The initial 1115 waiver enabling the HOP program was approved prior to the Biden administration announcing the HRSN framework, but it is very much in the spirit of HRSN waivers.
For states, ILOS remains viable for defined clinical substitutes (eg asthma remediation supplies instead of ER visits) while social care+ prog now faces higher evidentiary burdens. Ex:CalAIM, likely mod service reductions, delayed expansions, and increased admin costs to preserve CalAIM’s core HRSN.
When you say “higher evidentiary burdens” does that mean something like ILOS can no longer just be cost effective? Or do you think cost effectiveness and medical appropriateness will just be assessed more conservatively/harshly?
CA, as ex, previous flexibility on caregiver stipends, respite expansions, housing vouchers, homelessness interventions, non-medical transpo, high-risk HRSN srvcs (home mod, food insecurity, and palliative ICTs) will be impacted. Direct substitution evidence will likely be scrutinized heavily.
It seems the uncertainty this creates for MCPs and social service providers will really disincentivize making the investments of time and resources needed to address HRSNs. So in addition to the heavier scrutiny, I’d imagine a decline in participation just because of the uncertainty.
It changes the $ risk assumed; it puts pressure on new and community-based D-SNP plans. Given the unclear nature of how these will be evaluated, it will delay innovative models & make MCPs re-change their filing to factor more conservatism. More uncertainty -> more modest offerings -> lower growth
It creates headaches for a complicated program like D-SNP. For ex, CA's CY2026 D-SNP Policy Guide requires MCPs to file their Model of Care by 2/12/25. Now, this 2/25 memo withdrew the fast-track ILOS approvals certain supports (ex caregiver stipends, housing vouchers) now require CMS pre-approval.
Comments
Forgot the JAMA link in the last post: https://jamanetwork.com/journals/jama/article-abstract/2830892
It seems the uncertainty this creates for MCPs and social service providers will really disincentivize making the investments of time and resources needed to address HRSNs. So in addition to the heavier scrutiny, I’d imagine a decline in participation just because of the uncertainty.