A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 4.3. Medicaid State Plan Optional Behavioral Health Benefits--Rehabilitative Services and Targeted Case Management


States can use Medicaid state plan optional benefits to cover most of the Medicaid-reimbursed services delivered in or closely connected to PSH tenants. Most often these are Medicaid's Rehabilitative Services option, but services covered under the TCM option are used as well. This section briefly describes these optional Medicaid benefits that a state could include in its Medicaid state plan and use to cover some of the services for people living in PSH, as well as other people with disabilities who need them.

For people living in PSH, the Medicaid optional benefits most likely to be used to cover the care they receive are those their state defines as mental health or behavioral health services. A SAMHSA publication, Medicaid Handbook: Interface with Behavioral Health Services, contains more detailed information regarding Medicaid coverage for behavioral health services, complementing the information provided in this Primer.49 In addition, a December 2012 Information Bulletin from the CMS Center for Medicaid and CHIP Services provides information regarding services and good practices for individuals with behavioral health disorders.50 The Medicaid Handbook and the CMS guidance may be useful resources for states considering potential uses or changes in Medicaid optional benefits for behavioral health services.

In some states mental health services or behavioral health services are managed through a carve-out arrangement in which the state Medicaid agency may delegate some program administration duties, and potentially some financial responsibility for providing the funds to match federal funding, to another state agency or to counties. Some states have contracted with managed care plans, which are responsible for managing a broad range of mental health or behavioral health services, including many of the services covered by Medicaid, for a defined population. In some states the managed care plans are responsible for Medicaid-covered specialty mental health services for the group of people who are enrolled in Medicaid and also meet additional criteria related to SMI. In other states the plans are responsible for behavioral health services for a more broadly defined group of people who may have a range of behavioral health care needs that could be more or less severe, temporary or long term. The scope of services covered through these types of managed care arrangements are specified in agreements between the state and the plans.

4.3.1. Services Under Behavioral Health Optional Benefits

For people who have experienced chronic homelessness, the mental health or behavioral health services that are offered when they live in PSH often include a combination of services that may be covered as Medicaid benefits under the Rehabilitative Services option or TCM.

Rehabilitative Services Option

Medicaid's rehabilitative services option allows states to cover a fairly broad range of recovery-oriented mental health and substance use disorder services to individuals in the community. Coverage for rehabilitative services is authorized by §1905(a)(13) of the Social Security Act, and is defined at 42 CFR 440.130(d) as:

any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level.

To qualify for this option, the service must meet the purposes of "reducing disability and restoring function."51 Examples of specific services that some states cover under this option are described in detail in Chapter 5, Section 5.2.

States can choose to use the rehabilitative services option to furnish behavioral health services (including mental health and/or substance use disorder services) and/or to provide physical health rehabilitative services, such as physical or orthopedic rehabilitation. As of 2013, all 50 states and the District of Columbia covered behavioral health services to some extent under the rehabilitative services option. The majority of Medicaid beneficiaries who receive rehabilitative services are people with mental health disorders.52

The rehabilitative services option can offer states flexibility to cover services delivered in a range of settings, and to provide reimbursement for services delivered by licensed practitioners, paraprofessionals, peers, and teams who meet the practitioner qualifications established by the state, including the state's supervisory requirements and arrangements. Rehabilitative services can be used to help people restore the skills they need to function at home, work, school, and in the community.


TCM services are defined at 42 CFR 440.169 as "services furnished to assist individuals, eligible under the state plan…in gaining access to needed medical, social, educational and other services." States may target the TCM benefit to specific beneficiary groups. Targeted beneficiary groups can be defined by disease or medical condition or by geographic regions, such as a county or a city within a state. Targeted populations, for example, could be individuals with HIV/AIDS, tuberculosis, chronic physical or mental illness, or developmental disabilities. TCM is an optional service that states may elect to cover, for which they must get CMS approval through SPAs.

Examples of TCM Services
A Comprehensive Assessment: Gathering documentation of clinical assessments or medical records; arranging for clinical assessments; conducting a reassessment to identify a client's ongoing needs for medical, social, educational, and other services; completing a written functional assessment; and assisting in determining the client's eligibility for services.
Service Plan Development: Working with a client to develop a service plan based on the client's needs as identified in the assessment.
Referral, monitoring and follow-up: Conducting activities to help a client obtain services; assisting with linkages to services such as medical coverage and transportation; coordinating services identified in the service plan, including completion of necessary paperwork, monitoring/evaluating services, and determining whether the services were provided as requested and meet the clients' needs; adjusting services as needed and documenting referrals.

TCM services include a comprehensive assessment and periodic reassessment; development and periodic revision of a specific care plan; referral and linkage activities; and monitoring and follow-up activities. The services could include assistance in finding housing or linking people with other needed services and supports, but Medicaid TCM services do not include the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred. The text box provides some examples of assistance that may be part of TCM services.

