The link between housing and health is clear. Stable, supportive housing improves physical and behavioral health, and reduces readmissions and inpatient costs for vulnerable populations. This is particularly true for people dually eligible for Medicare and Medicaid. This group includes low-income, older adults as well as younger people with serious behavioral health conditions, physical disabilities, and/or intellectual and developmental disabilities.
Although Medicare and federal Medicaid funds cannot pay for room and board in community settings, the Centers for Medicare & Medicaid Services (CMS) encourages the use of Medicaid funds to cover housing-related activities like assisting with housing applications, developing a housing support plan, or providing tenant support services. Housing-related services are often provided through targeted state programs, such as home and community-based service waivers, however they are increasingly being provided through Medicaid managed care organizations (MCOs), which offer flexibility in paying for non-traditional services.
Dually eligible individuals often have complex medical conditions, and 40 percent of them also need long-term services and supports (LTSS) due to functional impairments. Under most state Medicaid programs, individuals using LTSS who qualify for a nursing facility level of care are eligible to receive housing-related supports. Paradoxically, this population also frequently transitions between hospitals, nursing facilities, and other short-term placements making it more difficult for them to qualify for supportive housing. Changes in their family circumstances or health status may mean a loss of Medicaid coverage, and in turn, the loss of Medicaid housing supports. Through the Center for Health Care Strategies’ Implementing New Systems of Integration for Dually Eligible Enrollees project, supported by The SCAN Foundation and The Commonwealth Fund, several states described how they are addressing the housing needs of dually eligible beneficiaries who use LTSS.
California: Expanding Access to Stable Housing
Recognizing the importance of social determinants of health, California’s Medicaid agency is addressing the needs of the whole person, with housing as a major component. The state’s new Medicaid 1115 waiver creates Whole Person Care pilot programs that let cities, counties, public hospitals, health authorities, and/or MCOs coordinate health, behavioral health, and social services. The social service component of the pilots allows them to pay for tenancy-based care management services, including help finding and maintaining housing in the community. The waiver also lets these organizations partner with other publicly funded entities to pool funds for direct rental subsidies or housing projects. These funds would counteract the effects of Medicaid churn by following the person, rather than being health plan or local entity-specific, so plans would have more incentive to contribute and less risk of losing out if members change plans or lose Medicaid eligibility.
California also uses its Money Follows the Person program to help Medi-Cal beneficiaries who use LTSS to move out of institutions. Between 2007 and 2014, California transitioned more than 2,000 people back to a home in the community. The state found that many of these individuals were able to live independently, but had difficulty finding appropriate, affordable housing. In response, the state applied for and received $24 million in Project Rental Assistance Demonstration funding from the U.S. Department of Housing and Urban Development’s Section 811 Supportive Housing for Persons with Disabilities program to provide supportive housing, with a focus on individuals in long-term care facilities who want to return to community living.
New York: Targeting Housing Subsidies Based on Need
The New York State Medicaid Redesign Team (MRT) Supportive Housing Initiative targets the highest-cost Medicaid beneficiaries, including those in need of LTSS. Since 2012, the state has invested $515 million in housing initiatives. To determine the best use of the MRT funds, the state convened an Affordable Housing Work Group of more than 40 stakeholders including advocates, agencies that operate housing programs, developers, and providers. The Work Group recommended allocating funds for new housing units and other capital projects, rental subsidies, and case management and clinical supervision for individuals who are homeless or have unstable housing arrangements. Funds have also supported pilot programs targeted to Medicaid beneficiaries, including many who are dually eligible, in nursing facilities, low-income senior housing, and homeless shelters, as well as to individuals with mental health and behavioral health conditions and HIV/AIDS.
Tennessee: Creating a Continuum of Housing Efforts
Tennessee is making housing a priority in a series of efforts connecting the Medicaid agency, MCOs, and stakeholders across the state. The state’s Medicaid LTSS program, TennCare CHOICES, requires MCOs to help members live in the community. Each MCO must employ a housing specialist, develop local partnerships to increase housing options, and create a comprehensive housing strategy for its members in need of housing supports. MCOs can earn incentive payments for developing community-based residential alternatives.
TennCare, the state’s Medicaid agency, hired a housing specialist to develop programs, policies, and procedures to build housing capacity and increase resources for TennCare CHOICES members. TennCare hosted two annual statewide housing conferences that brought together state agencies, stakeholders, and advocates to share best practices. These conferences strengthened partnerships and created a space to discuss the links between housing and health care. The housing specialist developed a series of ongoing, smaller stakeholder groups statewide to sustain the work that began at the housing conferences and enact change at the local level. Through its Money Follows the Person (MFP) sustainability plan, the state is awarding grants to select NeighborWorks network organizations for housing development projects across the state. In addition, the state used MFP funding to develop TNHousingSearch.org , a public online resource to help individuals find available housing.
Finally, the state established three regional housing steering committees to bring together representatives from TennCare, other state departments (e.g., mental health, substance abuse, and aging), MCOs, the U.S. Department of Housing and Urban Development, state housing development authorities, and non-profit and for-profit housing providers. Their quarterly meetings drive TennCare’s housing agenda by identifying specific objectives that the committee members work on together.
Focus of Future Work
Dually eligible individuals receiving LTSS need affordable, accessible housing as well as housing-related supports to live independently in their communities. Despite the constraints around using Medicaid funds to pay for housing, states like California, New York, and Tennessee are breaking new ground to address this important social determinant of health. Additional states participating in CMS’ Innovation Accelerator Program are receiving guidance in building collaborative relationships with housing partners and creating incentives for quality in community-based LTSS. States’ willingness to partner with MCOs and other cross-sector stakeholders allows them to leverage existing community resources and new funding opportunities to meet the housing-related needs of their dually eligible populations who use LTSS. Moving forward, it will be important to evaluate efforts to provide supportive housing to dually eligible individuals to ensure that their needs are being addressed and resources are being used effectively.