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Medicaid & Housing Services - CSH

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States recognize that supportive housing directed at the right population can improve health outcomes and reduce
Medicaid spending. They also recognize that supportive housing services need to be financed in a way that is more
sustainable than short term government and philanthropic grants that have been the historical funding sources. Therefore,
states, localities and health services payers such as managed care organizations are experimenting with ways to more
comprehensively finance outreach and engagement, tenancy supports and other tenancy sustaining services.

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Medicaid & Housing Services - CSH

  1. 1. SUMMARY OF STATE ACTIONS Medicaid & Housing Services Updated November, 2018 INTRODUCTION States recognize that supportive housing directed at the right population can improve health outcomes and reduce Medicaid spending. They also recognize that supportive housing services need to be financed in a way that is more sustainable than short term government and philanthropic grants that have been the historical funding sources. Therefore, states, localities and health services payers such as managed care organizations are experimenting with ways to more comprehensively finance outreach and engagement, tenancy supports and other tenancy sustaining services. The previous administration approved a number of 1115 research and demonstration waivers to cover tenancy support services including CA, IN, MA, MD and WA. CSH is involved in supporting a number of these program and is watching closely for lessons learned that can be applied to other states. The new administration has moved to shift the focus to a strategy using 1915I State Plan Amendments or SPAs. IL’s 1115 waiver was approved by the Trump CMS to include Tenancy Support Services in the second year of implementation, but the state was requested to structure the benefit similarly to a 1915I SPA rather than having the flexibility commonly found in 1115 waivers. 1915i SPAs are shorter, more focused and discrete and can be approved more swiftly and easily than the commonly large scale 1115 waivers. For budgeting purposes, states must know how many people will meet criteria for the service, as 1915i SPAs require that all persons who meet the state defined “needs based criteria” must receive the service. One of many challenges for states will be to define their population in a discrete manner that allows predictable budgeting for the state portion of services funding. Housing resources will need to be aligned with these services, and the supportive housing provider community will need assistance and guidance to step up and deliver these services through the health care delivery systems in their states. The table below highlights actions states and other entities have taken to improve service delivery and financing of the services delivered by supportive housing providers.
  2. 2. SUMMARY OF STATE ACTIVITY State/City Program Model Medicaid Mechanism Target Population Status California Whole Person Care Pilots managed through county health departments: can fund outreach and engagement, formation of partnerships to integrate care, and tenancy support/sustaining services. 1115 Medicaid Waiver (Whole Person Care pilot) New prospective tenants and existing supportive housing tenants, so long as meet eligibility criteria. Persons can receive care coordination services that are not tenancy focused, if person is stably housed but has complex care needs. Whole Person Care: State Summary at https://nashp.org/wp- content/uploads/2017/07/Hansen- Slides.pdf expires Dec. 2020 Health Homes Programs managed by Managed Care Organizations: can fund outreach, engagement, housing navigation, and tenancy support services Health Home State Plan Amendment (Health Home Program), with amendment to existing 1115 Medicaid Waiver (to have administered through MCOs) Whole Person Care: Counties can choose to include a focus on population Homeless or at risk of homelessness. The state has approved 25 WPC pilots, with the first beginning in 2016. The list can be found at http://www.dhcs.ca.gov/provgovpar t/Documents/WPCApplicationStats .pdf . Health Home Program: People with two chronic conditions or one serious mental illness who are either homeless or could exit institutions with available supportive housing. Heath Homes Program began in San Francisco in July, 2018. San Bernardino and Riverside counties will begin in January, 2019 and an additional 26 county pilots will commence in July, 2019. http://www.dhcs.ca.gov/services/D ocuments/HHP_Revise_Implement
