On March 31, 2022, the Centers for Medicare and Medicaid Services (CMS) announced it will, for the first time, allow states participating in the Medicaid program money follows the person demonstration of being fully reimbursed for short-term housing assistance. This demonstration is designed to increase states’ use of Home and Community Services (HCBS) and help people with disabilities transition from hospital to community facilities.
The newly announced flexibility offered to pay short-term housing assistance– which can include assistance with rent and utilities as well as a comprehensive package of housing-related support services – recognizes the difficulties of obtaining housing when people with disabilities move from hospital to home and community facilities. It also represents an important extension of ongoing Medicaid initiatives that are testing policies designed to improve coordination between public housing and health agencies and promote safe and affordable community housing options.
In this article, we first present a history of recent efforts to promote housing stability for those eligible for home and community services. We then describe ways the new rules aim to address ongoing challenges within the program and describe other Medicaid-related efforts to address housing needs. Finally, we highlight the need to study these initiatives as essential efforts to bridge housing and health care.
Bridging housing assistance and home and community services
The Supreme Court of the United States 1999 Olmstead Decision ruled that in public programs, segregation of persons with disabilities is a form of unfair discrimination under the Americans with Disabilities Act and reaffirmed the right of persons with disabilities to receive services in “the most integrated setting appropriate.” In the wake of the ruling, CMS set up the Money Follows the Person demonstration for Medicaid to expand community-based care and give people with disabilities more choice about where they receive healthcare services. .
One of the main challenges of this initiative has been the lack of accessible and affordable housing units for these people. The number of affordable rental units has been declining since 2000 and today represents only a small part of the rental stock. Recipients of Supplemental Security Income receive $9,528 per yearmaking it impossible to buy even the cheapest rental accommodation.
Using the flexibilities provided through the Money Follows the Person demonstration, states worked to connect people with disabilities to home and community services and supports. These include a wide range of housing transition and rental assistance, such as assistance with finding and moving into accommodation, assistance with security deposits and moving costs, and ongoing supports to stay in stable housing.
Lack of affordable housing has been the main barrier to transitioning people out of institutions, according to a Money follows person’s valuation from 2017. Federal and state housing agencies have worked to fill the gaps through targeted housing assistance for people with disabilities. At the federal level, the Department of Housing and Urban Development administers two programs: the Consumer Voucher Program, which is separate from the regular Housing Choice Voucher program and provides tenant-based housing assistance for non-elderly people with disabilities; and the Section 811 Project Rental Assistance Program (PRA)which offers rental assistance on a project basis.
Consumer vouchers and the Section 811 PRA program have both expanded access to affordable housing and encouraged (or required, in the case of the Section 811 PRA) partnerships between health and housing agencies. of the state to work on the coordination of housing and support services for people with disabilities. out of institutions.
Pay for short-term rental assistance
Despite efforts at the federal and state levels to better coordinate access to housing support and rental supports and services, the timing of the transition from an institutional setting to supported housing has been a challenge. Recently announced flexibilities aim to address this challenge by paying short-term rental assistance.
When a Mainstream voucher is issued or a PRA Section 811 unit becomes available, individuals have a limited time to find a unit on the market (in the case of Mainstream) or visit the unit (in the case of Section 811 PRA), submit the lease application, sign the lease and move in. Traditional vouchers are issued for a limited time and the Section 811 PRA program pays for vacant housing for up to a few months. People leaving institutions often need more time to research and visit available units, complete the lease application, process their release from the institution, and be approved and enrolled in home and community services.
CMS’s recent announcement to Money Follows the Person recipients allows for 100% reimbursement for up to six months of assistance with short-term rental and associated utility expenses. This assistance can help bridge the gap between when an individual is ready to transition into the community and the time it takes to apply for and receive a Mainstream Voucher, Section 811 PRA unit, or other housing assistance. state or local. To use this option, states will be required to develop and approve a housing plan that includes partnerships with state and local housing agencies to ensure that short-term housing assistance does not end without the individuals can obtain longer-term support from other agencies. This service and other housing-related services included in the Money Follows the Person demonstration will help people living in institutions exercise their right to live and receive services and supports in the community.
Additional opportunities under the Medicaid program to meet housing needs
The new rules for the Money Follows the Person protest are the first to explicitly allow federal grants to pay for short-term housing assistance. However, several other Medicaid demonstrations are experimenting with housing-related services as a way to meet participants’ needs.
Medicaid Section 1115 demonstrations are designed to test budget-neutral policy approaches to improve service delivery, health care coverage, and access to long-term services and supports. Six states, including California, Maryland, Washington, Illinois, Massachusettsand North Carolina, included housing case management and tenancy services in their Section 1115 demonstrations. Two others, Oregon and Virginia, have submitted Medicaid Section 1115 demos with plans to offer these services in the near future. Eligibility for programs varies, with many states targeting people with high medical needs, such as high users, and focusing on people who are homeless or at imminent risk of losing their homes.
State demonstrations have varied in their approach to rental services, with some including pre-rental supports such as helping individuals with budgeting, residential applications, security deposits, and application fees. Others have included landlord education and incentives and services designed to help people stay in stable housing after moving in, including home accessibility and security modifications and legal assistance. It is important to note that these housing-related services are intended to help individuals find and maintain housing, but they do not pay for the room and board of the housing itself.
Other Medicaid HCBS programs, such as those under the authority of Sections 1915(c) and 1915(i), have also permitted the use of housing-related services. California, Louisiana, Minnesota, and Wisconsin are examples of states that have included housing-related services in their section 1915(c) HCBS Programs; and Texas and North Dakota are examples of states that have included housing-related services in their section 1915(i) HCBS state plan programs. Section 1915(c) of the Social Security Act requires individuals to meet an institutional level of care, while Section 1915(i) targets services to individuals who meet state-defined criteria and needs-based, which may include those who are homeless or are at high risk of becoming homeless upon discharge from hospital. Similar to Section 1115 demonstrations, these states have used a variety of housing transition and tenancy support services to help secure stable and affordable housing for the people they serve.
Determine what works
There is a critical opportunity and urgent need to evaluate housing-related services across programs and investigate the partnerships that need to be in place to help ensure these services are successful in providing long-term housing stability. term. And, with the introduction of short-term housing support as part of the Money Follows the Person demonstration, it will be important to understand the extent to which these new flexibilities provide a bridge to help achieve the programmatic goals of enabling individuals to move from institutional to community- and improve their health and well-being.
As the contours of Medicaid’s commitment to housing are defined and debated, these demonstrations and waivers are poised to provide strong evidence of alignment across sectors. At the same time, the move towards Medicaid paying for short-term housing assistance in the Money Follows the Person demonstration highlights the broader difficulty of obtaining stable, affordable housing, and renews calls for increased the availability of housing assistance for low-income households. .
Craig Pollack works part-time on a temporary assignment with the Department of Housing and Urban Development (HUD). Teresa Souza works full time at HUD. The findings and conclusions in this article are those of the authors and do not necessarily represent those of HUD or other government agencies.