Skip to main content

Documentation of Social Need in 2018 Medicaid Data

Father and little daughter cooking pancakes
Analysis of Medicaid T-MSIS data to understand how well recipients’ social needs are documented
  • Funder
    NORC at the University of Chicago
  • Dates
    August 2021 - March 2022


There is limited information on documentation of social need in Medicaid claims and encounter data.

Non-medical factors affect nearly 70 percent of an individual’s health. Those factors include economic stability, food and housing security, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Medicaid enrollees are more likely to experience social risk factors, i.e., adverse social conditions like food insecurity and housing instability, which are associated with poorer health.

Z Codes are a subset of ICD-10-CM diagnosis codes based on factors that influence health status and an individual’s contact with health services and capture an individual’s health-related social needs (Z55 to Z65). However, limited information on documentation of social needs in Medicaid claims and encounter data is available. No studies have assessed the use of Z codes within Medicaid claims and encounter data using the Transformed Medicaid Statistical Information System (T-MSIS).


NORC assessed documentation of social need using Medicaid Transformed Medicaid Statistical Information System (T-MSIS) data.

NORC at the University of Chicago analyzed the extent to which social needs are documented in 2018 Medicaid claims and encounter data. We used 2018 T-MSIS claims (for Medicaid fee-for-service) and encounter (for managed care) data to assess the extent to which nine Z codes, identified by CMS as Z codes related to social determinants of health, were documented. We performed our analyses from September to December 2021. We also conducted an environmental scan of the recent literature to understand how varying state Medicaid policy environments could contribute to documenting social needs in Medicaid data.


Our study developed insights that can inform state programs and policies to improve the documentation of social needs.

Enabling systems-wide data on the social needs of Medicaid enrollees can provide states and the federal government with information that helps them tailor their efforts to improve health equity.

Key insights include: 

  • Documentation of social needs using Z codes was low in 2018; only 1.42 percent of Medicaid enrollees had social needs documented in their claims or encounter data. 
  • States varied in the level of social needs documented in 2018 Medicaid claims data. Documentation was higher for managed care enrollees and in states with active Medicaid accountable care organizations (ACOs) compared with fee-for-service enrollees and states without ACOs. In states with higher shares of documentation in 2018, early adoption of ACOs, all-payer alignment, value-based payment, and care delivery transformation were in place. 
  • States and the federal government should consider implementing strategies to increase provider awareness and use of Z codes; support standardization of social determinants of health measures; and create state policy environments that support identification, documentation, and sharing of social needs data.

Project Leads

Explore NORC Health Projects

Adapting and Implementing a Toolkit to Identify Pneumonia in Patients

Adapting and implementing patient safety practices in ambulatory care


Agency for Healthcare Research and Quality

Addressing Vaccine Hesitancy & Health Disparities Among Rural Farmworkers

Using Migrant and Seasonal Head Start infrastructure to distribute COVID-19 vaccines and document health disparities


W. K. Kellogg Foundation