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NYS FAM Research
Resource Guide

How Medicaid Delivery System Reform Can Support Care Integration for Populations with Complex Needs | Playbook

This article discusses how Medicaid accountable care organizations (ACOs) can support better care integration among those with complex needs, providing coordinated, continuous, and inclusive care, addressing behavior and social service needs. Suggesting policy strategy to break barriers of fragmented care and reach a goal of delivery system reform, advancing health equity.

Brykman, K. (2025, March 11). How Medicaid Delivery System Reform Can Support Care Integration for Populations with Complex Needs. Center for Health Care Strategies. https://bettercareplaybook.org/how-medicaid-delivery-system-reform-can-support-care-integration-for-populations-with-complex-needs/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program | Health Care Economics, Insurance, Payment | JAMA | JAMA Network

This investigation evaluates how health-related social needs are drivers of worse health and high health care spending, and the effectiveness of the North Carolina Medicaid's 1115 Waiver pilot program in addressing these needs.

Berkowitz, S.A., Archibald, J., Yu, Z., et al. (2025). Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program. JAMA. 333(12):1041–1050. doi:10.1001/jama.2025.1042

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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Medicaid is the New Tool to Expand Healthy Food Access

This article discusses the use of pilot programs in various states that expand healthy food and housing access through the state's Medicaid 1115 Waiver, and how it can connect patients to longer-term options if their coverage is disrupted.

Held, L. (2022, December 15). Medicaid Is a New Tool to Expand Healthy Food Access. Civil Eats. https://civileats.com/2022/12/15/medicaid-is-a-new-tool-to-expand-healthy-food-access/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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Addressing Health-Related Social Needs in Section 1115 Demonstrations (CMS)

This document addressing how Medicaid and the flexible use of the 1115 Waiver will allow for better coverage to meet the unmet health needs of individuals. This expands coverage in certain states that addressing health-related social needs (HSRN) that are resultant of a persons social determinants of health (SDOH) and account for approximately 50% of health outcomes.

Centers for Medicare & Medicaid Services. (2022, December 6). Addressing Health-Related Social Needs in Section 1115 Demonstrations. https://www.medicaid.gov/medicaid/downloads/addrss-hlth-soc-needs-1115-demo-all-st-call-12062022.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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About Section 1115 Demonstrations

This page of the government site explains how current state 1115 demonstrations may be handled when up for renewal, as well as the anticipated handling of future proposals by the authority of the Secretary of Health and Human Services.

Medicaid.gov. (n.d.). About Section 1115 Demonstrations. Centers for Medicare &Medicaid Services. https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

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CHLPI Letter to CMS - Implementation Survey and Recommendations

This letter is asking the CMS administrator of Maryland to consider support post-PHE Medicaid changes through guidance on 1115 demonstrations to include medically-tailored meals, and produce prescriptions in addressing food insecurity after SNAP benefits have been canceled for recipients.

Center for Health Law and Policy Innovation. (2023, April 24).
Food is Medicine Section 1115 Demonstrations – Implementation Survey and
Recommendations. Harvard Law School, Food is Medicine Coalition. https://www.healthlawlab.org/wp-content/uploads/2023/04/Letter-to-CMS-re-1115-Waiver-Survey-2023.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2023

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Section 1115 Waiver Watch: Approvals to Address Health-Related Social Needs 

This issue brief identifies states with approved and pending Medicaid 1115 waivers with SDOH-related provisions and summarizes approvals under the new Biden administration HRSN 1115 framework, highlighting approved services, target populations, and key requirements related to financing HRSN services.

Hinton, E. & Diana, A. (2024, March 4). Section 1115 Medicaid Waiver Watch: A Closer Look at Recent Approvals to Address Health-Related Social Needs (HRSN). KFF. https://www.kff.org/medicaid/section-1115-medicaid-waiver-watch-a-closer-look-at-recent-approvals-to-address-health-related-social-needs-hrsn/

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2024

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$2.3M in Grant Funding Available for Faith-Based and Not-for-Profit Organizations to Improve Public Access to Essential Technologies | NYS Department of State

This article by the New York State Department of State announces a 2.3 million dollar grant available to faith-based and nonprofit organizations meant to improve public access to essential technologies. "Interested organizations can apply for this grant funding to turn available spaces into community resource rooms where community members can use computers, Wi-Fi, audio/video equipment and other technologies for a variety of health, education, career and social services. The grants will allow these organizations to further break down barriers for people in need of technology services including telehealth appointments, career advance services, remote educational opportunities, social services applications and other computer service needs."

