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Develop Waiver and State Plan Amendment Options*

These Medicaid authorities may be considered by states interested in using Medicaid to pay for supportive housing services.

  Managed Care Contracts** 1115 Waiver 1915(c) Waivers 1915(i) Home and Community-Based Services (HCBS) State Plan Option
Health Homes State Plan Option 1905(a) Targeted Case Management
Eligible/Covered
Populations
  • Most individuals eligible under the Medicaid state plan
  • State can define qualifying criteria
  • Aged, disabled individuals or those with MH diagnoses who require institutional-level care
  • Aged or disabled individuals who have income at or below 150 percent of the Federal Poverty Level
  • Medicaid-eligible individuals who:
    • Have two or more chronic conditions;
    • Have one chronic condition and are at risk for a second; or
    • Have one serious and persistent MH condition
  • Most individuals eligible under the Medicaid state plan can qualify for targeted case management. However, states must target certain populations or individuals living in certain geographic areas
Support Services49: Health, Well-
Being and Community: Health Care, Behavioral Health (BH),
Referrals to Social Support
  • Managed care plans must cover state plan or waiver services, if applicable
  • Managed care plans may also cover cost-effective alternative services not included in the state plan
  • States can define the benefit package
  • The Centers for Medicare & Medicaid Services (CMS) have not approved capital expenses — only short-term operating expenses
  • Case management services, community transition services, home health aide services, habilitation services, respite care services, environmental modifications for accessibility
  • Case management services, community transition services, home health aide services, habilitation services, respite care services, environmental modifications for accessibility
  • Comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow up, patient and family support, referral to community and social support services
  • Case management services
  Note that traditional health care services integral to a supportive housing intervention would be covered under states' existing Medicaid authorities.
Support Services: — Housing:
Tenancy Supports50
  • States can require managed care plans to cover tenancy services if services are covered under the state plan or waivers
  • If tenancy supports are not covered under the state plan or waivers, managed care organizations (MCOs) may still elect to cover the services as "in lieu of" services (included as part of the capitation rate) or may cover those services outside the capitation rate (as part of administrative costs)
  • Most flexibility: States may cover a broad array of tenancy support services as a defined service in the waiver
  • Note that CMS does not currently allow states to cover capital costs
  • Broad flexibility: States may cover a broad array of tenancy support services — for example:
    • Case management services may include completion of housing applications, tenant training and communication with landlords; and
    • Community transition services may include security deposits, setup fees for utilities and essential household furnishings
  • Broad flexibility: States may cover a broad array of tenancy support services — for example:
    • Case management services may include completion of housing applications, tenant training and communication with landlords; and
    • Community transition services may include security deposits, setup fees for utilities and essential household furnishings
  • Broad flexibility: States may cover a broad range of tenancy support services by incorporating those services into the payment methodology for the health home network
  • States should define the tenancy support services that will be covered under payments to health homes in their state plan amendment
  • Limited flexibility: Targeted case management does not authorize coverage of tenancy support services, only the identification of and linkage to the services — for example:
    • Case management services may include identifying housing resources and linking individuals to those resources; and
    • States cannot cover community transition services such as security deposits, setup fees for utilities or essential household furnishings
Considerations
  • For in-lieu-of services, the state must determine that the services are medically appropriate, cost-effective substitutes and authorize coverage by identifying the services in the MCO contract
  • States may encourage MCOs to cover non-covered tenancy support services by establishing performance metrics linked to health outcomes for populations with housing instability
  • Provides the greatest flexibility to define covered populations, benefits and geographic areas
  • Requires budget neutrality and extensive negotiations with CMS
  • States can target specific populations in certain geographic areas and cap the number of eligible individuals
  • Covered population will need to meet the state's criteria for institutional care
  • Must be cost-effective, which is not difficult because all individuals would receive institutional care but for the provision of home and community-based services
  • Tenancy support can be defined as separate and discrete services under the waiver
  • States must offer benefits statewide but can target certain populations.
  • States cannot cap the number of eligible individuals
  • No cost-effective requirement
  • States can target specific populations in certain geographic areas
  • Enhanced federal match (90:10) is available only for the first eight quarters
  • Coverage is limited to case management services
  • States must offer the benefit statewide, but they must define eligible
    populations

*Not exhaustive; these are the most relevant Medicaid authorities for "housing as health" interventions. For example, states can also use 1915(k) or other Medicaid
authorities as approved by CMS. This information was gathered through an analysis of federal statutes, regulations and policy guidance as well as conversations with CMS.
** States can implement managed care programs through three authorities – Section 1115 demonstrations, 1915(b) waivers and Section 1932 State Plan Amendments.

Key Considerations

  • Does the target population for this initiative line up with the eligible population under each option?
  • How do the covered services51 in each option align with the services the state wants to cover?
  • Can the state accomplish this under managed care?
    • If so, is the target population already enrolled in managed care? If not, can they be enrolled?
    • How would the state build the services into the Medicaid managed care contract?