To address the housing needs of Medicaid beneficiaries, states can leverage a variety of Medicaid authorities, including through the state plan, a variety of waivers, and managed care arrangements, to cover housing-related services under state Medicaid programs. This brief provides a high-level summary of some of the most frequently used Medicaid authorities, including the associated eligibility requirements, services that may be covered, and additional considerations that may inform a states’ decision-making.[1]
Effective Medicaid approaches consider the following items and allow the broader health and housing strategy to guide their Medicaid approach:
- Priority population (target group(s), needs-based criteria, financial eligibility)
- Geographical considerations (statewide, pilots, or phased-in approach)
- Description, amount, duration, and scope of intended services
- Timelines for implementation
- Existing benefits and systems of providers
Before settling on authorities and revisions to Medicaid plans or contracts, it may be useful to conduct an “environmental scan” of housing-related services currently being provided through Medicaid and/ or other funding streams. This will assist the state in identifying existing resources, gaps, and opportunities. In addition, if services that are currently funded through other sources can be covered under Medicaid, these other funds may become available to extend funds to improve housing affordability and availability and increase access for target beneficiaries.
It is also important to note that 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 one potential resource.
State Plan
Section 1915(i) Home and Community Based Services (HCBS) State Plan Amendment Option
Eligibility
- Individuals at or below 150 percent of the Federal Poverty Level (FPL), or up to 300 percent of the FPL when also eligible for a HCBS waiver
- Needs-based criteria less stringent than criteria for an institutional level of care (unlike 1915(c) waivers)
- Ability to choose to target a specific population
Services
Must be based on a person-centered service plan and include the following:
- Support services such as care management, community transition, habilitation, respite, environmental modifications
- Tenancy supports such as housing applications, tenant training, and communication with landlords
- Community transition services such as security deposits, setup fees for utilities, and essential household furnishings
Other Considerations
- Must be offered statewide and the number of individuals may not be capped. States may restrict enrollment criteria if the number of individuals exceeds the states’ projections.
State Examples
- Connecticut Housing Engagement and Support Services
- District of Columbia Housing Support Services
- Michigan Community Support Services
- Minnesota Housing Stabilization Services
- North Dakota Home and Community-Based Services for Individuals with Behavioral Health Conditions
- Texas Home and Community-Based Services — Adult Mental Health
Health Homes State Plan Amendment Option
Eligibility
- Medicaid-eligible individuals with two or more chronic conditions; one chronic condition and at risk for a second; or one serious and persistent mental health condition
- States can target specific populations in certain geographic areas or specific chronic conditions
Services
Many of these services include coordinating and/or integrating with housing and other social service providers and directly supporting individuals with engaging and integrating with the community:
- Comprehensive care management
- Care coordination
- Health promotion
- Comprehensive transitional care/follow-up
- Patient and family support
- Referral to community and social support services
Other Considerations
- States receive enhanced federal matching funds for health home services for an initial eight quarters.
State Examples
Other State Plan Services
Pre-tenancy and tenancy support activities can also be incorporated into the service definitions for other state plan services, including:
- Case management and Targeted Case Management
- Peer supports
- Psychosocial rehabilitation
- Crisis intervention, including:
- Assertive Community Treatment
- Mobile crisis and mobile response and stabilization services
State Examples
- Georgia Housing Supports (Provider manual pages 238–263)
- Louisiana Permanent Supportive Housing
1915(c) HCBS Waivers
Eligibility
- Up to 300 percent of the FPL
- Individuals must meet institutional level of care (usually nursing facility or intermediate care facility)
Services
- Services must be in an individualized, person-centered plan of care based on a comprehensive assessment
- Wide variety of standard medical and non-medical services such as case management, habilitation, caregiver respite, environmental modifications, home-delivered meals, home health aide, personal care attendant, adult day health care, educational and employment supports
- Tenancy supports such as housing applications, tenant training, and communication with landlords
- Community transition services such as security deposits, setup fees for utilities, and essential household furnishings
Other Considerations
- Statewideness and comparability of services are waived under this authority, allowing states to target waivers to specific areas of the state and to specific groups that meet the criteria for nursing home level of care. Examples include older adults, people with behavioral conditions, and people with intellectual disabilities. States can also target services on the basis of disease or condition such as HIV/AIDS or brain injury.
- States must demonstrate that serving people in the waiver will not cost more than serving them in an institution.
- States must assure the health and welfare of waiver participants.
Medicaid Section 1115 Demonstrations
Eligibility
- Allows states the most flexibility with defining the eligible population
- May choose to pilot in a limited geographic area or to a capped number of individuals
Services
- Health-related social needs services must be clinically appropriate and based on medical appropriateness using clinical and other health-related social needs criteria.
- Can cover a broad array of pre-tenancy, tenancy support services, and housing transition costs (such as deposits, moving costs, etc.).
- This is the only Medicaid authority that can include up to six months of transitional rental assistance and up to six months of meals/prescribed food.
Additional Considerations
- Requires budget neutrality (note that budget neutrality calculations for health-related social needs were recently updated)
- Typically involves extensive negotiations with the Centers for Medicare & Medicaid Services (CMS). Recent approvals of health-related social needs demonstrations in Arizona, Arkansas, California, Massachusetts, New Jersey, Oregon, and Washington may be able to serve as an example.
