A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 5.8. Home and Community-Based Services

07/23/2014

Medicaid HCBS are most often covered through a 1915(c) waiver or increasingly through optional state plan services authorized by Section 1915(i) of the Social Security Act. Other options include covering personal care through the Medicaid state plan or through a 1915(k) state plan option. HCBS benefits can be used to cover some of the services that connect people with disabilities to housing and provide ongoing support for housing stability and community integration. These services may include the following:74

  • Case management/service coordination;
  • Homemaker/home health aide;
  • Personal care;
  • Health-related services, including skilled and unskilled nursing services to address chronic conditions and functional impairments;
  • Habilitation;
  • Psychosocial rehabilitation services;
  • Social supports to participate in community activities;
  • Family and caregiver supports, including training and education and respite care;75
  • Adaptive services for accessibility, including home modifications such as wheelchair ramps; and
  • Other services, including housing locator services.

In January 2014, CMS published a Final Rule regarding Medicaid HCBS.76 The Final Rule specifies that service planning for participants in Medicaid HCBS programs must be developed through a person-centered planning process that addresses health and long-term services and support needs in a manner that reflects individual preferences and goals, including those related to community participation, employment, health care and wellness, and education. The rule describes minimum requirements for person-centered plans developed through this process, which must include an independent assessment of the individual's functioning and needs for services and supports to achieve personally defined outcomes in the most integrated community setting.

Some psychosocial rehabilitation services may be included as HCBS benefits, or covered under Medicaid's rehabilitative services option. Covering these services as HCBS benefits may provide more flexibility for using Medicaid to cover psychosocial services that help people function in community housing, regardless of whether functional impairments are related to mental illness, substance use disorder, or other health conditions. Because HCBS benefits may include habilitation, as well as rehabilitation, these benefits may provide opportunities to deliver services and supports that help people develop new skills for community living, as well as helping to restore skills that have been lost as a result of a disabling health or behavioral health conditions.

For people transitioning to the community from institutional settings, CMS permits coverage for one-time transition expenses under HCBS waiver programs. Community transition services are nonrecurring set-up expenses necessary to enable a person to establish a basic household and do not constitute room and board.77 These expenses may include security deposits; essential household furnishings; set-up fees or deposits for utilities; services necessary for health such as pest eradication, moving expenses, home accessibility adaptations; and activities to assess need, arrange for, and procure necessary resources. Community transition services are furnished only to the extent that they are reasonable and necessary as determined through the person-centered planning process and clearly identified in the service plan.

5.8.1. Supporting Housing Stability with HCBS

A priority need for people experiencing chronic homelessness is access to housing, while the priority for people living in PSH is being able to maintain housing stability. For this to happen, the primary care, mental health care, and substance use treatment that are central to recovery work best if integrated with housing-related services. Provisions to accomplish this integration are built into the community psychiatric support and treatment services offered to participants in Louisiana's PSH Program under the state's 1915(i) SPA78 and include the following:

  • Providing restoration, rehabilitation, and support to develop skills to locate, rent, and keep a home; for landlord/tenant negotiations; for selecting a roommate, and for understanding renter's rights and responsibilities.

  • Assisting the individual to develop daily living skills specific to managing their own home, including managing their money and medications and using community resources and other self-care requirements.

Louisiana also sought and received approval for amendments to their HCBS waivers to incorporate similar services for any PSH Program clients receiving these services. Medicaid waivers allow states to establish caps for the number of participants who may receive waiver services, and also allow states to waive some requirements related to offering comparable services to all people with similar needs who are enrolled in Medicaid in the state. This allows Louisiana to link eligibility for these services to people who live in a housing unit that is part of the state's PSH program. Wording for this waiver is shown in box below.

EXHIBIT 5.1. Possible Service Definitions for Two New Housing Services Provided under 1915(c) Waiver
1. Housing Stabilization Services
Service Definition (Scope):

Housing Stabilization Services enables waiver participants to maintain their own housing as set forth in the participant's approved POC. Services must be provided in the home or a community setting. The service includes the following components:

  1. Participate in POC renewal and updates as needed, incorporating elements of the housing support plan.
  2. Provide supports and interventions per the individualized housing support plan. If additional supports or services are identified as needed outside the scope of Housing Stabilization Services, communicate the needs to the Support Coordinator.
  3. Provide ongoing communication with the landlord or property manager regarding the participant's disability, accommodations needed, and components of emergency procedures involving the landlord or property manager.
  4. Update the housing support plan annually or as needed due to changes in the participant's situation or status.
Specify Applicable (if any) Limits on the Amount, Frequency, or Duration of this Service:

This service is only available upon referral from the Support Coordinator. This service is not duplicative of other waiver services including support coordination. This service is only available to persons who are residing in a State of Louisiana PSH unit. No more than 72 units of Housing Stabilization Services can be used per year without written approval from the Support Coordinator. No more than 165 units of Housing Transition or Crisis Intervention and Housing Stabilization Services can be used per year without written approval from the Support Coordinator.

2.Housing Transition or Crisis Intervention Services
Service Definition (Scope):

Housing Transition or Crisis Intervention Services enable participants who are transitioning into a PSH unit, including those transitioning from institutions, to secure their own housing or provide assistance at any time the participant's housing is placed at risk (e.g., eviction, loss of roommate or income). The service includes the following components:

  1. Conduct a housing assessment identifying the participant's preferences related to housing (type, location, living alone or with someone else, accommodations needed, other important preferences) and needs for support to maintain housing (including access to, meeting terms of lease, and eviction prevention); to budget for housing/living expenses; to obtain/access sources of income necessary for rent, home management, and establishing credit; and to understand and meet obligations of tenancy as defined in lease terms.
  2. Assist participant to view and secure housing as needed. This may include arranging or providing transportation. Assist participant in securing supporting documents/records, completing/submitting applications, securing deposits, and locating furnishings.
  3. Develop an individualized housing support plan based upon the housing assessment that includes short-term and long-term measurable goals for each issue, establishes the participant's approach to meeting the goal, and identifies where other provider(s) or services may be required to meet the goal.
  4. Participate in the development of the POC, incorporating elements of the housing support plan.
  5. Look for alternatives to housing if PSH is unavailable to support completion of transition.
  6. Communicate with the landlord or property manager regarding the participant's disability, accommodations needed, and components of emergency procedures involving the landlord or property manager.
  7. If at any time the participant's housing is placed at risk (e.g., eviction, loss of roommate or income), Housing Transition or Crisis Intervention Services will provide supports to retain housing or locate and secure housing to continue community-based supports including locating new housing, sources of income, etc.
Specify Applicable (if any) Limits on the Amount, Frequency, or Duration of this Service:

This service is only available upon referral from the Support Coordinator. This service is not duplicative of other waiver services including support coordination. This service is only available to persons who are residing in a State of Louisiana PSH unit or who are linked for the State of Louisiana PSH selection process. No more than 93 units of Housing Transition or Crisis Intervention can be used per year without written approval from the Support Coordinator. No more than 165 units of Housing Transition or Crisis Intervention and Housing Stabilization Services can be used per year without written approval from the Support Coordinator.

 

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