New York State. (2024, November 22). NYS Office of Faith and Nonprofit Development Services Announces $2.3M in Grant Funding Available for Faith-Based and Not-for-Profit Organizations to Improve Public Access to Essential Technologies. Department of State. https://dos.ny.gov/news/nys-office-faith-and-nonprofit-development-services-announces-23m-grant-funding-available

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2024

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Approval of Colorado's Request to Include Nutrition Services in 1115 Waiver

This document outlines the authority given by The Centers for Medicare & Medicaid Services (CMS) to the state of Colorado in expanding targeted services, within the limitations of the 1115 Waiver, to certain incarcerated individuals for up to 90 days immediately prior to the individual’s expected date of release. This amendment will introduce new initiatives that increase and improve health access and equity.

Department of Health and Human Services. (2025, January 13). Letter addressed to: Medicaid Director Adela Flores-Brennan. CMS. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/co-continuum-care-appvl-01132025.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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Contracting Strategies: Community Based Organizations Value Based Payment (VBP) Guidance Document

This document covers potential contracting strategies CBOs may consider, and provides details on how CBOs are uniquely positioned to address social determinants of health (SDH).

New York State Department of Health (NYS DOH). (2017, September). Contracting Strategies: Community Based Organizations -Value Based Payment (VBP) Guidance Document. https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_u/docs/contracting_strategies-cbo.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2017

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General Instructions for CBOs enrolling in the NYS Medicaid program 

Provider enrollment and maintenance, information on applying for INITIAL ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or responding to a letter instructing you to REVALIDATE your enrollment, or Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or Reporting an OWNERSHIP CHANGE

eMedNY. (2025). Provider Enrollment, Community Based Organizations (CBOs). NYS DOH. https://itf.www.emedny.org/info/ProviderEnrollment/cbo/index.aspx

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2025

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Value Based Payment and Community Based Organizations - Training for Contracting Scenarios

This presentation gives guidelines on SDH intervention selection. VBP contractors in a Level 2 or 3 arrangement must implement at least one social determinant of health intervention. Language fulfilling this standard must be included in the MCO contract submission to count as an “on-menu” VBP arrangement. SDH interventions must align with five key areas: Education, Social, family, and community context, Health and healthcare, Neighborhood and environment, and Economic stability.

Engel, E. & Ahadzi, M. (2018, July). Value Based Payment and Community Based Organizations. New York State Department of Health, Office of Health Insurance Programs. [PowerPoint slides]. https://www.health.ny.gov/health_care/medicaid/redesign/sdh/docs/2018-07-11_vbp_cbo.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2018

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Standard Clauses for Managed Care Provider/IPA/ACO Contracts  

This document provides definitions and outlines standard clauses pertaining to the agreement for Managed Care Providers/IPA/ACO contracts.

New York State Department of Health. (Revised: 2017, April 1). New York State Department of Health: Standard Clauses for Managed Care Provider/IPA/ACO Contracts. https://www.health.ny.gov/health_care/managed_care/hmoipa/docs/standard_clauses_revisions.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2017

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Improving Health And Well-Being Through Community Care Hubs

This article discusses the issues around a continuity of care and how Hubs can be used to deliver a sustainable operating infrastructure, providing better aligned health and social care systems. Hubs support a network of CBOs and are considered the backbone organizations that allow multistakeholder collaborations to address SDOH and provide equitable social care.

Chappel, A., Cronin, K., Kulinski, K. et al. (2022, November 29). Improving Health And Well-Being Through Community Care Hubs. Health Affairs. DOI: 10.1377/forefront.20221123.577877

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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New York’s 1115 amendment proposal - Regional Social Determinant of Health Networks (SDHNs) (p. 9)

In this document New York State (NYS or the State) requests $13.52 billion over five (5) years to fund a new amendment to its 1115 Waiver Demonstration that addresses the inextricably linked health disparities and systemic health care delivery issues that have been both highlighted and intensified by the COVID-19 pandemic. This1115 Waiver amendment proposes to utilize an array of multi-faceted and linked initiatives to change the way the Medicaid program integrates and pays for social care and health care in NYS. It also lays the groundwork for reducing long standing racial, disability-related, and socioeconomic health disparities; increase health equity through measurable improvement of clinical quality and outcomes; and keep overall Medicaid program expenditures budget neutral to the federal government.

New York State Department of Health. (2022). New York State Medicaid Redesign Team (MRT) Waiver, Strategic Health Equity Reform Payment Arrangements: Making Targeted, Evidence-Based Investments to Address the Health Disparities Exacerbated by the COVID-19 Pandemic. NYS DOH, Office of Health Insurance Programs. https://www.health.ny.gov/health_care/medicaid/redesign/2022/docs/2022-04_1115_waiver_draft_amendment.pdf

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Addressing Health-Related Social Needs: Information, Guidance, and Lessons Learned

2022

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