- Intensive reporting and evaluations to CMS; monthly progress calls; quarterly and annual progress reports
- Typically approved for a five-year period and then can be renewed for three to five years
State Examples
- Arizona Housing and Health Opportunities (H2O) (2022 approval)
- Arkansas Life360 HOME (2022 approval)
- California Advancing and Innovating Medi-Cal (CalAIM) (2022 approval). Note that part of CalAIM is approved through a 1915(b) in-lieu-of services approach.
- Hawaii Community Integration Services (CIS) (2020 approval)
- Massachusetts Community Support and Flexible Services Programs (2017 approval; 2022 approval)
- New Jersey (2023 approval)
- North Carolina Healthy Opportunities Pilots (2019 approval)
- Oregon Health Plan (2022 approval)
- Rhode Island Home Stabilization Services (2020 approval, extension/amendment request pending)
- Washington Foundational Community Supports (2023 approval)
Managed Care
States can direct or incentivize Medicaid managed care organizations (MCOs) to address their members’ housing needs using the following levers
Care Coordination Requirements
Many states direct or encourage their MCOs to screen for members’ health and social needs and permit MCOs to engage in coordination with providers of non-medical, social drivers of health related services.
State Examples [2]
- Mississippi 2021 Medicaid Coordinated Care Request for Qualifications and Model Contract
- Pennsylvania 2022 HealthChoices Physical Health MCO Contract
Additional Services
Many state contracts with MCOs also reiterate federal authority for value-added and in-lieu-of services, which MCOs can take advantage of to cover housing-related services. These services are implemented at the MCOs’ discretion. States do not need a waiver to implement but must update contracts, which are reviewed by CMS.
Value-Added Services
Services that are not covered under the state plan but that a managed care plan opts to spend a portion of its administrative funding from its capitation to improve quality of care and/or reduce costs.
State Example
- Virginia Medallion 4.0 Contract and CCC Plus Contract
“In Lieu Of” Services
Substitutes for services or settings covered in a state plan as a cost-effective, medically appropriate alternative.
CMS released guidance in January 2023 outlining in lieu of services as an innovative option for addressing health-related social needs.
State Examples
- Most recently, California used its 1915(b) waiver to add in lieu of services. Allowable in lieu of services include housing transition; housing deposits; tenancy and sustaining services; caregiver respite; day habilitation; nursing facility transition and diversion; community transition; personal care and homemaker services; environmental modifications; medically supportive meals; sobering centers; and asthma remediation. Medical respite and short term post-hospitalization housing were covered through the Section 1115 demonstration. California 2022 Medi-Cal Managed Care Plans RFP
- Oregon 2022 CCO Contract
Incentive and Withhold Arrangements
States can use incentives and withholds to encourage plan investment in housing or other social drivers of health (SDOH) interventions.
State Example
Quality Assessment and Performance Improvement (QAPI)
Federal rules require states to instruct MCOs on establishing and implementing quality assessment and performance improvement (QAPI) programs. Several states use their required QAPI terms to focus MCO efforts on housing initiatives while allowing MCOs the flexibility to design interventions.
Additional Resources
Note that resources released before 2022 do not include the most recent CMS direction on coverage of short-term rental assistance but have helpful background on Medicaid authorities and the connection with housing support services and housing transition services.
- 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 2021 letter to state health officials, “Opportunities in Medicaid and CHIP to Address Social Determinants of Health”
- State Health and Value Strategies, October 2022, “Addressing Health-Related Social Needs Through Medicaid Managed Care”
- Center for Health Care Strategies/Association for Community Affiliated Plans, February 2023, “Financing Approaches to Address Social Determinants of Health via Medicaid Managed Care: A 12-State Review”
- The National Governors Association’s 2018“Housing as Health Care: A Road Map for States”
- The Medicaid and CHIP Payment and Access Commission’s 2018 brief, “Medicaid’s Role in Housing”
- Corporation for Supportive Housing’s 2017 “A Quick Guide to Medicaid Waivers and State Plan Amendments” and 2022 Summary of State Action
- NASHP’s 2021 overview “How States Use Federal Medicaid Authorities to Finance Housing-Related Services”
- Center on Budget and Policy Priorities, 2020 update “Medicaid Can Partner with Housing Providers and Others to Address Enrollees’ Social Needs
- Center on Budget and Policy Priorities, 2020 update “Housing and Health Partners Can Work Together to Close the Housing Affordability Gap
Endnotes
[1] Certified Community Behavioral Health Clinics (CCBHCs) are one additional mechanism that some states are exploring that is not detailed in this document. CCBHCs are designed to ensure access to coordinated comprehensive behavioral health care regardless of an individual’s ability to pay and include coordination and connection with needed services as a critical component of the model. CCBHCs have been created via CCBHC Medicaid Demonstrations, SAMHSA Expansion Grants, state plan amendments, and section 1115 demonstrations.
[2] State examples in this section were identified from the October 2022 State Health & Value Strategies and Health Foundation of South Florida “Addressing Health-Related Social Needs Through Medicaid Managed Care” resource.
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.
