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CMS sets standards for non-medical services, settings under Medicaid, CHIP

On Jan. 4 CMS issued new guidelines for the use of non-medical services and settings under Medicaid managed care programs and the Children’s Health Insurance Program (CHIP) – further advancing the agency’s agenda to use such means to meet beneficiaries’ social determinants of health (SDOH).
“Today’s step ensures people with Medicaid receive the broader care they need to live safe and healthy lives,” said HHS Secretary Xavier Becerra in a related statement. "We call on all states to leverage these innovative options and stand ready to partner with them in providing essential health care services.”

"In lieu of services and settings” (ILOS) choices are already being used by some state Medicaid plans – for example, in December 2022 CMS renewed an existing waiver for California Medicaid (Medi-Cal) under the California Advancing & Innovating Medi-Cal (CalAIM) program, re-authorizing them to offer beneficiaries 12 ILOS including “Housing Tenancy and Sustaining Services,” “Personal Care and Homemaker Services,” and “Environmental Accessibility Adaptations (Home Modifications).”

ILOS services may include asthma remediation via dehumidifiers and mold removal as well as “medically tailored meals,” for example, and settings may include enrollment in alternative care centers such as “sobering centers."

In its letter to State Medicaid Directors, CMS says it seeks to “meet the HRSNs [health-related social needs] of Medicaid enrollees more effectively” by ensuring the program meets both care and cost-efficiency targets. To this end, it specifies that the ILOS cost percentage applicable to each program cannot exceed 5%, and when the ILOS percentage exceeds 1.5% of budget “states must provide a description of their processes to determine that each ILOS is medically appropriate for the target population.”

CMS also lays out documentary reporting requirements such as the use of appropriate HCPCS and CPT codes and evidence of medical necessity, and reiterates that enrollees “retain all the rights afforded to them in [law],” including the right to reject or abandon the ILOS offered as a substitute for their contractually-mandated Medicaid services.

All ILOS under the program, new or existing, must conform to the stated guidelines starting Jan. 1, 2024, the letter concludes.
Blog Tags: CMS
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