In 2019, more than 500,000 individuals experienced homelessness and nearly 20 million renters spent 30 percent or more of their income on housing. These numbers are increasing as the COVID-19 pandemic exacerbates housing insecurity for people of color and low-wage workers. To improve housing stability – a critical social determinant of health (SDOH) – states are using Medicaid managed care contracts to encourage health plans to support members’ housing-related needs and promote coordination between housing providers and health plans.
How States Use Medicaid Managed Care Contracts to Address Housing Needs
While Medicaid managed care contract language varies significantly between states, there are some similarities in states’ approaches to addressing Medicaid enrollees’ housing needs, including these managed care organization (MCO) contractual requirements:
- Screen enrollees for housing-related needs;
- Hire designated housing coordinators; and
- Ensure the coordination of care between housing providers or agencies and Medicaid programs.
States working to address housing insecurity and homelessness among Medicaid enrollees, or states that already require plans to focus on SDOH more broadly but wish to tailor initiatives specifically towards improving housing status, can adopt some of the contractual language and initiatives described below.
Screening for Housing Insecurity
According to NASHP’s scan of states’ Medicaid managed care contracts, 16 states (of 38 with publicly available contracts or requests for proposals) require contractors to conduct routine screenings for certain SDOH. Of the 16 states, 14 require their managed care plans to screen members about their housing needs during these assessments. These screenings can occur at any interval from annually to quarterly, with some states specifying that individuals who qualify as high-needs members should be screened more frequently. In New Hampshire, community mental health programs that contract with the state’s Medicaid program are required to conduct quarterly assessments and document all members’ housing status. In Pennsylvania, providers must complete an SDOH assessment that focuses on housing security, among other things, at least annually and more often depending on the individual’s risk level.
While some states require health plans to screen all enrollees, others only require screenings for certain populations. For example, Minnesota’s Medicaid MCO requires outreach and screening for members who have been to the emergency department for services three or more times within four consecutive months. In Alabama, the maternity psychosocial assessment includes questions related to homelessness.
Screening for housing status in order to identify members experiencing housing insecurity or homelessness is an important first step in addressing housing needs. However, in the absence of mechanisms to connect individuals to community resources that can help them find appropriate housing assistance, the impact of SDOH screenings is limited.
Hiring Housing Coordinators
According to NASHP’s analysis, seven state Medicaid MCOs identify a designated, full-time employee exclusively responsible for addressing enrollees’ housing needs – Arizona, Kansas, Louisiana, New Hampshire, New Jersey, New Mexico, and North Carolina. Other states, including Delaware and Pennsylvania, require their plans to hire more broadly defined care coordinators or SDOH specialists. They work on housing as part of their jobs, but are also responsible for addressing other member needs, such as employment, transportation, and education.
Through its contract with Kansas Medicaid, United Healthcare employs a housing navigator, a position added in 2016. The housing navigator develops partnerships statewide to identify resources for providing housing supports – including vouchers, prevention services, public housing, and homeless service agencies – and to help members locate housing. United Healthcare’s housing navigator has assisted more than 200 Medicaid members with housing needs.
The Louisiana MCO contract requires the plan to hire a permanent supportive housing program liaison who works with the Louisiana Department of Health to help implement the PSH program deliverables, which include providing affordable housing and tenancy supports. While hiring housing navigators or specialists requires MCOs to invest financial resources, onboarding navigators to help connect members directly to housing services and supports has been shown to be one effective way to address Medicaid enrollees housing-related needs, especially those identified during SDOH screenings.
Some state Medicaid contracts also identify opportunities for MCOs to support housing initiatives run by state or federal housing agencies. In Texas, the Medicaid MCO service coordinator must work with staff from their Section 811 Project Rental Assistance program, a federal program that helps provide supportive housing for individuals with disabilities, to coordinate care for Texans receiving Section 811 services and those leaving nursing facilities. This helps integrate health and housing services for individuals previously identified as having housing needs. In Louisiana, the state housing authority and the Department of Health co-manage the permanent supportive housing (PSH) program. The Louisiana MCO contract outlines a number of ways that MCOs are required to support the PSH program, including:
- Provide outreach to members who qualify for PSH;
- Help members apply for PSH;
- Ensure timely prior authorization for PSH tenancy and pre-tenancy supports;
- Refer members approved for PSH to relevant providers; and
- Work with PSH program management to ensure an adequate and qualified network of PSH program staff and service providers.
