2023 and 2024, CMS provided a roadmap for states looking to offer Medicaid-coverable HRSN options and through multiple authority paths including managed care in lieu of services and settings (ILOS), HCBS 1915(c/i/j/k) Waivers and Section 1115 Demonstration Waivers. This guidance was primarily communicated through two CMS informational bulletins (CIBs):
These documents provided information for states to use when designing HRSN coverage and included the following guidance:
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- General intervention guidelines and state responsibilities to ensure appropriate use and coordination with other like social services
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- Limitations on expenditures and require that minimum thresholds on payment rates for primary care, obstetrics care, and mental health and substance use disorder services are met
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- A “framework” that provides detailed information for each HRSN service, including which authority they are approvable through, and any associated limits. Services included are case management, housing interventions (with and without room and board), home environment interventions, and nutrition interventions (with and without the provision of food).
New Guidance and Next Steps
The 2025 guidance rescinded these two CIBs and their accompanying frameworks. CMS noted that even though this guidance has been withdrawn, new Section 1115 Waiver applications that include HRSN services will continue to be reviewed on a case-by-case basis in alignment with federal requirements. Additionally, existing approvals of Section 1115 HRSN Waivers will not be retracted.
States with HRSN waiver applications in progress are not required to follow or reference the rescinded guidance but may consider continuing to use the framework as best practice to consider as they design services. Alternatively, states can propose to test new innovative HRSN designs outside of the services and limits previously required in the retracted guidance.
Health Policy News will continue to follow these federal policy changes and provide updates as they are released.