top of page

2023 Cohort: Social Determinants of Health

Medicaid Innovation Collaborative's second cohort seeks to identify scalable solutions to close gaps in social needs for Medicaid beneficiaries in Iowa, Kentucky, Nevada, and New York.  



The Medicaid Innovation Collaborative (MIC) aims to improve the health and wellbeing of individuals on Medicaid by connecting the ecosystem to tech-enabled innovations. The 2023 cohort enables state Medicaid programs, their managed care plans, and other key stakeholders to identify and implement solutions to address the health related social needs of Medicaid beneficiaries. Those selected from the Application Review process will have the opportunity to pitch their solution directly to Medicaid directors, managed care plans, community members, and other stakeholders for potential contract opportunities.

About the 2023 Social Determinants of Health Focus 

Innovative strategies and solutions are needed to successfully address the health-related social needs of Medicaid beneficiaries. As disparities have remained unchanged over decades, solutions must overcome the social, economic, and environmental disadvantages outlined in the research, with the goal of equitable access and outcomes. 


Addressing social needs is important for improving health and reducing longstanding inequity in health and health care. The participating MIC states prioritized addressing the challenges associated with social determinants of health. Informed by in-depth research with Medicaid beneficiaries, the MIC process aims to identify and showcase innovative solutions that can demonstrate a positive impact in addressing at least one of the social needs outlined in the Areas of Focus below.

Research Insights

Addressing health-related social needs in Iowa, Kentucky, and New York requires multiple strategies and approaches to address the variety of challenges faced by Medicaid beneficiaries. In partnership with the three 2023 cohort states, MIC conducted research with Medicaid beneficiaries to inform this process. These insights uncovered that individuals on Medicaid typically have multiple, interrelated social needs, which are risk factors for poor health outcomes. More detail on insights from our research can be found in the report linked below.

Areas of Focus

This application had six opportunity areas for organizations to choose from in their response to how their solutions would address health-related social needs. Solutions were expected to focus on one or more aspects of the social needs challenges within this opportunity. We welcomed applications from companies or nonprofit organizations with scalable tech-enabled solutions.

Food Assistance

Food and Nutrition Security

Current Challenges

Many individuals do not have enough food each month and must make the tough choice between buying groceries and other living expenses. Even when they do have enough, families often struggle with getting the “right” food on the table. It is often difficult to access the kinds of healthy foods they would want. While SNAP and WIC provide essential assistance, there is often a stigma associated with accessing these programs, or food supplies are not always enough to meet the full need.

Innovation Opportunities

Solutions should provide individuals and families with supplemental food, including flexibility in how and when users can access foods. Solutions should also increase access to healthy food options, including vegetables and fruits as well as a greater variety of foods. Solutions may incorporate nutritional education, recipes, and/or cooking lessons as part of their offering. A best-fit solution would provide people with options for both pre-made meals and healthy ingredients that they can use to prepare meals themselves, including medically-tailored meals or ingredients. It would also be connected with or integrated into local settings (grocery stores, food pantries) and provide culturally-appropriate options based on user-indicated preferences.

Current Challenges

Individuals and families are concerned with the rising cost of living, and surging rent prices are a major stressor when it comes to their overall financial security. Limited affordable housing options are extremely challenging in both urban and rural settings. Many individuals do not feel completely stable in their current housing situations and worry their circumstances could change at any moment. People struggle with navigating governmental housing assistance and other programs to support safe and affordable housing. Additionally, even those in stable situations have concerns about the quality of their housing or keeping utilities paid. They could use assistance with seasonal preparations, pest control, facility repairs, and improvements where landlords fall short.

Innovation Opportunities

Solutions should provide individuals and families with assistance to navigate programs for affordable housing and supportive services. Solutions could support households in paying utilities and security deposits, weatherizing their homes, or ensuring housing is safe and accessible with a focus on home improvements.

Apartment Building_edited.jpg

Housing Affordability and Quality

black train_edited.jpg

Transportation Services

Current Challenges

Many individuals and families struggle with reliable transportation options, as they either do not have a vehicle or permit or their cars are older and need costly maintenance and repairs. Individuals often share a car with family members or friends, which can be challenging to coordinate. This can be even more challenging for people in rural communities who do not have access to reliable and timely public transportation. Without reliable transportation, individuals struggle with getting to work, health care appointments, or other important activities.

