Many state Medicaid enrollees will soon have access to nonmedical services like housing and nutrition assistance, violence prevention, and support for transitioning out of incarceration that aim to improve overall health. Thanks to the Biden administration's policy, state Medicaid programs could apply for federal waivers to cover “social determinants of health”—factors in people's living conditions that directly impact their health.
On July 2, the federal Centers for Medicare and Medicaid Services approved Illinois' waiver, effective through June 30, 2029, with a possible extension. CMS also extended a waiver from 2018 that covers substance use disorder treatment in mental institutions.
The waiver was originally titled “Illinois Behavioral Health Transformation.” The state has since requested that the title be updated to “Illinois Healthcare Transformation.” This name change request is currently waiting for approval.
The original section 1115 demonstration, “Behavioral Health Transformation,” was approved in 2018. In June 2023, the state submitted the extension application. Under the extension, the state will continue two SUD programs from the original demonstration and the Employment Services Pilot while introducing additional programs and pilots.
Requests Not Approved
Safety Net Hospital Health Equity and Access Leadership Grant Program
Funding for safety-net hospitals
Cook County Disproportionate Share Hospital (DSH)
Re-direct DSH funding to fund strategies to improve the health in underserved communities
Health care Transformation Collaboratives (HTCs)
Acronym Dictionary
HRSN: Health-Related Social Need
CMS: Centers for Medicare and Medicaid Services
CMCS: Centers for Medicaid and CHIP Services
CHIP: Children’s Health Insurance Program
SDOH: Social Determinants of Health
SHO: State Health Officials
HCBS: Home and Community-Based Services
HSI: Health Service Initiatives
ILOS: In Lieu of Services
SMDL: State Medicaid Director Letter
CIB: Common Information Bulletin
SUD: Substance Use Disorder
Focus Areas
1. Residential and Inpatient Treatment for Individuals with Substance Use Disorder (SUD) (Original Demonstration)
2. SUD Case Management Pilot (Original Demonstration)
3. Supported Employment Services Pilot (Original Demonstration)
4. Expenditures for Pre-Release Services (Extension)
5. Expenditures for Pre-Release Administrative Costs (Extension)
6. Health-Related Social Needs (HRSN) Services (Extension)
7. Expenditures for HRSN Services Infrastructure (Extension)
8. Expenditures for Violence Prevention and Intervention Services (Extension)
9. Expenditures for Non-Medical Transportation (Extension)
Substance Use Disorder (SUD)
The goal of the SUD initiatives are to:
Increase rates of identification, initiation, and engagement in treatment for SUD
Increase adherence to and retention in treatment
Reduce overdose deaths, particularly those due to opioids
Reduce utilization of emergency departments and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate through improved access to other continuum-of-care services
Fewer readmissions to the same or higher level of care where the readmission is preventable or medically inappropriate
Improve access to care for physical health conditions among beneficiaries with SUD.
Reentry Demonstration
Facilitate an individual’s access to healthcare services and case management provided by Medicaid-participating providers while they are incarcerated, allowing them to establish a network of providers to utilize upon reentry.
Coverage begins shortly before release through short-term Medicaid enrollment assistance and pre-release coverage for certain services.
It aims to increase coverage, improve access to services before release, improve connections between correctional facility settings and community services, reduce deaths and emergency department visits, and provide behavioral health interventions.
Pre-Release Services
To be eligible for pre-release services, an individual must be determined eligible for Medicaid, file an application before or during incarceration, and have an expected release date no later than 90 days after initiation of the demonstration-covered services.
Illinois will not terminate Medicaid coverage but suspend coverage for Medicaid-covered individuals entering a correctional facility.
For individuals not covered by Medicaid entering a correctional facility, Illinois will ensure they receive assistance completing and submitting a Medicaid application before being eligible for pre-release services.
Case management to assess and address physical and behavioral health needs
HRSN (Health-related social needs)
Medication-assisted treatment (MAT) services for all types of SUD including coverage for medications in combination with counseling/behavioral therapies
A 30-day supply of all prescription medications and over-the-counter drugs (as clinically appropriate) provided to the individual immediately upon release from the correctional facility, consistent with approved Medicaid state plan coverage and policy
Services provided by community health workers
Diagnostic and treatment services, including laboratory and radiology services
Medical equipment and supplies and/or medical equipment provided upon release
HRSN Services
Services will be provided through a managed care delivery system, as managed care plans will provide referrals to HRSN services.