The MCO is also required to contract directly with housing providers approved by the state to provide tenancy and pre-tenancy supports to members participating in the PSH program. One analysis of Louisiana Medicaid recipients pre- and post-PSH showed a 26 percent reduction in emergency room visits, a 12 percent reduction in hospitalizations, and an increased use of behavioral health services among participants. Through partnerships with PSH programs, MCOs can improve integration of health and housing services for members and expand the reach of housing programs by helping to identify Medicaid enrollees in need of housing and connect them directly to resources.
State Medicaid managed care contracts employ creative ways to use Medicaid funding to support efforts to address housing insecurity among enrollees. Although Medicaid cannot directly fund housing, there are many other strategies to effectively invest in housing services. Oregon’s Coordinated Care Organizations (CCOs) are required to spend a portion of their profits or reserves on health-related services, and specifically on housing supports. Starting January 2021, CCOs are also required to submit annual spending plans to the state, which include the CCO’s spending priorities related to addressing SDOH and health equity, and how they align with the state’s housing-related priorities. In Kansas, the state’s MCO request for proposal calls for alternative payment strategies to incentivize warm handoff transitions for individuals moving from institutions into community-based programs and services.
In Massachusetts, the managed care contract mentions the Social Innovation Financing for Chronic Homelessness Population Program (SIF), a Pay For Success (PFS) initiative that finances PSH. Through the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), Medicaid managed care entities fund support services for PSH tenants in the PFS program. As of October 2020, 860 members have enrolled in CSPECH. Together with the PFS program, CSPECH has improved housing retention, decreased emergency room stays, and saved millions in costs. While the current budget climate arising from the COVID-19 pandemic makes adopting new funding strategies difficult, investing health plan dollars in housing services can not only improve members’ housing status, but also decrease Medicaid spending down the line.
In addition to established methods, such as screening for housing needs and partnering with housing service providers, some states are using their managed care plans to launch new initiatives to address their Medicaid enrollees’ housing needs. In Florida, MCOs are participating in a voluntary pilot program to provide behavioral health services and supportive housing assistance directly to Medicaid enrollees who are homeless or at risk of homelessness and who also experiencing either serious mental illness or substance use disorder. The North Carolina managed care contract provides for an Enhanced Case Management Pilot program in up to four areas of the state. MCOs in each area work to determine the most effective, evidence-based interventions to address four priority domains, which include housing. The program also requires each program to evaluate the effect of the interventions on health care costs and outcomes. There is no “one-size-fits-all” approach to addressing housing, but piloting programs like these, or creative financing solutions like those mentioned above, can help MCOs determine which methods are best for reaching housing-insecure members in their state, while also improving health outcomes and decreasing costs.
As efforts to address SDOH become increasingly common among Medicaid managed care plans, many states are narrowing their focus to address housing insecurity and homelessness specifically. By working to identify enrollees’ housing needs and directly connect them to housing and supportive services, health plans can improve housing stability, which in turn improves health outcomes and decreases costs.
During the COVID-19 pandemic, states face budget challenges while their Medicaid managed care plans may experience financial gains from a decline in demand for physical health services. This leaves health plans in a unique position to invest new resources upfront in housing-related services. In 2020, many insurers reported large profits, in part due to the decline in non-COVID-19-related hospital admissions. Medical Loss Ratio rules, however, limit the amount insurers can keep for profit or overhead costs – health plans must either issue rebates or spend more on health-related services, which presents an opportunity to use these additional funds to address housing insecurity and homelessness among enrollees. And, by requiring health plans to indirectly invest in housing by hiring housing coordinators, partnering with existing housing agencies who are already immersed in the work, financing housing-related services, or by piloting new, creative solutions, states can take the lead in guiding Medicaid managed care plans’ work.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
Inequities in oral health and health outcomes are driven by upstream factors, including diet, education, transportation, and access to care. A growing number of states are working to improve the oral and physical health of Medicaid enrollees and reduce costs by addressing these social determinants of health in their managed care contracts.
