CMS Pub. 100-16, ch. mc86c16b, § 90.2

Access to Transportation

(Rev. 129; Issued: 08-11-23; Effective: 01-01-24; Implementation: 01-01-24)

SNPs can meet the requirement at 42 CFR 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 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 HRA content requirement in 42 CFR

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 42 CFR

422.101(f)(1)(i) for CY 2024.

In addition, CMS recognizes 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 42 CFR 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 state-specified instrument to meet the 42 CFR 422.101(f)(1)(i)

requirement to include questions in the specified domains in CY 2025 so long as that

instrument includes the questions in the three required domains. Such SNPs may use

questions on the three required domains from a state-required assessment as part of their

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

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, 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 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.

While many states that require screening for these three domains are using validated

screening instruments, 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, CMS believes the need for flexibility outweighs this potential

challenge but may revisit this position in the future. We encourage SNPs to reach out to the

states in which they operate with any questions about state-specific screening requirements.

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. Table 7 in section 90.1.2

specifies CMS’s list of social needs screening instruments from which SNPs must select

questions on the three required domains to meet the requirement at 42 CFR 422.101(f)(1)(i)

if the SNP does not use a state-required screening instrument that includes questions on the

required topics (see Table 7 below).

CMS aimed to include validated, widely used screening instruments and considered the

availability of screening instruments, including whether they are proprietary or require a fee.

The list in Table 7 includes a number of screening instruments that are non-proprietary

and/or available at no cost. 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, use of the questions from a specific screening instrument specified by CMS must

be consistent with the instructions for the screening instrument for the SNP’s use of the

question(s) on housing, food security, and access to transportation to satisfy the SNP’s

obligations under 42 CFR 422.101(f)(1)(i). CMS’s review of the questions on the screening

instruments specified in Table 7 has taken into account instructions and permissible

variations. Therefore, when the developer of a screening instrument allows users to make

certain adaptations (e.g., translation into other languages), SNPs should make changes

consistent with the screening instrument’s specifications or 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. 42 CFR 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 addition, beginning for 2024, fully integrated and highly

integrated D-SNPs (and applicable integrated plans as defined in 42 CFR 422.561) must

translate required materials into the language(s) required by the Medicaid translation

standard specified in the capitated Medicaid managed care contract held by the D-SNP or its

affiliated Medicaid managed care plan.

In selecting the screening instruments from which a SNP may select questions to comply

with 42 CFR 422.101(f)(1)(i), CMS applied the following criteria:11

• 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.12

• 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 described in the CY 2023 MA and Part D Final Rule, CMS considered the extensive work

various stakeholders have already done to research and validate screening instruments in

developing the above criteria. The above criteria 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.13 By identifying

validated screening instruments that use available health IT coding terminology as acceptable

sources for the questions required by 42 CFR 422.101(f)(1)(i), CMS aims to encourage

greater standardization of social needs screening data and facilitate interoperable exchange of

such data.

The screening instruments in Table 7 meet the above criteria at the time CMS updated this

11 Furthermore, Table 7 in section 90.1.2 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.

12 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”).

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

2021-Final.pdf.

section. However, the social needs screening field is evolving quickly, and screening

instruments that currently do not meet the criteria outlined 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 specified in Table 7, 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).14 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

• 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 Table 7. In the

future, the VSAC lists may expand to include additional instruments that meet the above

criteria. CMS will review the VSAC resources linked above to ensure that questions on the

three domains are acceptable under 42 CFR 422.101(f)(1)(i). SNPs may use questions from

assessment instruments included in this value set as of July 2023.

CMS Post-Acute Care (PAC) Assessment Instruments

Table 7 includes several CMS PAC assessment instruments that include a question on access

to transportation that is almost identical to a transportation question included in the Protocol

for Responding to and Assessing Patients’ Assets, Risks, and Experiences (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. 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.