For a few years, 1115 waivers became the main way states covered housing and food. Then the federal framework was rescinded. This lesson tells that story accurately.
The expenditure authority in Section 1115 lets a state pay for things Medicaid does not normally cover. For a few years, states used it for something new: health-related social needs (HRSN), unmet conditions like housing instability and food insecurity that drive medical cost. This lesson is a case study in why verifying current policy matters, because the federal posture changed sharply.
What the 2023 framework did
In November 2023, CMS released an HRSN framework and informational bulletin that standardized how states could cover social needs through 1115 demonstrations. It set concrete limits:
- Up to six months of transitional housing supports (including rent) for eligible enrollees.
- Up to six months of nutrition services, such as medically tailored meals or food boxes, renewable if eligibility continued.
- Guardrails: expenditure limits, monitoring and evaluation, and non-supplantation rules so new HRSN spending would not replace existing services.
Target populations included people who were homeless or at risk of it, people with serious mental illness or substance use disorder, high-risk pregnant people, and people in high-risk care transitions. Roughly 18 states received approvals to address HRSN.
What changed
On March 4, 2025, CMS rescinded the November 2023 framework and related bulletins. Going forward, CMS said it would evaluate HRSN applications case by case, without reference to the rescinded framework. The rescission did not, by its terms, terminate the waivers already approved; those state demonstrations continued to operate.
Worth remembering: as of this writing, there is no standing federal framework encouraging HRSN coverage. States with approvals still run their programs; states seeking new ones face case-by-case review with no guaranteed pathway. Anyone working in this area has to check the current federal stance, not a framework that no longer governs.
Why it still matters
The mechanism proved that Medicaid can pay for housing and food as health services, and the states that built these programs did not unbuild them. Module 5 examines HRSN as a delivery challenge in its own right. The policy vehicle, though, is a moving target, which is exactly the lesson.
Key takeaways
- 1115 expenditure authority let states cover housing and nutrition supports as HRSN benefits.
- A 2023 CMS framework standardized this (six-month housing and nutrition limits, with guardrails); about 18 states were approved.
- CMS rescinded the framework in March 2025 and now reviews requests case by case; existing approvals were not terminated. Always verify the current federal stance.
Sources
Check your understanding
What is the current federal status of the 2023 CMS framework for covering health-related social needs through 1115 waivers?
The November 2023 framework and related bulletins were rescinded on March 4, 2025. New HRSN requests are now judged case by case, while the roughly 18 existing state approvals were not canceled by the rescission.