CMS-10825_HRA SDOH Guidance

SUBJECT: List of screening instruments for CY 2024 requirement to include one or more questions on housing stability, food security, and access to transportation in health risk assessments

Purpose

The purpose of this memorandum is to provide guidance on the screening instruments available for Medicare Advantage (MA) special needs plans (SNPs) to meet the new requirement to include one or more questions on housing stability, food security, and access to transportation in their health risk assessments (HRAs) beginning in contract year (CY) 2024.

Background

New regulations at 42 CFR § 422.101(f)(1)(i)¹ require that all MA SNP HRAs must include at least one question from a list of screening instruments specified by CMS in sub-regulatory guidance on each of three domains (housing stability, food security, and access to transportation) beginning in CY 2024. This new requirement will help better identify the risk factors that may inhibit enrollees from accessing care and achieving optimal health outcomes and independence and enable MA SNPs to take these risk factors into account in enrollee individualized care plans. This guidance provides the list of CMS-specified screening instruments available for SNPs to meet the new requirement.

Instruments for Screening for Housing Stability, Food Security, and Access to Transportation

SNPs can meet the new requirement at § 422.101(f)(1)(i) in one of two ways:

1. Use a state-required screening instrument that includes questions on the required domains.

As discussed in the recent CY 2023 MA and Part D Final Rule (87 FR 27734), SNPs can use state- required Medicaid screening instruments that include questions on housing stability, food security, and access to transportation to satisfy the new HRA content requirement in § 422.101(f)(1)(i). By allowing SNPs to use the questions in state-required screening instruments, we aim to prevent duplication of screening efforts. For the purposes of this requirement, SNPs that are required by a state to use a certain screening instrument in the same contract year may use that state-required instrument to meet this requirement. For example, a SNP required by a state to use an assessment instrument in CY 2024 that includes questions on these domains could use that instrument to meet the requirement at § 422.101(f)(1)(i) for CY 2024.

In addition, we recognize that SNPs operating in a particular state that are not subject to state assessment requirements (e.g., chronic condition special needs plans [C-SNPs] and institutional special needs plans [I-SNPs] are not required to have contracts with states) may wish to use an assessment instrument a state requires for dual eligible special needs plans (D-SNPs) to satisfy the requirement at § 422.101(f)(1)(i) if that instrument includes questions in the three required domains. C-SNPs and I-SNPs may use such a state-required assessment instrument to meet this requirement as long as the state requires that instrument for D-SNPs in the same state in the same contract year, as outlined above. For example, a C-SNP operating in a state that requires D-SNPs to use a certain assessment instrument in CY 2025 may use that instrument to meet this requirement in CY 2025 so long as that instrument includes the questions in the three required domains. We also clarify that such SNPs may use questions on the three required domains from a state-required assessment as part of their HRA without using the entire state-required assessment (i.e., adding questions on the three domains to the SNP’s own existing HRA instrument). Finally, we clarify that SNPs may use state-required screening instruments for plans whose service areas include a state that requires a particular state-specific screening instrument. For example, a SNP plan benefit package whose service area encompasses the Kansas City metro area could include counties in both Missouri and Kansas. In this example, if Missouri required a certain state-specific screening instrument

¹ https://www.govinfo.gov/content/pkg/FR-2022-05-09/pdf/2022-09375.pdf

and Kansas did not, the plan may use the Missouri state-required screening instrument for all enrollees in that service area, including those who reside in Kansas.

Through our contractor, the Integrated Care Resource Center, we gathered information from states that currently require screening for social needs in these three areas in their Medicaid programs, including for D-SNPs. States take a variety of approaches to screening for social needs. Some states have established state-specific screening instruments and platforms, some encourage or require use of existing screening instruments such as PRAPARE or the Accountable Health Communities (AHC) instrument, and others require screening for certain domains but don’t require use of specific screening instruments. While many states require or incentivize social needs screening for their Medicaid managed care plans, few require D- SNPs to conduct such screening. As states place increasing emphasis on screening for health-related social needs in their Medicaid programs and as enrollment in SNPs continues to increase, we anticipate that more states may require D-SNPs to conduct social needs screening in the future, including in the three areas where § 422.101(f)(1)(i) requires HRAs to include questions. The option for SNPs to use a state-required assessment instrument to meet this requirement will allow flexibility for states to expand use of state-specific assessment tools to D-SNPs.

While many states that require screening for these three domains are using validated screening instruments, we understand that some state-required screening instruments may be state-specific and not meet the standards described below (e.g. not a validated, health information technology (IT)-encoded instrument). This could create a challenge for data standardization and interoperability. However, we believe the need for flexibility outweighs this potential challenge, at least as SNPs initially implement this requirement. We also encourage states with non-standardized state-specific screening instruments to begin the process of creating health IT coding for their instruments, such as by submitting a terminology request to the Regenstrief Institute, which maintains LOINC^® coding terminology.

