Toolkit
Fall, 2023
A growing number of states are using their Medicaid programs to address the Social Drivers of Health for Medicaid members. This trend includes Housing Related Services (HRS) such as Housing Navigation, Tenancy Sustaining Services and funds for move in costs. The referral processes and details will differ state to state and CSH is tracking those details with an eye to scaling supportive housing services in our communities.
Interest in these details vary by audience. State medicaid offices are interested in which Medicaid authority, delivery system or payment mechanism is used so they can develop their own programs and build on lessons learned of early adopter states. Health centers as referral sources for these services want to how what are the services, the target population and how to make referrals. Supportive housing providers want to know service definitions, provider requirements and rates to see if it makes sense for their agency to contract for these services.
CSH has summarized publicly available material in a system to answer the key questions via audience and state. The tool will be updated twice a year, as programs are evolving quickly. And if you see a section that requires updating, please contact CSH at health@csh.org.
Use the dropdown menu below to learn how states have taken to improve service delivery and financing of the services that cover Housing Related Services (HRS) and are now commonly delivered by supportive housing providers.
Supportive Housing Providers
What providers need to know about their state's coverage of Housing Related Services via Medicaid.
Program Name
Housing and Health Opportunities (H2O)
Status
State Planning Post CMS approval
Health-related Social Needs (HRSN) Waiver approved October 14, 2022.
Implementation Plan
Services Protocol
Services Include
Pre and Post tenancy services, 6 months housing costs including enhanced shelter and outreach
Key Administrative Details
The state is using a Third-Party Administrator.
Delivery System
Third Party Administrator (TPA). Statewide TPA expected to be on board as of 7/1/2024.
Provider Type:
TBD
Payment Methods and Rates
TBD
Program Name
MediCal Transformation
Services Include
Pre and Post tenancy services, 90 days of recuperative care, 6 months housing costs
Key Administrative Details
State using In Lieu of Services (ILOS) in which MCPs decide what services to offer and to whom.
Deliver System
Managed Care Plans (MCPs).
Provider Type:
Agencies can now enroll as a Community Based Organization (CBO) provider type. Providers will submit enrollment applications through the PAVE Provider Portal (ca.gov) online portal.
Payment Methods and Rates
State Non-Binding ILOS Pricing Guidance
Determined by MCPs.
Most plans are using Per Diem or PMPM but that is decided by MCPs.
Program Name
State Wide Supportive Housing Expansion (SWSHE)
Services Include
Pre and Post Tenancy Support Services
Key Administrative Details
The program is currently grant funded via HCBS ARPA funds with the state planning for a Medicaid financing method when grant funds run out in 2024.
Delivery System
Provider Type
Payment Methods and Rates
Web Resources
Program Name
The CT Housing Engagement and Support Services (CHESS) Initiative
Services Include
Pre and post tenancy support services
Key Administrative Details
Administered by Carelon Behavioral Health of Connecticut (ctbhp.com)
Delivery System
Carelon Behavioral Health of Connecticut (ctbhp.com) manages the benefit.
Provider Type
Payment Methods and Rates
Web Resources
Program Name
Housing Supportive Services | dhs (dc.gov), including Housing Stabilization Services and Housing Navigation Services
Services Include
Pre and post tenancy support services
Key Administrative Details
Assessment for the services is integrated into the Coordinated Entry process.
Providers are paid by DC Medicaid on a Per Member, Per Month (PMPM) basis. Rate raised to $770.31 in FY 2023.
Taxonomy Code- Case Management, 251B00000X
Procedures Codes
H00044 U1- Housing Navigation Services
H00044 U2- Housing Stabilization Services
Delivery System
Coordinated Entry is the access point to the benefit.
Coordinated Entry is the system by which all housing referrals are processed within a local Homeless Continuum of Care.
Provider Type
DC created a new Provider Type, Housing Supportive ServicesHousing Supportive Services
Payment Methods and Rates
Taxonomy Code Case Management, 251B00000X
Procedures Codes Housing Navigation H0044 U1; Housing Stabilization Services H00044 U2;
Web Resources
Housing Supportive Services | dhs (dc.gov)
Program Name
Housing Assistance Waiver
Pilot Program in HHS regions 5 and 7.