A 50-state review by the National Academy for State Health Policy (NASHP) of Medicaid dental and medical managed care contracts, requests for proposals, and other similar documents publicly available through September 2020, identified how states address social determinants of oral health. Dental contracts were reviewed for a comprehensive list of social determinants and medical contracts were analyzed for references to care coordination, community resources, food access, social determinants of health screening, and coordination with dental contractors. In total, NASHP scanned dental contracts in 19 states and medical contracts in 38 states.
Of the dental contracts, nine referenced coordination between dental plans and medical plans and 13 referenced coordination with social and community services. Other common references in dental contracts included equity/cultural competence, education, and transportation (each referenced in 10 state contracts).
All but one of the 38 medical contracts referenced coordination with social and community services. Thirty-three states referenced food in their medical contracts, 25 referenced adverse experiences (such as domestic violence and child abuse), and 15 referenced care coordination between dental and medical care. Three states (Florida, Michigan, and Virginia) referred to food in both their dental and medical contracts, while only one (Virginia) referenced adverse experiences in both contracts.
State Medicaid Program Delivery of Dental Care
While Medicaid covers some form of adult dental care in 47 states and Washington, DC, and all states cover dental care for children under 21 as part of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, adult dental coverage is optional for state Medicaid programs. Currently, 35 states provide limited dental benefits for adults and 19 states offer extensive adult dental benefits.
States have different options for delivering dental care. Some states with managed care use a carve-in model, where the dental benefit is integrated into medical managed care programs. With a carved-in benefit, managed care organizations (MCOs) may administer the dental benefit or subcontract the dental benefit to another vendor. In carve-out dental programs, states contract with a dental MCO or dental benefits manager (DBM). Alternatively, states with Medicaid managed care medical delivery systems may have fee-for-service dental systems.
Medicaid dental and medical contracts illustrate how states can consider social determinants affecting oral health and overall health through:
- Screening, referral tracking, and follow-up;
- Educational initiatives;
- Staffing and training requirements;
- Data sharing and technology;
- Coordination between dental and medical systems; and
- Performance improvement.
Social Determinants of Health in Dental and Medical Medicaid Contracts
Almost all states scanned have some requirement for plans to refer members to community resources and social services. NASHP focused specifically on requirements that are applicable to the general population, rather than individuals designated as high risk or high needs. States use a variety of strategies to encourage investment in SDOH.
Screening for SDOH Needs
Sixteen states use routine screenings for certain social determinants, including employment status and access to food and transportation. The scan of 14 medical contracts and two dental contracts indicate that states are more likely to require medical plans to conduct needs assessments, often within a specified time frame after enrollment, than dental plans. States may also require medical plans to use this data to appropriately target interventions to meet enrollees’ needs.
While dental plans do not necessarily have the same explicit requirement to conduct a screening, some states do ask their dental plans to use SDOH data to target their educational and outreach activities.
- Michigan’s dental plan is required to use social determinants of oral health data from the state in order to target interventions, outreach, and education efforts.
- Nevada’s dental contract requires the contractor to complete a community-based needs assessment to inform their health promotion and educational activities, including ensuring that any interventions are culturally appropriate and meet the needs of the target population.
Referral Tracking and Follow-up
While screening is an important first step in identifying members’ social needs, it also raises a question of how states use the data to address social determinants. NASHP found that in almost every state with publicly available contracts, Medicaid agencies partner with community-based organizations to meet the social needs of enrollees. For example, plans may facilitate referrals to these community agencies based on information collected through SDOH screenings. States can use tracking, follow-up, and reporting requirements to ensure that referrals to community resources and organizations are effective and successful. Contractors can support these efforts by documenting “closed-looped” referrals that ensure that an enrollee is successfully connected with a community-based organization to address other health and social needs.
- In Louisiana, the Dental Benefit Program Manager is required to connect enrollees with community-based service providers and document referrals and referral outcomes in enrollees’ dental records.