2. Select questions on the required domains from validated, health information technology (IT)- encoded screening instruments.

Alternatively, if not using a state-required screening instrument, SNPs may select questions from other validated, health IT-encoded screening instruments. We provide a list in the table below of social needs screening instruments from which SNPs must select questions on the three required domains to meet the requirement at § 422.101(f)(1)(i) if the SNP does not use a state-required screening instrument that includes questions on the required topics (see the table below, Social Needs Screening Instruments).

We aimed to include validated, widely used screening instruments. We also considered the availability of screening instruments, including whether they are proprietary or require a fee. We included a number of screening instruments that are non-proprietary and/or available at no cost. We note that, for those screening instruments that are proprietary, SNPs are responsible for securing the necessary licenses to use the intellectual property of entities that own these instruments and the questions as formulated in them.

In addition, developers of some of the screening instruments included below allow users to make certain adaptations (e.g., translation into other languages). SNPs should consult with the relevant screening instrument developer to determine what adaptations may be acceptable and whether such adaptations require permission from the instrument developer. SNPs may also want to consult with the instrument developer to understand how any adaptations to the instrument questions might affect their validity. We remind SNPs that § 422.2267(a)(2) requires that MA organizations must translate required materials, including HRAs, into any non-English language that is the primary language of at least five percent of the individuals in a plan benefit package service area.

In selecting the screening instruments from which a SNP may select questions to comply with § 422.101(f)(1)(i), we applied the following criteria:²

• Screening instruments that are validated, widely used, and available. CMS determined that the screening instruments the stakeholder-led Gravity Project has identified as appropriate to screen for the each of the three required domains meet this standard. The Gravity Project is a national public collaborative that convenes stakeholders through an open and transparent collaborative process to develop and test consensus-based standards to facilitate social determinants of health (SDOH) data capture.³

• Screening instruments that maximize opportunities for SNPs to collect and analyze standardized, quantifiable, and actionable data. CMS determined that, in order to meet this standard, questions and responses in screening instruments should be mapped to health IT vocabulary standards (i.e., have available LOINC^® coding terminology).

As we described in the CY 2023 MA and Part D Final Rule, we considered the extensive work various stakeholders have already done to research and validate screening instruments in developing the above criteria. The above criteria also align with the data elements established as part of the United States Core Data for Interoperability, Version 2, in which LOINC^® is identified as an applicable vocabulary standard for SDOH assessments.⁴ By identifying validated screening instruments that use available health IT coding terminology as acceptable sources for the questions required by § 422.101(f)(1)(i), we aim to encourage greater standardization of social needs screening data and facilitate interoperable exchange of such data.

The screening instruments in the below table meet the above criteria at the time we are issuing this guidance. However, we recognize that the social needs screening field is evolving quickly, and screening instruments that currently do not meet the criteria we outline above may meet those criteria in the future (e.g., new LOINC^® coding terminology may be created for a screening instrument for which it was previously not available).

Therefore, in addition to the list of screening instruments below, SNPs can use questions on the three required domains from screening instruments included in the Gravity Project’s lists linked below of screening instruments by domain, which can be found in the National Library of Medicine Value Set Authority Center (VSAC).⁵ The Gravity Project compiles these lists to include screening instruments with available LOINC^® coding that its members have identified as appropriate to screen for each domain, and will update them if and when new screening instruments meet these standards. CMS has determined the assessment instruments on these lists meet the criteria described above and are permissible for a SNP to draw from for the required questions on housing stability, food security, and access to transportation.

Please note that VSAC users must create an account and be logged in to access the links below.

• Food Security: VSAC Food Insecurity Screening Assessments

² Furthermore, we note that the table below also incorporates screening instruments included in the specification for the National Committee for Quality Assurance’s (NCQA) Social Need Screening and Intervention” measure in HEDIS Volume 2: Technical Specifications for Health Plans, 705-717.

³ The Gravity Project convenes subject matter experts to evaluate and vote on the validity and appropriateness of available assessment instruments to screen for various domains. For the purposes of this requirement, we have combined Gravity’s three housing-related domains (housing instability, homelessness, and inadequate housing) into one topic (“housing stability”).

⁴ See the final USCDI v2 document: https://www.healthit.gov/isa/sites/isa/files/2021-07/USCDI-Version-2-July- 2021-Final.pdf.

⁵ VSAC is a repository for clinical coding vocabularies that define clinical concepts to support interoperable health information exchange, and is provided by the National Library of Medicine in collaboration with the Office of the National Coordinator for Health Information Technology and CMS.