To be eligible, an individual must be Medicaid-eligible with a documented medical need for the services
People who have been determined high-risk, complex physical health needs, behavioral health needs, high-risk pregnancy, and chronic health conditions
The following services will be eligible for state coverage:
Housing interventions (housing transition and navigation services, pre-tenancy navigation services, one-time transition and moving costs, care coordination, first-month rent, post-hospitalization housing, utility assistance, accessibility modifications, etc.…)
Nutrition Interventions (care coordination, nutrition counseling, home delivery, nutrition prescriptions, grocery provisions)
Excluded services: Construction costs, capital investments, research grants, costs for services in prisons, services to people who are lawfully present in the U.S., expenditures on services funded by other state or federal entities, general workforce activities not linked to Medicaid or Medicare beneficiaries.
Employment Services Pilot
Serves Medicaid beneficiaries aged 18 or older who are enrolled in managed care. The beneficiary must also meet at least one health needs-based criteria:
Serious/persistent mental health needs, substance use needs, physical, intellectual, or developmental needs where there is a need for improvement, stabilization, or prevention.
They must also be unemployed for 90 consecutive days, most than one instance of inpatient substance abuse treatment, or be at risk for deterioration from mental illness, SUD, our physical, intellectual, or developmental needs.
The following services will be eligible:
Pre-Employment:
Pre-vocational/job-related discovery or assessment
Employment planning
Job carving (defined as working with clients and employers to modify an existing job description containing one or more, but not all, of the tasks from the original job description when a potential applicant for a job is unable to perform all of the duties identified in the job description)
Benefits education and planning (defined as counseling to assist the client in fully understanding the range of state and federal benefits they might be eligible for, the implications that work and earnings would have for continued receipt of these benefits, and the client’s options for returning to work)
Transportation
Employment Sustaining:
Career advancement services
Employer negotiation assistance (defined as services where a provider identifies and addresses job accommodations or assistive technology needs with the employer on behalf of the individual)
Job analysis (defined as the gathering, evaluating, and
Recording of accurate, objective data about the characteristics of a particular Illinois job to ensure the specific matching of skills and amelioration of maladaptive behaviors)
Job coaching (defined as supporting the beneficiary to learn and complete employment-related skills and objectives, such as learning specific work duties and performing job tasks)
Benefits and education and planning (defined as counseling to assist the client in fully understanding the range of state and federal benefits they might be eligible for, the implications that work and earnings would have for continued receipt of these benefits, and the clients’ options for returning to work)
Transportation
Asset development
Follow-along supports (defined as ongoing support necessary to assist an eligible client to sustain competitive work in an integrated setting of their choice)
Violence Prevention and Intervention
To be eligible, a person must be a Medicaid beneficiary and enrolled in managed care and who has survived violence, is currently experiencing violence, or is at risk of experiencing violence.
Services must be recommended by a physician or licensed practitioner
Services include:
Screening/assessment of needs
Individual service plan development
Trauma-specific therapy
Mentoring/peer support services
Life skills training
Psychoeducation
Conflict Meditation
Crisis intervention
Care coordination
Additional Resources and News related to Illinois' 1115 Waiver Demonstration and Updates (Last Updated 8.11.2024):
Town Hall Event: HFS Director Elizabeth Whitehorn and other HFS staff provided updates on approval parameters, implementation planning, and next steps at a town hall webinar on Monday, August 26, 2024, at 2:00 - 3:00 PM CST. (Meeting Slides posted here)
1115 Demonstration Waiver – Behavioral Health Transformation 5-Year Extension | IL HFS | Link here
Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State | KFF | Link here (National Updates)
Illinois receives federal approval for 1115 waiver application | Health News Illinois (7.8.2024) | Article here
Federal Waiver Options to Increase Health Care Affordability for People in Illinois | United States of Care & Shriver Center on Poverty Law (7.11.2024) Recording here; Slides Below
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