Dental contracts are less likely to require or encourage the plan to monitor referral follow-up. However, dental plans could adopt some of the medical MCOs’ language in order to track the status of referrals, strengthen care coordination between insurance plans and community resources, and ensure individuals are receiving adequate social services that meet their evolving needs. For example, New Hampshire requires MCOs to track the effectiveness of community-based providers and resources, and Oregon requires reporting on referrals to culturally diverse social and support services.
Healthy People 2020 identified health literacy as a component of SDOH, noting that individuals’ ability to access and understand relevant health information affects their health and health outcomes. To help improve health literacy, many states require managed care plans to implement educational initiatives. For dental plans, this includes educating members about the importance of oral health or launching community oral health initiatives designed to help eliminate barriers to dental services and improve population oral health.
- In both Nevada and Texas, the dental contractor must develop and implement programs designed to educate members about nutrition, the importance of oral health, and the relationship between oral health and overall health.
- Florida’s dental plan includes incentives for participation in health education classes. Examples of incentives members can receive that support healthy child development include clothes, food, books, safety devices, publications, and memberships in health and education clubs.
- In its response to Nebraska’s request for proposals (RFP), dental contractor MCNA referenced a program it implemented in Texas that uses the fotonovela (a comic book-style communication popular in the Latinx community) to distribute health information materials to children of migrant farm workers.
Staffing and Training Requirements
Plans may also be responsible for training their employees to better meet members’ needs. In their contracts, states can prioritize the type of training that a plan’s staff receive.
- Nebraska’s dental contract requires all staff to be trained on how social determinants (including food, housing, education, violence, and physical and sexual abuse) affect members’ health and wellness. Staff also receive training on how to find community resources and make referrals.
Both medical and dental plans also employ staff members who are responsible for care coordination, addressing social determinants, and improving access to care for historically marginalized populations.
- Nebraska’s dental contract requires the plan to employ a tribal network liaison to coordinate and expand dental services to Native Americans and connect them to community resources. Arizonaand New Mexico both require medical MCOs to employ someone to coordinate services with Native Americans.
Examples of other medical plans’ required staff positions include a community liaison in Illinois, who connects enrollees with community-based services, and a service coordination director in Kansas, who oversees quality improvement initiatives related to SDOH. Dental contractors could potentially leverage medical MCO positions and their expertise to streamline care experiences for enrollees across medical and dental systems.
Coordination between Dental and Medical Systems
To better integrate dental and medical care, dental and medical managed care use staff members to connect physical health and oral health services across contracts. These staff members also connect Medicaid enrollees to community services to meet social needs.
- In its dental contract, Tennessee requires a coordinator to work with the medical MCO and develop a system to exchange data with the MCO.
- Florida requires MCOs to have a liaison for their prepaid dental health plan to help integrate medical care, behavioral health, and long-term benefits with the dental plan.
- Iowa requires the dental contractor to send a care facilitation plan to the state with information on how the plan will facilitate coordination between dental and medical plans and providers.
Data Sharing and Technology
Eleven states require some form of data sharing between dental and medical plans, or between plans and community organizations. Requirements for integrating different agencies’ social determinant data and sharing information across systems allow medical, dental, and social services to work together to coordinate care for members and encourage referrals and follow-up tracking.
- In Tennessee, the dental benefits manager must facilitate data exchange with school-based health programs to coordinate any needed follow-up care.
- Washington State tasks its dental contractors with using health information technology and health information exchanges to coordinate care between physical health, behavioral health, and social services and other community-based organizations.
Other states are creating their own online platform or mobile applications to improve access to social services for their Medicaid enrollees. These platforms are mentioned specifically in medical managed care plan contracts, but have the potential to be used by dental contractors as well.
- Kansas developed a web-based, mobile-friendly application that connects service coordinators to community resources, such as food banks and pantries, housing, clothing, legal resources, and transportation.
- Medicaid Prepaid Health Plans in North Carolina will use a telephonic, online, and interfaced IT platform to refer members to social services and track the outcomes of these referrals.