4.3.2. Providers of Behavioral Health Services

In general, state policies determine which individuals, organizations, or facilities are qualified to diagnose and treat mental illness or substance use disorders, within the scope of applicable state laws and professional licenses. Some of the services that may be delivered in PSH, including mobile services that may be delivered through home visits, are likely to be subject to these state laws and requirements. Individuals who are not licensed--including many social workers, case managers, community support paraprofessionals, and peers--deliver many of the services that are provided to people living in PSH, including some of the services that can be reimbursed by Medicaid. States may establish specific requirements that determine who is eligible to deliver covered services, and these requirements may specify the type of training and supervision that these workers must receive for the services they provide to qualify for Medicaid reimbursement.

Some state plan rehabilitative services can be performed by individuals who are not licensed under professional scope of practice laws, including paraprofessionals and peers, as long as they have training and experience consistent with the requirements established by the state and work under the supervision of a licensed mental health professional.

Unlike clinic or outpatient hospital services, for which treatment location is included as part of the service definition, many of the benefits provided under the state plan rehabilitative services benefit can be delivered in a variety of settings, including the consumer's own home or another living arrangement. This makes it possible to deliver and use Medicaid reimbursement to pay for state plan rehabilitative services for people living in PSH or other settings where people experiencing chronic homelessness can be served.

Peer Support Providers

Many Medicaid state plans include peer support providers as a distinct provider type for the delivery of counseling and other support services to Medicaid-eligible adults with mental illnesses and/or substance use disorders. Under Medicaid, peer support providers include self-identified consumers who are in recovery from mental illness and/or substance use disorders. Peer support providers can be effective in engaging and building trust with consumers, motivating change, reducing stigma, facilitating community integration, and serving as role models for the opportunity to live a fulfilling and productive life.

In 2007, CMS provided guidance to states interested in covering peer support services under their Medicaid program.53 The CMS guidance recognizes the value of including peer support services as a component of a comprehensive mental health and substance use service delivery system, and provides more information about requirements for supervision, care coordination, and minimum training criteria.

Medicaid-reimbursed peer support services furnished by peer support specialists may be covered as a service under state plan rehabilitative services or HCBS for people with mental health and/or substance use disorders. Supervision must be provided by a competent mental health professional. Peer support services must be coordinated within the context of an individualized plan of care (POC) that includes specific individualized goals for participants. Peer support providers must complete training and certification as defined by their state to ensure that they have the basic set of competencies needed to support the recovery of others.

Among the new directions in integrating health and behavioral health care (discussed in Chapter 5, Section 5.5) is the use of peer support specialists as part of integrated health teams. Peer support specialists working in this context promote outcomes of integrated health self-management and skills that help people manage situations that might once have caused a crisis leading to hospitalization or other emergency care. The Center for Integrated Health Solutions has developed training for people interested in becoming "whole health and wellness coaches," called Whole Health Action Management. Georgia's Medicaid program includes coverage for whole health and wellness peer support provided by certified peer specialists. At least 29 additional states and the District of Columbia have added certified peer specialists to their Medicaid programs.54

4.3.3. Settings for Medicaid Rehabilitative and TCM Services

Unlike clinic or outpatient hospital services, for which treatment location is included as part of the service definition, many of the benefits provided under the state plan rehabilitative services benefit or TCM services benefit can be delivered in a variety of settings, including the consumer's own home or another living arrangement in the community. This makes it possible to deliver and use Medicaid reimbursement to pay for rehabilitative and TCM services in PSH or other settings where people experiencing chronic homelessness can be served.

Settings for Medicaid Substance Use Disorder Services

A common exception to the flexibility of service delivery locations occurs in some states with respect to services for substance use disorders. Under the rehabilitative services option, states may offer services to address substance use disorders. These services may be offered as an aid in recovering from co-occurring mental illness and substance use or, more rarely, as services for people with a substance use disorder but without a mental illness. These services are critically important to people experiencing chronic homelessness or living in PSH, as a very high percentage of them have problems with alcohol, drugs, or both.

Many states specify that all or most Medicaid-covered services to address substance use disorders must be delivered in clinics or in certain types of facilities that the state certifies as treatment programs. These policies may limit the potential for Medicaid reimbursement for substance use disorder services to people experiencing homelessness or living in PSH that are fully integrated with other health care or mental health services covered by Medicaid, including services delivered by multi-disciplinary teams that are mobile or based in PSH settings.

States have the authority to allow a wide variety of service locations, including in people's own homes. Federal law and Medicaid program rules do not limit settings for delivering services to address substance use disorders.

Some individuals with serious substance use disorders are more comfortable receiving services in their own home or community. Substance use services delivered outside a clinic, in turn, help people experiencing chronic homelessness and PSH tenants in numerous ways. They are designed to reduce health-related risks and other harms related to substance use, to help people get and keep housing, and to increase their motivation to take steps toward recovery, including engagement in treatment and self-help programs. Provisions in Medicaid state plans that restrict service delivery sites for substance use disorder treatment can limit the potential for using Medicaid to finance some of the services that are most often provided to achieve the goals just noted.

Medicaid specifications of service locations are state policy decisions. Federal law and Medicaid program rules generally do not impose limits on the settings in which some types of substance use disorder services can be delivered, including services that could be included as a component of covered rehabilitative services, Health Home, or HCBS. However, state plan rehabilitative services may only be furnished in noninstitutional community-based locations. States could merely describe their covered services and not ascribe a location for their delivery.

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