  3. 3. _Sch_4.4.18.pdf Florida Pilot Program in 5 Central Florida Counties 1115 Waiver Amendment 21 and Older Waiver Amendment in discussion between CMS and the state. https://www.medicaid.gov/Medicaid -CHIP-Program-Information/By- Topics/Waivers/1115/downloads/fl/ fl-medicaid-reform-pa4.pdf Services include Pre-Tenancy, Tenancy Sustaining Services and Mobile Crisis Management and Peer Support. Significant Behavioral Health needs including SMI and SUD. Homeless or at risk of Homelessness. Noted as a pilot program, Program cap is noted as “42,500 member months”. Hawaii Waiver amendment focused on services to increase supportive housing capacity for the state. 1115 waiver Behavioral Health, physical illness or a substance use diagnosis and chronically homeless. Waiver approved by CMS 10/31/2018. https://www.medicaid.gov/Medicaid -CHIP-Program-Information/By- Topics/Waivers/1115/downloads/hi /hi-quest-expanded-ca.pdf
  4. 4. Persons living in institutions, who cannot be discharged due to a lack of appropriate housing plan for discharge. After health plan assignments, people eligible for the service, will be assigned a service coordinator from the health plan that will work with them to obtain services and housing. Face to Face interview with the service coordination and beneficiary is required. Living in Public Housing and at Risk of eviction AND has a qualifying condition/ diagnosis. CMS in 2018, is indicating will approve the waiver amendment, but will require HI to structure the benefits similar to a 1915i SPA. Benefit to be managed by the state’s Managed Care delivery system. https://medquest.hawaii.gov/en/me mbers-applicants/already- covered/health-plans.html Illinois Waiver focused on Behavioral Health Transformation. 1115 Waiver Significant or HIGH Behavioral Health needs and Homeless or at risk of Homelessness. Approved 5/7/18; effective 7/1/18. Capped at serving 2250 in year 2, raising to a maximum of 3,750 in year 5. https://www.medicaid.gov/Medicaid- CHIP-Program-Information/By- Topics/Waivers/1115/downloads/il/il- behave-health-transform-ca.pdf https://www.illinois.gov/hfs/info/111 5Waiver/Pages/default.aspx ACIS (tenancy supports) pilot to be implemented July 2019. https://www.medicaid.gov/medicaid /section-1115- demo/demonstration-and-waiver- list/?entry=40098
  5. 5. Services include Pre-tenancy services, move in services. Security Deposits not noted. Tenancy Support Services are 1/ 10 pilot programs. Start date for these services is in year 2 (July, 2019). IL also implementing Integrated Health Homes through SPA. Will need to be alignment with ACIS pilot implementation and IHH, no specifics available yet. SPA All Medicaid enrollees to be assigned to IHH by July 2019. 4 tiers in total. Top three tiers represent 300,000 people. They will be enrolled in IHH starting January 2019. Tier A includes those with high behavioral health needs and high physical health needs. State will determine tier placement. Services will be administered by the state’s Managed Care Organizations. https://www.illinois.gov/hfs/SiteColl ectionDocuments/StatewideHealth ChoiceIllinoisPlans5418.pdf Indiana Waiver focused on Market Driven Health Reforms 1115 Waiver Medicaid Beneficiaries with SUD treatment needs A component of the Healthy Indiana Plan 2.0 https://www.medicaid.gov/medicai d/section-1115- demo/demonstration-and-waiver- list/?entry=25478 Significant cost sharing requirements. Persons eligible for “Addiction Recovery Management Services” State working on benefit implementation. Maryland Use Medicaid for Tenancy Support Services per 6/26/15 IB 1115 Waiver Persons who are either experiencing homelessness or transitioning to the community from an institution or at high risk of institutional placement; In a Nursing Home for at least 60 days. Waiver Approved by CMS. County driven, as counties are required to put up what has historically been ‘state match’ funding as well as the aligned housing resources. https://mmcp.health.maryland.gov/ Pages/Assistance-in-Community- Integration-Services-Pilot.aspx Initial program capped at 300 people. Round one awards can serve 190 people. Round two adds an additional community (PG County) and 110 new slots, bringing the total to the initial cap of 300. First round awards went to Harford, Cecil and Montgomery Counties, and Baltimore City. Round 2 pilots include Prince George's County and an expansion in Montgomery county.