A number of states encourage both dental and medical plans to engage in performance improvement projects (PIPs) in order to address SDOH.
- In Nevada, dental vendors are required to conduct both a clinical and non-clinical PIP every year. Non-clinical PIPs can focus on cultural competency and accessibility of services, among other SDOH.
- Oregon Coordinated Care Organizations (CCOs) must implement PIPs that address at least four of eight designated focus areas, which include addressing SDOH and equity, and integrating primary care, behavioral health care, and/or oral health care.
Through these PIPs, state managed care plans (both dental and medical) can launch pilot interventions to improve health outcomes by addressing SDOH and reducing barriers to care.
Research shows that addressing individual social needs leads to better oral health outcomes. Despite having different levels of funding and varying Medicaid adult dental benefits, states across the country are finding ways to invest in SDOH. While not all states have started to include SDOH requirements in their dental contracts, these examples show potential opportunities for dental plans to integrate some of the medical plans’ language and guidance into their own work. To learn more about how state Medicaid programs include SDOH-related language in their dental and medical Medicaid managed care contracts, view this interactive map.
Acknowledgements: This blog and map were made possible by the DentaQuest Partnership LLC. The authors would like to especially thank Trenae Simpson for her guidance and assistance, and Trish Riley and Jill Rosenthal for their helpful feedback. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of the DentaQuest Partnership LLC.
Colorado and Michigan have joined Oklahoma to become the nation’s pioneering states with approved State Plan Amendments (SPAs) that enable Medicaid alternative payment models (APMs) for prescription drugs in the form of outcome-based contracts with pharmaceutical manufacturers.
In early May, state experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their APMs during a NASHP webinar. A recording of the webinar is available here.
The SPAs enable states to negotiate contracts based on agreed-upon outcome measures tailored for specific drugs. Outcomes measures vary but may include measures such as patient adherence or reduced hospitalizations. If the drug’s performance fails to meet agreed-upon outcomes and triggers the need for additional manufacturer payments to the state, those payments are made in the form of supplemental rebates. The contract template was developed with the support of the State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D).
Though these outcomes-based APMs are valuable tools for states to manage escalating drug costs, APMs are best understood as “one more tool in our toolbox,” which are most effective when used in tandem with other strategies rather than in isolation, explained Cathy Traugott, pharmacy office director of the Colorado Department of Health Care Policy and Financing. Though these APMs may help states manage payment for high-cost drugs, the high-list prices themselves remain a problem that states are also attempting to address head on. During this year’s state legislative session alone, 47 states have filed 254 drug-cost-related bills (as of May 22, 2019).
Executing and implementing outcome-based contracting can be a time-consuming endeavor for states because of the necessity for state officials to engage with multiple manufacturers in exploratory discussions to identify drug candidates, followed by the data analysis necessary to design, and then track the outcome-based measures.
Oklahoma, whose work NASHP supported through a subgrant from the Laura and John Arnold Foundation, found that the process took longer than anticipated. Terry Cothran, director of the University of Oklahoma’s College of Pharmacy, advised states that pursue outcomes-based contracting to consider dedicating a project coordinator to execute the work most effectively.
To date, these contracts are with state Medicaid agencies only, and have not included inter-agency efforts. Rita Subhedar, state assistant administrator for Michigan’s Department of Health and Human Services, stressed the importance of broad engagement within a Medicaid department to effectively implement these APMs, including pharmacy, medical, and behavioral health staff. A separate, subscription-based payment approach, known as the “Netflix” model, utilizes a cross-agency approach engaging both Medicaid and a state corrections department. This approach was explored in another NASHP webinar, How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model.
The first results from outcome-based contracting will come from Oklahoma, whose first, one-year contract is scheduled to end July 2019, with three other contracts concluding soon after. Colorado and Michigan have not yet executed contracts.
Escalating drug prices are forcing state Medicaid agencies to explore new payment models. According to Burl Beasley, director of Pharmacy Services for Oklahoma’s Medicaid program, older Medicaid payment strategies, such as negotiating enhanced rebates and multi-state purchase agreements, are not keeping pace with rising drug expenditures.
