CHCS June 18, 2024
Over the past decade, Medicaid managed care organizations (MCOs) have increasingly chosen to provide services that address their members’ health-related social needs (HRSN), such as medically tailored meals, home remediation to reduce asthma triggers, and housing navigation services. However, because MCO capitation rates have not traditionally reflected these HRSN services, many MCO activities to address HRSN have remained in pilot phases.
New Centers for Medicare & Medicaid Services (CMS) guidance on in lieu of services (ILOS) is changing this dynamic. ILOS are defined as medically appropriate and cost-effective substitutes for state Medicaid benefits, with special treatment in managed care rates (discussed below). ILOS authority is particularly valuable for states aiming to avoid a Section 1115 demonstration, which involves lengthier planning...
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