Appendix A - Standardized Housing, Food Insecurity, and Transportation Questions For the Special Needs Plan Health Risk Assessme

Appendix A: Standardized Housing, Food Insecurity, and Transportation Questions For
the Special Needs Plan Health Risk Assessment (§ 422.101)
This appendix lists the questions identified in Section II.A.4 of the January 2022 proposed rule.
Should we finalize our proposal, SNPs would comply with the new requirement added to
§ 422.101(f) by including in their HRAs the standardized questions on these topics that we
would specify in sub-regulatory guidance. At a minimum, we intend to align selected questions
with the Social Determinants of Health (SDOH) Assessment data element 1 established as part of
the USCDI v2, when finalized and where applicable.
We provide here the questions on these topics used in other Medicare contexts that were listed in
the January 2022 proposed rule to provide better context on the proposed requirement and to
solicit public comment. These examples include the transportation question in the post-acute care
patient/resident instruments and the housing and food insecurity questions from the AHC Model
HRSN Screening Tool: 2
Housing. What is your living situation today? 3
● I have a steady place to live
● I have a place to live today, but I am worried about losing it in the future
● I do not have a steady place to live (I am temporarily staying with others, in a hotel, in
a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or
train station, or in a park)
Food. Some people have made the following statements about their food situation.
Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and
your household in the last 12 months. Within the past 12 months, you worried that your food
would run out before you got money to buy more. 4
● Often true
● Sometimes true

For more information, see: https://www.healthit.gov/isa/taxonomy/term/1801/uscdi-v2.
For the Accountable Health Communities Health-Related Social Needs Screening Tool, see
https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf. The PAC assessment utilized the same
transportation question as the AHC HRSN Tool.
3
Adapted from National Association of Community Health Centers and partners, National Association of
Community Health Centers, Association of Asian Pacific Community Health Organizations, Association OPC,
Institute for Alternative Futures. (2017). PRAPARE. http://www.nachc.org/research-and-data/prapare/.
4
Adapted from Hager, E. R., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., Cook, J. T.,
Ettinger de Cuba, S. E., Casey, P. H., Chilton, M., Cutts, D. B., Meyers A. F., Frank, D. A. (2010). Development
and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics, 126(1), 26-32.
doi:10.1542/ peds.2009-3146.
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● Never true
Within the past 12 months, the food you bought just didn't last and you didn't have money
to get more.
● Often true
● Sometimes true
● Never true
Transportation. Has lack of transportation kept you from medical appointments,
meetings, work, or from getting things needed for daily living? 5
● Yes, it has kept me from medical appointments or from getting my medications
● Yes, it has kept me from non-medical meetings, appointments, work, or from getting
things that I need
● No

National Association of Community Health Centers and partners, National Association of Community Health
Centers, Association of Asian Pacific Community Health Organizations, Association OPC, Institute for Alternative
Futures. (2017). PRAPARE. http://www.nachc.org/research-and-data/prapare/.
5