Services Include
Pre and post tenancy support services
Key Administrative Details
Administered by the Managed Care Organizations (MCOs) in the pilot regions.
State Snapshot of MCOs
Delivery System
Community Mental Health Providers either offer services directly or subcontract with other agencies.
Provider Type
Unclear. State Medicaid provider manual has not been updated online since before the program started.
Payment Methods and Rates
Program Name
Community Integration Services (CIS)
Services Include
Pre and post tenancy support services
Key Administrative Details
Administered by state’s Medicaid Managed Care Organizations (MCOs). State MCO listing
State modifying implementation guidelines to improve access for target population.
Delivery System
Delivered via MCO health plans: AlohaCare, HMSA, Kaiser Permanente, ‘Ohana Health Plan, and UnitedHealthcare Community Plan
Provider Type
Atypical Provider Enrollment is allowed and No NPI is required per
CIS PROVIDER ENROLLMENT Training.
Facility, Agency, or Organization (FAO) enrollment is also allowable for CIS services.
CIS Provider Types:
• PT A3 Community Service Agency
• PT 77 Mental Health Rehab Option (MRO)
-CCS provider
• PT 02 Hospital
Hawaii Online Kahu Utility or HOKU Provider Enrollment System
Payment Methods and Rates
Recommended CIS NPI Taxonomy Codes:
Primary 251S00000X Community/Behavioral Health Secondary 251B00000X Case Management
Outreach- T1023
Support- H0044
Program Name
Permanent Supportive Housing (PSH) Initiative
Services Include
Pre and post tenancy support services
Key Administrative Details
State plan process integrated across housing and services sectors.
Delivery System
A mix of providers and the state. The state web site explains how to apply.
Provider Type
Permanent Supportive Housing Agency. Provider requirements include that the agency must be a Medicaid enrolled provider of CPST and Psychosocial Rehabilitation services
Payment Methods and Rates
No specific taxonomy Code is recommended.
Under HCBS waivers, tenancy supports bill under G9012
State BH plan services
Tenancy Services under CPST- H0036, TG; Tenancy Services under Psychosocial Rehab - H2017, TG;
Web Resources
Program Name
- Community Supports Program for Homeless Individuals (CSP-HI)
- Flexible Services to evolve to Health-Related Social Needs (HRSN) services
Opertaing
For CSP-HI- Code- H2016 Modifier HK and rate is a per diem of rate of $27.72
CSPECH Cost Savings Report- 2017
New Waiver approved 9/28/2022.
DSRIP HRSN Protocol Approved June, 2023
Services Include
Key Administrative Details
- Administered by state’s MCOs
- Administered by ACOs to members of their choosing to reduce costs and improve health
Delivery System
Administered by MCOs
MA ACO (Accountable Care Organization) and MCO (Managed care organizations) listing
Administered by state’s Accountable Care Organizations
Provider Type
Unclear till HRSN implementation plan is approved if CBOs will need to enroll as Medicaid providers, which requires a provider type.
Payment Methods & Rates
No specific taxonomy Code is recommended.
HCPCS code- H2016 HK
Unclear till HRSN implementation plan is approved, if CBOS need to enroll in Medicaid and what information CBOs will need to submit for payment including HCPCS codes.
Web Resources
Program Name
Assistance in Community Integration (ACIS) program
Status
Opertaing
State ACIS Project Website
State Report on program
An updated waiver in 2022 took the program statewide
Services Include
Pre and post tenancy support services
Key Administrative Details
Administered by the counties who are responsible to align with housing resources.
Delivery System
Counties/ Lead Entities to administer the program. Only Baltimore City, Cecil, Montgomery and Prince George’s counties are participating.
Provider Type
Providers are not required to enroll in Medicaid, so provider type not required.
Payment Methods and Rates
Providers are not required to enroll in Medicaid, so taxonomy codes are not required.
HCPS codes are also not required in the billing between the providers and the lead entities. Providers are submitting invoices to the LE not claims.
Website Resources
Program Name
Housing Assistance
SDOH In Lieu of Services
Services Include
TBD
Key Administrative Details
Services are a component of the state’s Behavioral Health Transformation Plan. The benefit is offered through the Prepaid Inpatient Health Plans or PIHPs that manage community behavioral health provider network.