  6. 6. New request to increase cap to 600 persons. https://www.medicaid.gov/Medicaid- CHIP-Program-Information/By- Topics/Waivers/1115/downloads/md/ md-healthchoice-pa2.pdf MD has RFPed out to counties. Counties must provider 50% of services funding and aligned housing. Persons served will need to be determined eligible for Home and Community Based Waiver Services and ready to leave nursing home. Massachusetts Medicaid funds used for tenancy support services, billed monthly on a per diem rate New 1115 Waivers are basing the system in ACOs. State considering the intersection. Members who are chronically homeless or high utilizers of homeless and health services Expanded through Pay For Success Model and offered through all MCOs. https://www.medicaid.gov/state- resource-center/innovation- accelerator-program/iap- downloads/webinar2-slides.pdf Project is called CSPECH or Community Support Program for people Experiencing Chronic Homelessness, Initial cap of 50 with two providers, expanded to state wide population in 2016. CSH Provider Profile at http://www.csh.org/wp- content/uploads/2017/01/CSPECH -Provider-Profile-FINAL-2016.pdf Pays supportive housing providers to deliver housing based case management ($17 per day, per person) Outcomes report http://bluecrossmafoundation.org/p ublication/estimating-cost- reductions-associated-community- support-program-people- experiencing Provider can bill up to 60 days prior to lease up for services.
  7. 7. Michigan Waiver focused on tenancy support services to align with 200 Pilot Vouchers 1915I State Plan Amendment Benefit targeted for individuals with chronic homelessness and high utilizing populations within the Specialty Behavioral Health Service System 1115 waiver was NOT approved. Per CMS guidance, State is now developing a 1915I State Plan Amendment with similar goals and populations. MI was a second round IAP state and is implementing their action plan developed as part of that process. CSH working with the state on a Crosswalk and Business Plan Plan is for the benefit to be managed through the Regional Behavioral Health authorities.
  8. 8. Minnesota Housing Support Services to support transition to the community, increase long-term stability in the community & avoid future periods of homelessness or institutionalization. 1915I State Plan Amendment People with disabilities, including mental illness, who are homeless or at risk of becoming homeless, are living in institutions or other segregated settings, or are at risk of living in those settings and adults who are 65 years or older who are homeless or at risk of becoming homeless. State submitted 1915i state plan amendment on /2018 to CMS on 8/23/18. Concept paper can be found at https://mn.gov/dhs/assets/housing- stabilization-services_tcm1053- 346907.pdf Oregon Housing related services are options for State Coordinated Care Organizations 1115 Medicaid Waiver Not specified in the waiver. Communities can choose to include as an optional benefit under 'health related services. Pennsylvania Tenancy Support Services for IDD/DD population 1915I State Plan Amendment Those already eligible for IDD waivers. Process remains the same as prior to the waiver. Tenancy support services are now added to the menu of services available for persons eligible for the IDD waiver. No new funding attached, education of providers on best practices in supportive housing or alignment with housing resources. Rhode Island Part of the Governor’s Reinventing Medicaid Initiative to improve coordination and decrease costs in Medicaid. 1115 Medicaid Waiver Focus on chronically homeless population. Used a SAMHSA CABHI grant as start up for the project. Also includes elderly transitioning from Nursing Homes and Youth transitioning from Foster Care. State has completed Home Stabilization Services Certification Standards. Standards are at http://www.eohhs.ri.gov/Portals/0/U ploads/Documents/ReinventMedic aid/HomeStabilizationCertStds042 816.pdf Requesting support for Home Stabilization Services Shifting from FFS to an MCO model. Rhode Island expects their 1115 waiver approval shortly. http://www.eohhs.ri.gov/Reference Center/MedicaidStatePlanand1115 Waiver/WaiverExtension.aspx
  9. 9. Shifting current Supportive Housing Services funding from grant and McKinney to Medicaid. Payment mechanism is a per diem model. http://www.eohhs.ri.gov/Portals/0/U ploads/Documents/1115Waiver/Su mmary1115WaiverExtension03231 8.pdf In some cases using Community Mental Health Centers as Administrative Services Organizations (ASO) for Supportive Housing Providers. Some case management but a focus on Peer Recovery Models Services are for 24 months only and include Housing Search services. Washington State Foundational Community Supports or services in supportive housing. 1115 Waiver WA Health Authority projected need at 4,000 eligible persons across the state. Waiver approved and implementing as of 1/1/2018. https://www.hca.wa.gov/assets/pro gram/foundation-community- supports-faq.pdf Persons who are currently homeless are eligible as engaged for supportive housing. Providers cannot use the benefit for current residents. Providers are paid a per diem rate of $105. Amerigroup is the third party administrator. Their provider manual for these services can be found at https://providers.amerigroup.com/d ocuments/WAWA_TPA_ProviderM anual.pdf

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