Executive Summary:

This report is provided in accordance with section 1017 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub. L. No. 115-271), enacted on October 24, 2018, herein referred to as the “SUPPORT Act.” Section 1017 of the SUPPORT Act directs the U.S. Department of Health and Human Services to issue a report to Congress on innovative state initiatives and strategies for providing housingrelated services and supports under a state Medicaid program to individuals with substance use disorders (SUD) who are experiencing or at risk of experiencing homelessness.

The background section describes the impact of SUD on Medicaid beneficiaries and the relationship between SUD and homelessness and includes references to existing research and literature providing context about the impact of SUD and homelessness on health care utilization. The background section also establishes a conceptual framework for housing supports and services and housing stability.

This report focuses on five state Medicaid programs—Arizona, California, Maryland, Pennsylvania, and Washington State—in addition to highlighting several local programs across multiple other states. Case studies providing detailed descriptions of the listed five state programs are included in the appendix.

As required by section 1017(b)(1) of the SUPPORT Act, this report details existing methods and innovative strategies developed and adopted, with examples from the above mentioned states, that have achieved positive outcomes in increasing housing stability for Medicaid beneficiaries with SUD who are experiencing homelessness or are at risk of experiencing homelessness who are receiving treatment for substance use disorders in inpatient, residential, outpatient, or home-based and community-based settings, transitioning between SUD settings, or living in supportive housing or another model of affordable housing. A number of state program outcomes show favorable results: high housing retention rates, reductions in emergency services utilization, reductions in inpatient admissions, increased connection to primary and behavioral health care, and overall reduced health care expenditures for program participants. Several innovative strategies, broadly adopted by all five state programs, were identified: integrated care coordination strategies, peer support models, funding coordination strategies, payment models, and data strategies, among others.

As required by section 1017(b)(2) of the SUPPORT Act, this report also details strategies employed by Medicaid managed care organizations, hospitals, accountable health care organizations, and other care coordination providers to deliver housing-related services to individuals with SUD who are experiencing or are at risk of experiencing homelessness and to coordinate services provided under state Medicaid programs across different treatment settings. These entities appear to be particularly focused on expanding services to holistically improve health outcomes for high-need, high-cost Medicaid-eligible individuals, while averting costs to health care and public systems.

As required by section 1017(b)(3) of the SUPPORT Act, this report details innovative strategies and lessons learned by states with Medicaid waivers approved under sections 1115 or 1915 of the Social Security Act (Act), including challenges experienced by states in designing, securing, and implementing such waivers or plan amendments; how states developed partnerships with other organizations such as behavioral health agencies, state housing agencies, housing providers, health care services agencies and providers, community-based organizations, and health insurance plans to implement waivers or state plan amendments; and how and whether states plan to provide Medicaid coverage for housing-related services and supports in the future, including by covering such services and supports under state Medicaid plans or waivers.

States are increasingly testing, evaluating, and advancing best practices around providing housing-related and recovery services and supports for Medicaid-eligible individuals. Few states have chosen the section 1915(c) home and community-based services (HCBS) waiver program authority to cover housing-related services for individuals experiencing or at risk of experiencing homelessness, since individuals would need to meet an institutional level of care, among other requirements, to qualify. However, states are exhibiting a growing interest in section 1915(i) State Plan Amendments (SPA) which allow states to provide HCBS to individuals who meet state-defined needs-based criteria that are less stringent than institutional criteria and, if chosen by the state, target group criteria. Many states are exercising the flexibility through demonstration projects under section 1115 of the Act to test new approaches to providing Medicaid coverage of housing-related services and supports for individuals who are experiencing or are at risk of experiencing homelessness with a focus on HCBS-like services under these demonstrations. As further required by section 1017(b)(3), this report also describes challenges experienced by states in designing, securing, and implementing housing-related services and supports under section 1115 demonstration authority and section 1915 authority. States have responded to challenges by developing and strengthening partnerships at the local, state, and federal levels.

States can use several different federal authorities to cover services that may assist an individual with SUD who is experiencing homelessness or at risk of homelessness with gaining access to and maintaining housing as well as optimizing community integration. As directed by section 1017(b)(4) of the SUPPORT Act, this report details existing opportunities for states to provide housing-related services and supports under sections 1115 or 1915 of the Act or through a State Medicaid plan amendment, section 1945 health home state plan benefit, section 1915(b)(3) waiver programs and risk-based managed care, section 1915(c) and section 1915(i) HCBS programs, and section 1115 authority. States have flexibility to cover a variety of housing-related services and supports under these different authorities; however, the services authorized under one Medicaid program may not always be the same as those authorized under another one. An example is the Assistance in Community Integration Service pilot program, which promotes supportive housing and other housing-related supports under Medicaid for individuals with SUD and for which Maryland has a waiver approved under section 1115 authority to conduct the program. Medicaid can also be an integral part of a collaboration with other community-based programs.

Finally, as required by section 1017(b)(5) of the SUPPORT Act, this report details innovative strategies and partnerships developed and implemented by state Medicaid programs to identify and enroll eligible individuals with SUD who are experiencing or are at risk of experiencing homelessness in state Medicaid programs. Several Centers for Medicare & Medicaid Services (CMS) regulations and other policies regarding enrollment procedures in state Medicaid programs provide flexibility to states to address some of the more unique needs of individuals who are experiencing homelessness. Several states have initiated effective strategies to identify individuals who are experiencing homelessness by partnering with homeless services providers, hospitals, managed care organizations, and others. Some states are also developing programs that connect with individuals who are at risk of homelessness as they exit correctional, behavioral health, and other institutional settings.

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