• Housing Stability: VSAC Homelessness Screening Assessments; VSAC Housing Instability Screening Assessments; VSAC Inadequate Housing Screening Assessments

• Access to Transportation: VSAC Transportation Insecurity Screening Assessments

Currently, the screening instruments included in the VSAC are also listed in the below table. In the future, the VSAC lists may expand to include additional instruments that meet the above criteria and CMS will review the VSAC resources linked above to ensure that questions on the three domains are acceptable under § 422.101(f)(1)(i). SNPs may use questions from assessment instruments currently included in this value set. We remind SNPs that when audit protocols are subject to the Paperwork Reduction Act process, they will have an opportunity to comment before they are finalized.

CMS Post-Acute Care (PAC) Assessment Instruments

In the table below, we include several CMS PAC assessment instruments that include a question on access to transportation that is almost identical to a transportation question included in the PRAPARE assessment instrument, but has a small modification to the response choices. These assessment instruments have been thoroughly tested, have associated LOINC coding to collect standardized data, and are already in use by providers. We are including each of these assessment instruments in the table below to clarify that SNPs may use them to meet the requirement for including one or more questions on access to transportation in their HRAs. More details about the CMS PAC assessment instruments can be found in the CMS Data Element Library.

Additional Considerations

Equity & Accessibility

We encourage SNPs to consider equity issues in selecting screening instruments and questions, including the questions required by § 422.101(f)(1)(i). In particular, we encourage SNPs to consider whether the instrument has been validated for racial and ethnic minority populations that the SNP serves and whether the instrument can be translated into languages that are commonly spoken by the SNP’s enrollees. In addition, SNPs should consider whether they can provide the questions in accessible formats using auxiliary aids and services as required by section 1557 of the Affordable Care Act and implementing regulations at 45 CFR Part 92. These regulations require plans to provide appropriate auxiliary aids and services, including interpreters and information in alternate formats, to individuals with impaired sensory, manual, or speaking skills where necessary to afford such persons an equal opportunity to benefit from the service.

Questions from Multiple Assessment Instruments

SNPs are not required to adopt any of these screening instruments wholesale; rather, SNPs must adopt one or more questions related to each of the required three domains specified in § 422.101(f)(1)(i) in their HRAs. SNPs do not need to select questions on the three required domains from just one assessment instrument. For example, a SNP may choose one question from a particular screening instrument on food security, and a question on housing stability from another screening instrument. This also applies to state- required assessment instruments. For example, if a SNP uses a state-required assessment that includes questions about housing stability and food security, but does not include any questions about access to transportation, the SNP must still include a question on access to transportation in its HRA and therefore must select one or more questions on access to transportation from an assessment instrument specified by CMS in this guidance.

Assessment Instruments with Multiple Questions on the Same Domain

There may be instances where an instrument includes multiple questions in the required domains. For example, an assessment instrument may include a question about housing instability as well as a question

about quality of housing—both of which pertain to the required housing stability domain. If an instrument includes more than one question for a domain and a SNP elects to screen for that domain using that instrument, we recommend and strongly encourage the SNP adopt all of the questions for that domain in their health risk assessment. Validated assessment instruments with multiple questions on the same domain have been validated as a panel of questions and may be less accurate at screening an enrollee for a particular need when only one question from that panel is used. However, a SNP can comply with § 422.101(f)(1)(i) even if the plan does not use the full suite of questions on a domain from a particular screening instrument.

Social Needs Screening Instruments
	Housing Stability	Food Security	Access to Transportation
Accountable Health Communities (AHC) Health- Related Social Needs (HRSN) Screening Tool	X	X	X
American Academy of Family Physicians (AAFP) Social Needs Screening Tool	X	X	X
Health Leads Screening Panel®	X	X	X
Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences [PRAPARE]®	X	X	X
We Care Survey	X	X
WellRx Questionnaire	X	X	X
Hunger Vital Sign™ (HVS)		X
U.S. Household Food Security (SNPs can select questions from the 18-, 10-, or 6-item surveys)		X
Comprehensive Universal Behavior Screen (CUBS)			X
PROMIS®			X
CMS Post-Acute Care (PAC) Assessment Instruments: Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF-PAI) Long-Term Care Hospitals Continuity Assessment Record and Evaluation Data Set (LCDS) Home Health Agencies Outcome and Assessment Information Set (OASIS)			X

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-TBD (Expires XX/XX/XXXX). This is a mandatory information collection. The time required to complete this information collection is estimated to average three hours for each SNP parent organization to update the care management system in order to comply with this information collection, and one quarter of an hour for each SNP to register a username with the National Library of Medicine Value Set Authority Center. If you have comments concerning the accuracy of the time estimate(s) or

suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not submit any documents containing sensitive information to the PRA Reports Clearance Office. If you have questions or concerns regarding where to submit your documents, please contact Michelle Conway at [email protected].

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