Addressing SDOH needs including potentially Housing Related Services
Delivery System
Administered by the Prepaid Inpatient Health Plans (PHIPs) and in some cases by the Community Mental Health (CMH) clinics
Provider Type
Provider type is Community Mental Health Center
Payment Methods and Rates
No Taxonomy code is recommended in the State Medicaid Provider Manual
HCPCS codes
Housing Assistance is T2038
Community Living Supports is H2015
Web Resources
Program Name
Housing Stabilization Services
Services Include
Pre and Post tenancy services
Key Administrative Details
Benefit administered by MCOs, approved by the state.
Housing Transition reimbursed at $17.17 per 15-minute increment. The code is H2015 U8.
Housing Sustaining reimbursed at $17.17 per 15-minute increment. Code- H2015 U8/TS.[1]
Delivery System
Services are authorized by DHS and managed and paid for by the MCOs.
Provider Type
Provider Type 18- HCBS provider
Payment Methods and Rates
Taxonomy code: 251B00000X - Case Management
Housing Transition code is H2015 U8.
Housing Sustaining Services code- H2015 U8/TS.
Housing Stabilization Services (state.mn.us)
Program Name
Services Include
Pre and Post tenancy services
Key Administrative Details
TBD- Montana is one a few states that does not have Medicaid Managed Care
Delivery System
Provider Type
Provider Type
Payment Methods and Rates
Program Name
Housing Support Services
Status
Opertaing
For a Medicaid funded tenancy support services benefit.
Services Include
TBD
Key Administrative Details
Delivery System
Provider Type
TBD
Payment Methods and Rates
Web Resources
Program Name
Housing Stabilization Services
Status
State Planning post CMS approval
The State Plan Amendment is approved and the state is developing regulations to govern operations
Services Include
TBD
Program capped at 50 people
Key Administrative Details
Administration is TBD but the state’s current Home and Community Based Services programs is administered by Managed Care
Delivery System
State Medicaid Office, Department of Health and Human Services (DHHS)
Provider Type
Payment Methods and Rates
Web Resources
Program Name
Housing Transition and Tenancy Sustaining Services as part of a Health-Related Social Needs program
Status
State Planning post-CMS approval
The HRSN 1115 waiver is approved as of 3/30/2023 and the state is developing regulations to govern operations.
Services Include
TBD
Key Administrative Details
TBD
Delivery System
Managed Care
Provider Type
TBD in the implementation Plan
Payment Methods and Rates
TBD in the implementation Plan
Web Resources
Program Name
Supportive Housing Units, including capital funds
Status
Operating
Program is called Linkages and provides state funded rental assistance with Medicaid services for those with Behavioral health Challenges
Updated Centennial Care 2.0 waiver includes growing the program
Services Include
Pre and post tenancy services
Key Administrative Details
The Services are administered by Managed Care
Delivery System
Managed care
Provider Type
Limited to Behavioral Health Services Division and state approved providers
Payment Methods and Rates
State Linkages Policy Manual recommends Certified Peer Support Workers (CPSW) using a H0044 code but the Behavioral Health Billing Manual uses H00043.
Web Resources
Program Name
Social Determinants of Health (SDOH) Initiatives can include Housing Support Services.
Status
Operating
State Program Website
Services Definitions and Fee Schedules updated March, 2023
Services Include
Key Administrative Details
Lead Pilot Entities (LPE) are operating as Community Care Hubs supporting CBOS administratively.
Delivery System
Pilot program administered by regional Healthy Opportunities Network Leads
Provider Type
Payment Methods and Rates
Taxonomy and HCPCS codes not included in the state’s Service Definition and Fee Schedules
Web Resources
Program Name
Housing Support Services
Status
Operating
The state has an approved 1915(i) SPA. Services began on February 2, 2021.
The rate is $10.49 per 15-minute increment. The code is H2021 U4.
Services Include
Pre and post tenancy services
Key Administrative Details
Providers bill the state for the traditional Medicaid population or an MCO for those who are part of the Medicaid Expansion population.
Delivery System
Administered by the state for the Traditional Medicaid population and the MCO for the expansion population
Provider Type
Provider type 25, Provider Type 25- Agency
Payment Methods and Rates
Web Resources
Program Name
Health-related services can include housing services. Housing services are optional for Coordinated Care Organizations (CCOs) to fund.
