As Congress considers Medicaid work requirements as part of the budget resolution process, and more than a dozen states weigh waiver applications, providers are concerned about the financial implications of suspended or lost coverage.
Proactive providers should also be asking themselves:
- How can we go beyond modeling theoretical financial impacts?
- What role can we as providers play in addressing shared goals?
- Does this impact the communities we operate in, and how can I support these communities?
The most proactive providers may see that public-provider partnerships addressing health-related social needs (HRSN) will be increasingly critical to align with legislative goals addressing long-term poverty, while also focusing on improving the integrity of the programs through reduction in fraud, waste and abuse.
In recent years, federal guidance has encouraged integrating HRSN services, including food, housing, transportation, and childcare, into Medicaid via managed-care flexibilities and Section 1115 waivers.
Programs like Tennessee’s Health Starts’ use of provider partnerships demonstrate how providers screen and refer members for social support, improving outcomes and reducing hospital admissions.
In Arkansas, the pending Pathway to Prosperity waiver reframes work requirements as personal development supports, using data-matching and cross-agency coordination rather than punitive disenrollments
This blog explores recommendations for providers to align HRSN interventions with emerging work-oriented Medicaid policies. For support on accessing and implementing these efforts, HORNE is here.
Understanding HRSN and Medicaid Work Requirements
Many Medicaid beneficiaries face barriers – unstable housing, food insecurity, lack of childcare – that undermine health and limit work readiness.
CMS has expanded states’ flexibility to address these HRSN through managed-care contracts and demonstration waivers, encouraging partnerships with social services and housing agencies.
Meanwhile, momentum for Medicaid work requirements has re-emerged in several states, aiming to transition able-bodied adults from dependence to economic independence.
However, studies have found that 92% of Medicaid recipients already work, study, or care for family, underscoring the need to tackle underlying social barriers in addition to eligibility maintenance incentives (1).
Types of Provider–State Agency Partnerships that Address HRSN
Screening & Referral at the Point of Care
Providers embed standardized HRSN screening tools into clinical workflows, such as electronic health record prompts, to identify food, housing, and transportation needs during patient visits. Once risks are flagged, care teams immediately refer patients to community-based organizations (CBOs) or social service agencies, often via closed-loop referral platforms that confirm service delivery and related beneficiary compliance.
This approach, used in CMS’s Accountable Health Communities Model, has demonstrated improved patient satisfaction and reduced avoidable hospital utilization when resources are available.
https://www.cms.gov/priorities/innovation/innovation-models/ahcm
Case Management and Success Coaching
Under this model, providers partner with state agencies to assign dedicated case managers or success coaches who work one-on-one with beneficiaries to navigate clinical and social services. These professionals develop individualized care plans, set actionable goals—like securing stable housing or enrolling in job training—and monitor progress and compliance over time.
By combining motivational coaching with direct linkage to state-funded programs, this partnership ensures that work requirement mandates become supportive “carrots” rather than punitive “sticks.”
Data-Sharing and Cross-Sector Information Systems
State Medicaid agencies can establish secure data-sharing agreements that link Medicaid enrollment and claims data with SNAP, TANF, and housing assistance databases.
Providers access real-time dashboards to identify members who have unmet needs across programs, enabling proactive outreach before health crises arise. These interoperable systems can also support the measurement of outcomes, allowing all partners to track reductions or increases in food insecurity, housing instability, and health care utilization.
Co-Location of Services and Community Resource Hubs
Some states fund community resource hubs within provider sites – like clinics or managed care plan offices – where beneficiaries can meet with social workers, housing navigators, or workforce program staff in a single location. This “one-stop shop” model reduces transportation barriers and promotes warm hand-offs between medical and social service teams.
By situating services under one roof, states and providers foster stronger interagency relationships and more seamless care experiences for participants.
Case Study: Arkansas Pathway to Prosperity
Waiver Overview
In January 2025, Arkansas DHS filed a Section 1115 amendment to its ARHOME expansion waiver, titled “Pathway to Prosperity,” covering ~220,000 adults 19–64 at ≤138% FPL.
Carrot Over Stick
- According to DHS Secretary Kristi Putnam, the waiver is not intended as a penalty. It is about purpose—moving healthy adults from government dependence to financial independence, all while improving their health during the process. Arkansas Advocate.
- Rather than permanent lock-outs, beneficiaries can regain full benefits by notifying DHS of their intent to comply and engaging in work, schooling, or community service Arkansas Advocate.
HRSN Integration Opportunities
The waiver’s data-matching could be extended to SNAP, TANF, and housing databases – triggering provider outreach for food supports, childcare referrals, or transportation vouchers.
Providers could contract with DHS to offer on-site HRSN screenings and personal development coaching, ensuring that social needs barriers to meeting work requirements are addressed proactively.
Aligning Work Requirements with HRSN Solutions
- Embed Social Needs Screening in Work Plans
Incorporate HRSN assessments into beneficiaries’ personal development plans, linking them to community services before imposing suspension. - Leverage Provider Networks
Use existing primary care and behavioral health providers as touchpoints for ongoing case management, referrals, and progress tracking. - Secure Sustainable Funding
Partner with state agencies to include HRSN services in Managed-Care Organization capitation rates or carve-out payment pools under Section 1115. - Measure Impact
Track KPIs such as reduction in food-insecurity rates, stable housing placements, and employment retention to demonstrate ROI and advocate for program continuation.
Arkansas’s Pathway to Prosperity offers a blueprint: a supportive, data-driven model that centers on people’s needs first. Providers can engage in waiver design, pilot HRSN-informed service bundles, and advocate for funding structures that sustain these life-changing collaborations.
As Medicaid work requirements advance, providers have a pivotal role in ensuring these policies lift – rather than punish – the vulnerable. By forming robust partnerships with state agencies, embedding HRSN interventions into personal development plans, and leveraging waiver flexibilities, we can transform work requirements into a true pathway out of poverty
Ready to Take the Next Step?
HORNE is here to help you transform uncertainty into opportunity – let’s start the conversation today.
