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How is CMS is Addressing Social Determinants of Health (SDOH) in 2025?

Saquib Mahmud, Vice President of Healthcare Quality at DocGo.

In 2025, the Centers for Medicare & Medicaid Services (CMS) is significantly expanding its focus on Social Determinants of Health (SDOH) to better address non-medical factors influencing patient outcomes. Research shows that up to 80% of health outcomes are affected by factors like housing, food security, transportation, and financial stability, rather than medical care alone.

To address these disparities, CMS is rolling out new screening requirements, reimbursement models, and data-sharing initiatives to help providers systematically identify and respond to patients’ social needs. These policies aim to improve health equity, patient outcomes, and cost efficiency across Medicare and Medicaid programs.

DocGo’s affiliate clinical practice groups align with these CMS-driven changes by integrating SDOH screenings and intervention strategies into their mobile healthcare and remote patient monitoring services. By proactively addressing social barriers to care, we help facilitate access, reduce disparities, and drive better patient outcomes.

1. Expanded SDOH Screening Requirements

CMS is requiring more frequent and standardized screenings across Medicare and Medicaid programs to ensure social risk factors are consistently identified. Healthcare providers must collect data on:
• Housing stability – Ensuring patients have a safe place to live.
• Food insecurity – Identifying whether patients have consistent access to nutritious meals.
• Transportation access – Determining if patients have reliable means to attend medical appointments.
• Financial security – Assessing employment and income stability.

These screenings must be documented in electronic health records (EHRs), using CMS-approved tools such as:
• The CMS Health-Related Social Needs (HRSN) Screening Tool
• Medicaid Managed Care Organization (MCO) SDOH screening requirements
• Accountable Care Organization (ACO) REACH SDOH reporting mandates

By making these screenings a standard part of care, CMS aims to proactively identify and mitigate health disparities before they contribute to worsening medical conditions.

2. Incorporation of SDOH into Risk Adjustment Models

CMS is integrating SDOH data into its risk adjustment models to ensure adequate reimbursement for providers serving socially at-risk populations. Historically, risk adjustment focused on clinical conditions, but in 2025, CMS will factor in social risk data when determining funding for Medicare Advantage and Medicaid.

Key changes include:
• Increased reimbursement for providers caring for high-SDOH-risk patients.
• Expanded use of Z-codes to document social risk factors and link them to reimbursement.
• New CMS methodologies that adjust payments based on social determinants such as housing and food insecurity.

These adjustments ensure that healthcare organizations are properly funded to care for populations facing significant social challenges.

3. Enhanced Reimbursement for SDOH Interventions

To encourage proactive SDOH screenings and interventions, CMS is introducing new billing codes that compensate providers for addressing social risk factors. These changes reinforce the link between social care and improved patient outcomes.

Updates include:
• New CPT codes for SDOH screenings and care coordination services.
• Expanded Medicaid reimbursement for services such as housing support and food assistance referrals.
• Financial incentives for providers that integrate SDOH interventions into routine care.

These policies make it financially sustainable for healthcare providers to incorporate social care into their patient management strategies.

4. Strengthening Health Equity Measures

As part of its broader Health Equity Framework, CMS is incorporating mandatory SDOH data collection and reporting into its Medicare and Medicaid programs. The goal is to identify disparities and hold health plans accountable for closing care gaps.

Key initiatives include:
• Mandatory SDOH reporting for hospitals, health plans, and Medicaid MCOs.
• CMS audits of health plans’ efforts to address inequities in high-risk populations.
• New Medicaid Health Equity Index (HEI) requirements to measure and track social disparities in care.

These measures push healthcare organizations to actively address systemic inequalities, rather than just document them.

5. Development of Interoperable Data Systems for SDOH

To improve coordination between healthcare providers and social services, CMS is investing in interoperable data-sharing platforms that allow organizations to securely exchange SDOH-related patient information.

These systems aim to:
• Enable real-time referrals to social services such as food banks, housing agencies, and transportation programs.
• Improve coordination across care teams by linking medical and social care data.
• Ensure better tracking of patient outcomes based on social interventions.

By creating a more connected ecosystem, CMS is ensuring that patients receive holistic care that extends beyond the clinical setting.

6. Pilot Programs and Funding for SDOH Initiatives

To refine best practices for integrating SDOH into healthcare, CMS is launching pilot programs and expanding funding for community-based interventions.

This includes:
• Grants for health systems implementing SDOH-focused models of care.
• Funding for programs that test innovative ways to address social barriers to health.
• Expansion of the Accountable Health Communities (AHC) Model to evaluate SDOH interventions in real-world settings.

By funding evidence-based approaches, CMS is ensuring that SDOH integration remains a long-term priority rather than a short-term initiative.

How DocGo is Aligning with CMS’s SDOH Strategy

As CMS takes major steps to incorporate SDOH into healthcare policy, organizations must adapt to these changes to remain compliant and improve patient care.

DocGo’s affiliate clinical practice groups are actively aligning with CMS’s SDOH-driven policies by:

Implementing CMS-approved SDOH screenings into patient care workflows.

Our teams integrate standardized screening tools, such as PRAPARE, into clinical assessments to identify social risk factors early. This data informs care plans, ensuring timely interventions for food insecurity, housing instability, and transportation barriers, in line with CMS’s emphasis on addressing social determinants within value-based care models.

Leveraging mobile healthcare and remote monitoring to reach patients facing social barriers to care.

By deploying mobile medical units and utilizing remote patient monitoring (RPM), we extend care beyond traditional settings, meeting patients where they are. This proactive approach aligns with CMS’s push for expanded access, particularly for rural and high-risk populations, reducing hospitalizations and enhancing continuity of care.

Using data-driven insights to improve outcomes for underserved communities.

Our data analytics capabilities allow us to track health trends and measure the impact of interventions on patient outcomes. By leveraging predictive analytics and real-time reporting, we tailor care strategies to high-risk populations, supporting CMS’s goals for equitable, outcome-driven healthcare.

By addressing social and medical factors together, we ensure that the care we facilitate is not just healthcare, but whole-person care that supports long-term well-being.