States can leverage a variety of Medicaid authorities, including through their state plans, waivers, and managed care arrangements, to cover housing-related services for Medicaid beneficiaries.[1] States considering creating or amending covered housing-related services can draw from numerous approaches. This crosswalk provides an overview of 18 states’ supportive housing programs under Medicaid, including the Medicaid authority/mechanisms used, the target population(s), in-depth information on included services and service descriptions, and reimbursement approaches for each covered service.
Crosswalk: Service Definitions and Reimbursement Approaches for Housing-Related Services Under Medicaid
Below is a brief summary of state approaches covered in the crosswalk. Contact Elaine Chhean (echhean@nashp.org) for questions about this resource.
Target Populations
Most Medicaid programs that address housing-related needs target populations with a combination of health and social conditions or circumstances. Each state defines its target population(s) and more specific eligibility requirements differently, but typical elements are summarized in Table 1. Most commonly, states prioritize individuals with disabilities (often behavioral health and/or complex health conditions) who are transitioning from institutional settings and/or experiencing or at risk of homelessness.
Table 1. Common Target Populations for Medicaid Programs Addressing Housing-Related Needs |
A combination of health and social conditions or circumstances. Target health conditions and circumstances
Target social circumstances
|
Services
The 18 states reviewed include a large variety of housing-related and other health-related social needs services within their programs. Each state designed their service benefit and descriptions differently, but commonly included services are summarized in Table 2. While some states (DC, Hawaii, Louisiana, Minnesota, and Rhode Island) focused on pre-tenancy and tenancy sustaining services (see Box 1 for an overview of the most common service description), others (Arkansas, California, Michigan, North Carolina, North Dakota, and Texas) implemented programs that addressed a suite of health-related social needs.
Table 2. Services Included in Medicaid Programs Addressing Housing-Related Needs |
Housing-related
|
Other social needs-related services
|
Wrap-around supports
|
Other services
|
Box 1. Summary of State Medicaid Service Descriptions for Pre-tenancy and Tenancy Sustaining Services in Medicaid
Pre-tenancy services
- Screening and assessment
- Housing application process
- Housing search
- Ensuring units are safe and ready for move-in
- Arranging and supporting move-in
Tenancy sustaining services
- Early identification and intervention for risks to housing status
- Education and training on roles, rights, and responsibility of tenant and landlord
- Coaching on developing and maintaining key relationships, assistance with resolving disputes
- Assistance with and training on independent living skills
- Care management, coordination, and referrals
Reimbursement Approach
There are a variety of reimbursement approaches that Medicaid programs use for housing-support services such as pre-tenancy and tenancy sustaining services. See Table 3 for a summary of the reimbursement approach for the 12 states that had publicly accessible information available. For the pre-tenancy and tenancy support services, per member per month (PMPM) approaches and 15-minute payment increments were the two most common approaches, followed by a daily rate. All of the states used case rates for pre-tenancy and tenancy sustaining services — meaning several services/components are included within the rate. The reimbursement approaches for home modifications, one-time transitional housing costs, and housing deposits are typically payments per item with a set annual or lifetime limit. Two states (Arkansas and Connecticut) include incentives or performance payments to reward providers for meeting certain goals and outcomes.
Table 3. State Medicaid Reimbursement Approaches for Pre-tenancy and Tenancy Support Services | |||
| Reimbursement approach | 1115 Demonstration | 1915(i) | State Plan |
| Per member per month | CA, HI, NC, RI | DC | – |
| 15-minute increment | – | CT, MN, ND | GA, LA[2] |
| Daily | MA,[3] WA[3] | – | – |
| Incentive/performance payments | AR | CT | – |
The associated chart provides specific reimbursement approaches, procedure codes, and payment rates where available, in addition to the service definitions associated with each. This information is particularly helpful for states considering how to design their reimbursement approach. States make decisions about their reimbursement approach based on a variety of factors, including administrative simplicity, ease of budgeting, supporting provider capacity, beneficiary attribution, and data collection (see NASHP brief “Payment Approaches for Housing-Related Services” for more information).
Methodology and Notes
The associated crosswalk does not represent a complete list of every state program or Medicaid authority. It does not include services covered under 1915(c) Home and Community-Based Services waivers (with the exception of Louisiana’s), Health Homes, Money Follows the Person, or through managed care contracting. Many states use 1915(c) Home and Community-Base Services waivers and Money Follows the Person to provide housing-related services to individual with disabling conditions that meet a nursing-facility level of care. It primarily focuses on states with statewide benefits that set out a goal of addressing beneficiaries’ housing-related needs for individuals with broader eligibility criteria. For additional information on Medicaid authorities for housing related services, see NASHP’s brief. In addition, several states have pending Section 1115 Demonstration requests that are not reflected in this version of the crosswalk (see Table 4 in the Appendix for a summary of select pending demonstrations).
All information was gathered through publicly available information, and links to those resources are included for each state’s program. The crosswalk does not list the in-depth beneficiary eligibility requirements or provider requirements — that information can be found in the linked resources for each state.
Additional Resources
- CMS Guidance:
- CMS guidance, December 2022, “Addressing Health-Related Social Needs in Section 1115 Demonstrations”
- CMS state Medicaid director letter, January 2023, “Additional Guidance on Use of In Lieu of Services and Settings in Medicaid Managed Care”
- CMS state health official letter, January 2021, “Opportunities in Medicaid and CHIP to Address Social Determinants of Health”
- The Medicaid and CHIP Payment and Access Commission’s (MACPAC) 2021 brief, “Medicaid’s Role in Housing”
- Corporation for Supportive Housing, 2022, “Summary of State Actions on Medicaid and Housing”
- State Health and Value Strategies, October 2022, “Addressing Health-Related Social Needs Through Medicaid Managed Care”
- Center for Health Care Strategies and Association for Community Affiliated Plans, February 2023, “Financing Approaches to Address Social Determinants of Health via Medicaid Managed Care: A 12-State Review”
- National Governors Association, 2016“Housing as Health Care: A Road Map for States”
- NASHP’s blog post, March 2021, “How States Use Federal Medicaid Authorities to Finance Housing-Related Services”
- Center on Budget and Policy Priorities, January 2020, “Medicaid Can Partner with Housing Providers and Others to Address Enrollees’ Social Needs”
- Center on Budget and Policy Priorities, January 2020, “Housing and Health Partners Can Work Together to Close the Housing Affordability Gap”
Appendix
Table 4. Summary of Select States’ Pending Health-Related Social Needs Section 1115 Demonstrations | |
| State | Summary of Proposed Demonstration Health-Related Social Needs Services |
| Delaware Diamond State Health Plan (Submitted December 2022) |
|
| New Mexico Turquoise Care (Submitted December 2022) |
|
| New York Medicaid Redesign Team Waiver (Submitted September 2022) |
|
| Rhode Island Comprehensive Demonstration (Submitted December 2022) |
|
| West Virginia Substance Use Disorder Continuum (Submitted June 2022) |
|
Endnotes
[1] Effective health and housing approaches braid funds together to achieve the “three-legged stool” of supportive housing: affordable housing stock, rental assistance or subsidies, and supportive services to help an individual find a home and remain in their home. This resource primarily focuses on the supportive services and hones in on Medicaid as just one potential resource.
[2] Louisiana uses State Plan and a 1915(c) Home and Community-Based Services waiver.
[3] Massachusetts and Washington’s newly approved Section 1115 Demonstration Waivers may affect their reimbursement approach.
NASHP is thankful for support of this project by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the National Organizations of State and Local Officials co-operative agreement.
