Impacting Social Determinants of Health Through Managed Care Contracts
October 13, 2022
Approximately 67 million Americans are enrolled in some form of Medicaid Managed Care plan.1 Consequently, state Medicaid agencies contracting with managed care organizations (MCOs) is a powerful tool for scaling evidence-based public health practices. Through a scan of Medicaid MCO contract requirements, ASTHO identified examples of contract language that state health agencies (SHAs) can consider for inclusion in future Medicaid funding cycles as a component of ongoing collaboration with their Medicaid counterparts.
ASTHO organized examples of contract language from eight states (California, Colorado, Illinois, Florida, Tennessee, Wisconsin, Michigan, and New Hampshire) into the following categories: community health worker (CHW) collaboration, population health program design and reporting, State Health Agency (SHA) collaboration, social determinants of health (SDOH) community engagement, SDOH data analysis, SDOH screening, SDOH staffing requirements, and social services referral requirements.
Table 1. Population Health Equity: Sample Contract Language by Category, State 2
| Theme | State, Contract Section | MCO Contract Language |
|---|---|---|
CHW Interventions |
Michigan | Requires MCOs to “…support the design and implementation of Community Health Worker (CHW) interventions delivered by community-based organizations which address Social Determinants of Health and promote prevention and health education and are tailored to the needs of community members in terms of cultural and linguistic competency and shared community residency and life experience.” |
Population Health Program Design and Reporting |
Tennessee Population Health Reports | “The MCO shall submit an annual Population Health Impact Report including the data elements described by TennCare. The Population Health Model touches members across the entire care continuum, promoting healthy behaviors and disease self-management as well as providing care coordination and intense care management as needed and supported by evidence-based medicine and national best practices. The CONTRACTOR shall evaluate the entire member population and identify members for specific cohorts, according to risk rather than disease specific categories.” |
| Colorado Member Engagement Report | “The plan shall submit a bi-annual report to the Department describing how the Contractor engaged Members and Community stakeholders in the Accountable Care Collaborative, in a format determined by the Department. The Member Engagement Report shall include a number of population health educational outreach contacts in alignment with the Department’s Population Management Framework.” | |
SHA Collaboration |
Colorado Community and the Social Determinants of Health | “Plans shall collaborate with local public health agencies to design opportunities for integration of local public health activities into the Accountable Care Collaborative. Plans are also required to establish relationships and collaborate with economic, social, educational, justice, recreational and other relevant organizations to promote the health of local communities and populations.” “The plan shall establish relationships and communication channels with Community organizations that provide resources such as food, housing, energy assistance, childcare, education, and job training in the region. The plan shall establish relationships and collaborate with economic, social, educational, justice, recreational and other relevant organizations to promote the health of local communities and populations.” |
| California Purpose and Background | “Establish and expand a stable local presence and collaborate and engage with local community partners and resources to ensure community needs are met.” | |
| Florida Coverage and Authorization of Services | “The Managed Care Plan shall consider partnering with other agencies such as State and local public health entities, provider organizations, local community groups, or other entities to educate enrollees about the program or to help administer [program].” | |
| New Hampshire Collaboration with Tobacco Cessation Programs | States may include requirements for MCOs to use existing public health services like the tobacco cessation quitline. Generally, the tobacco control division is part of Local/State/Territorial Health Agencies (L/SHAs) Public Health department and can foster collaboration between the MCO and the L/SHA. However, without specific requirements to refer tobacco users to the Quitline, Medicaid beneficiaries might be unaware of treatment options. Contract language in New Hampshire: “The MCO shall promote and utilize the DHHS-approved tobacco cessation quitline and tobacco cessation program.” | |
SDOH Community Engagement |
Washington Coordination Between the Contractor and External Entities | The MCO is required to “participate in the local Accountable Communities of Health (ACH) in each Regional Service Areas in which the Contractor provides services under this Contract.” An ACH is a regionally governed, public-private collaborative to achieve healthy communities. ACHs coordinate various stakeholders involved in health including public health, healthcare providers, and systems that impact SDOH. The goals of ACHs are to promote health equity and coordinate around SDOH. |
| Colorado Community and the Social Determinants of Health | “Establish relationships and communication channels with Community organizations that provide resources such as food, housing, energy assistance, childcare, education, and job training in the region.” | |
SDOH Data Analysis |
Wisconsin Care Management Requirements | Based on the SDOH screening and referral to services, HMOs are required to “provide data analysis to determine needs across the HMO’s membership including examining prevalence of social risk factors/HRSNs and disparities stratified on gender, race, ethnicity, disability, age, and language.” |
| Tennessee Personnel Requirements | “The MCO shall submit a monthly Member Experience Report that contains the following completed tabs: Housing Profile Tab - monitors the housing needs of enrollees waiting to transition or post-transition and includes, but is not limited to, transition wait times, transition barriers, monthly income amounts, housing options chosen, and counties chosen for transition.” | |
SDOH Screening |
Wisconsin Care Management Requirements | “Include drivers of health in their screening process for adult members within 90 days of enrollment and annually thereafter.” “HMOs are required to develop a screening plan to include written policy and procedure and screening questions to capture the following categories of drivers of health: housing, utilities, transportation, and food to identify social risk factors and health related social needs.” |
SDOH Staffing Requirements |
Tennessee Personnel Requirements | The MCO is required to hire a staff person dedicated to overseeing Housing Services and Supports for long-term services and support (LTSS) programs. “The Housing Specialist shall be responsible for working with the housing agencies to help develop and access affordable housing services for members receiving LTSS, educating and assisting Care/Support Coordinators/Independent Support Coordinators regarding affordable housing services for CHOICES, ECF CHOICES, and 1915(c) waiver members.” |
| Illinois Designated Liaisons | “The MCO shall hire a staff person dedicated to population health initiatives. This staffer will serve as a liaison who will be responsible for all population health and related issues, including population health activities and coordination between behavioral health services.” | |
Social Services Referral Requirements |
Wisconsin Care Management Requirements | Following the SDOH screening HMOS must provide a “referral to appropriate resources as identified and in consultation with the member.” |
1. Total enrollment data reflects individuals enrolled in comprehensive managed care programs and partial managed care programs (including primary care case management and limited benefit plans e.g., prepaid ambulatory health and prepaid inpatient health plans) according to CMS.↩
2. ASTHO queried the Health Management Associates Information Services (HMAIS) managed care database using key population health equity search terms: collaboration, coordinate, public health, population health, performance measure, partner, data sharing, population health management, housing, transportation, food insecurity, utilities, interpersonal safety.↩
The development of this product is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services under grant number 2 UD3OA22890-10-00. Information, content, and conclusions will be 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 U.S. Government.