Beasley cited the strain prescription drug costs were putting on Oklahoma’s Medicaid budget as a driver behind the decision to pursue alternative payment models (APMs) during a Dec. 12, 2018 National Academy for State Health Policy (NASHP) webinar. The webinar featured Beasley, Terry Cothran, director of Pharmacy Management Consultants at the University of Oklahoma College of Pharmacy, and Russell Knoth, director of Health Economics and Outcomes Research at Eisai, a drug manufacturer that entered into an APM agreement with Oklahoma. Since committing to APMs, Oklahoma’s Medicaid agency has become a national leader, with four separate Medicaid APM agreements executed with drug manufacturers.
Oklahoma Medicaid Alternative Payment Models for Prescription Drugs
|Drug Name||Manufacturer||Therapeutic Class||Outcome Measured|
|Aripiprazole lauroxil (Aristada)||Alkermes||Long-acting, injectable antipsychotic||Patient adherence to medication|
|Oritavancin (Orbativ)||Melinta||IV antibiotic for bacterial skin infections||Net costs to the state|
|Invega Trinza and Sustenna||Janssen/Johnson & Johnson||Long-acting, injectable antipsychotic||Overall population adherence|
Beasley drew an important distinction between the two main types of APMs — financial APMs and health outcome-based APMs. Financial APMs are essentially price/volume agreements and may include target measures such as adherence. Financial APMs, which can be managed with claims data, are easier to administer than health outcomes-based APMs, which often require clinical data. The four contracts that Oklahoma has executed to date are all financial APMs, though Oklahoma continues to explore potential health outcomes-based APMs. Oklahoma’s fee-for-service Medicaid payment model helped expedite the execution of APMs, which otherwise may have required additional negotiation and coordination with managed care organizations.
To enable Medicaid APMs, Oklahoma submitted a Medicaid State Plan Amendment (SPA) to the Centers for Medicare & Medicaid Services, and received approval for the amendment on June 27, 2018. The SPA allows Oklahoma to negotiate supplemental rebate agreements that could produce extra rebates for the state depending on a drug’s performance against outcomes agreed upon in the contract with the drug manufacturer. The extra rebates are excluded from “best price” implications, an important consideration to encourage manufacturer participation in APMs.
Michigan has since followed Oklahoma’s lead, receiving approval in November 2018 for a SPA to enable APMs there. Both states received support from SMART-D, the State Medicaid Alternative Reimbursement and Purchasing Test for High-Cost Drugs, including development of a contract template. NASHP provided a grant to Oklahoma to support the extensive data analysis necessary to explore potential drugs and outcomes for measurement in order to execute contracts. NASHP provided the grant through its Center for State Rx Drug Pricing, supported by the Laura and John Arnold Foundation.
Results, including assessments of potential cost savings, are not expected for any of Oklahoma’s APMs until 2019. In the meantime, Cothran was able to share some lessons learned from Oklahoma’s successful efforts to pursue and finalize contracts with manufacturers.
- Building a strong relationship and trust between the state and a manufacturer is necessary.
- Smaller manufacturers may have greater flexibility than larger manufacturers to enter into APMs more quickly.
- Manufacturers are new to Medicaid APMs and are generally not yet ready to take on high-risk contracts.
- State Medicaid programs should be willing to pull initial data on drug utilization to get manufacturers to the table.
Knoth shared the manufacturer’s perspective on APMs, which he believes can be a win-win for payers and manufacturers. He stressed that though the concept of an APM is easy to grasp, transitioning from the concept to a signed contract can be challenge because it requires designing an agreement with the power to measure a real effect. Eisai’s contract with the Oklahoma Health Care Authority measures reductions in hospitalizations following initiation of its epilepsy drug Fycompa, and is Eisai’s first APM.
- Read a Q&A about how Oklahoma implemented its APM and how it plans to evaluate and expand this innovative model here.
- Listen to the Dec. 12, 2019 webinar Medicaid Alternative Payment Models for Prescription Drugs: Do They Add Value for States? here.
- Listen to the May 9, 2019, webinar Medicaid Alternative Payment Models for Prescription Drugs: A Look at Three States here.