Innovation Opportunities

Solutions should provide individuals and families with the flexibility to schedule rides or shuttles to help them get to and from their work, school, or health-related appointments. Solutions could offset costs of ridesharing options or provide subsidies for gas or bus fare. Solutions should work in both rural and urban settings.

Business Owner in Workshop_edited.jpg

Economic Stability through Education and Employment

Current Challenges

Access to and support for consistent income is core to addressing many of the social needs experienced by Medicaid beneficiaries. For those able to work, people want access to jobs that allow them to support themselves and their families; they desire to be self-sufficient without requiring assistance for things like food, transportation, or housing. Many people are currently participating in the gig economy or seasonal jobs, which are not providing them with stability, and many supplement their incomes with cash-paying side jobs. Being un- or underemployed and unable to navigate finding high quality jobs to support themselves and their families can foster a sense of shame. Some would like the opportunity to learn new skills or professions but are not sure where to find the tools or financial resources to get started.

Innovation Opportunities

Solutions should help individuals navigate resources for educational or employment assistance. These solutions could help them identify job opportunities appropriate to their training and experience or support them in strengthening their resumes and interviewing skills. Solutions could support people in accessing training and education to transition into better paying jobs that strengthen their financial stability long term. Solutions could also help individuals navigate the benefits cliff associated with increasing household income, which is a concern for many.


Navigating and Coordinating Care, Resources, and Services

Current Challenges

Too often, individuals and families do not know what services are available to them nor how to access those services. Medicaid enrollees have difficulty understanding the complexities of eligibility for services, coverage through health insurance, or knowing how to access particular providers or services in a timely manner. Furthermore, individuals aren’t comfortable discussing their social needs with just anyone. While there isn’t a big difference in preferences around the type of role (e.g., physician) they share with, what is important is that they have a trusted relationship with the person asking questions, that they are approached with empathy, and that they have context as to why they are being engaged on social needs.  Individuals are also more comfortable when they perceive the person or organization as having expertise in the subject matter.

Innovation Opportunities

Solutions should be able to create a unified way for individuals to find out what resources and services are available to them and what they are eligible to access. Solutions should provide up-to-date resources and the ability to get answers to questions about how to access local services to address their social needs. Solutions should help people navigate to high quality services and may take advantage of support from community health workers or navigators. Solutions should improve access to culturally-competent care, bridge the digital divide, and build trust in the community. Solutions which include social needs screening should employ strategies to build trust with users, considering a balance of empathy and expertise. Best-fit solutions would offer a one-stop-shop for enrollees to be screened for eligibility, understand options, and streamline benefit applications.


Infrastructure and Data Tools for Providers, Plans, and States for Social Determinants of Health Management

Current Challenges

For many state Medicaid programs and their managed care plans, it can be difficult to understand the extent of health-related social needs for Medicaid enrollees in their state. This makes it difficult to plan resources, create appropriate policies and programs, and support members to get their needs met. There is a great deal of infrastructure needed to assess and identify health-related social needs at an individual and aggregate level, connect people to the appropriate resources to address their needs, and ensure care teams have the information needed to address these needs,both in health systems and in community and governmental organizations.

Innovation Opportunities

Solutions should help state Medicaid programs and managed care plans build the data systems and tools to be able to identify and track social needs at an individual and population level, analyze the data as needed for care provision and strategy, ensure care teams have the information to enable members receive services across the continuum of care, including within the community, and to enable different entities to easily exchange information to increase coordination and integration of services.

Participating States and Health Plans

The following three states and their managed care plans partnered with Medicaid Innovation Collaborative in this effort.

Image by National Cancer Institute
The New York State Medicaid Department is excited to be partnering with the Medicaid Innovation Collaborative to help us identify innovative solutions to improve the social drivers of health and address health equity. We believe it is essential to address social determinants of health in order to address the health needs of New Yorkers and believe there is an important role innovation will play in meeting these needs.
Amir Bassiri

Medicaid Director, Office of Health Insurance Programs

New York State Department of Health

bottom of page