Health Related Social Needs (HRSN) services including Housing Support Services
Status
Operating
The state is working to incentivize CCOS to offer tenancy supports to pair with new housing-related resources that are coming online.
State Health-Related Services Overview
State Planning post CMS approval
Housing Services GO LIVE, November 2024 for those at risk of Homelessness.
State submitted Implementation Plan in August 2023.
Waiver approved 9/28/22
Services Include
TBD by the CCOs
Pre and post tenancy services
Rental Assistance
Housing Transition Costs
Key Administrative Details
Coordinated Care Organizations or CCOs are Oregon’s community focused evolution of Managed Care.
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State working with CCOs to implement and TPA for individuals who are not CCO members
Provider Type
TBD, needs additional state/CMS plans to be approved.
Payment Methods and Rates
TBD, needs additional state/CMS plans to be approved.
HCPCS codes- H0043 U1
$20.24 for a 15 minute increment
Program Name
Tenancy Support Services for intellectual or developmental disability/developmental disability (IDD/DD) population
Status
Operating
The state has added tenancy support services to the menu of services for persons eligible for the IDD waiver.
Services Include
Key Administrative Details
Delivery System
Via Managed Long-Term Services and Supports
Payment Methods and Rates
HCPCS codes- H0043 U1
$20.24 for a 15 minute increment
Web Resources
Program Name
Home Stabilization Services
Services Include
Home FIND and Home Stabilization Services
Delivery System
Services are provided in a Fee for Service System and providers bill the state.
Provider Type
Not required.
Payment Methods and Rates
The per month rate per member is $331.84
Program Name
Supported Home Living
Services Include
Supported home living services that could be used in Supportive Housing
Key Administrative Details
Delivery System
Provider Type
Payment Methods and Rates
TBD
Web Resources
Program Name
Housing Related Services and Supports
Status
Operating
Waiver Approved 6/30/2022
Services Include
Tenancy Support Services, Community Transition Services and Supportive Living Services
Key Administrative Details
Services are authorized by state HRSS staff
HCPCS Billing Code: T2024 – Tenancy Support Service - $18.37 per 15 minutes
HCPCS Billing Code: T2038 – Community Transition Services, 2 episodes per 5-year period per person up to $2,000 per each occurrence
HCPCS Billing Code: T2017 – Supportive Living Service - $18.37 per 15 minutes
Delivery System
Provider Type
TBD
Payment Methods and Rates
TBD
Web Resources
Program Name
Supportive Housing Assistance Pilot Program
Services Include
Key Administrative Details
Delivery System
TBD- state operates most of the Medicaid program with a single state controlled MCO.
Provider Type
TBD
Payment Methods and Rates
TBD
Program Name
High Needs Support Benefit
Status
Planning
CMS approved the waiver as of July 9, 2020.
The state timeline for implementation is TBD.
High Needs Support (virginia.gov)
Services Include
Key Administrative Details
Delivery System
Provider Type
Program Name
Foundational Community Supports (FCS) for supportive housing and supportive employment services.
Status
Operating
The waiver was approved and implemented as of January 1, 2018.
State Program Website
State Planning post-CMS approval
Waiver renewal approved June 30, 2023
Services Include
Pre and Post tenancy services and supported employment services
A variety of Health-Related Social Needs services including pre and post tenancy services, housing transitional costs and rental assistance
Key Administrative Details
The state is using a Third-Party Administrator to simplify administrative processes.
Wellpoint (formerly Amerigroup) Provider Manual
Using Billing Codes H0043 Community Support services: daily rate of $112 with a benefit limitation of 30 days over 180 days.
Delivery System
The state is using a Third-Party Administrator to manage the program. Amerigroup won a competitive bid for this contract. Amerigroup is now called Wellpoint.
Wellpoint Provider Manual
Provider Type
Provider One Enrollment Guide
FCS Providers enroll as a facility, agency, organization or institution (FAOI) provider
The state’s third party administrator has a FCS Provider Application that that does not require a Provider Type but does require a Washington Medicaid Provider ID
Payment Methods and Rates
Per Diem rate of $112 with a benefit limitation of 30 days over 180 days.
Web Resources
Program Name
CHIP Housing Support Initiative
Housing Support Services
Services Include
-Housing Consultation
-Transition Supports
-Sustaining Supports
-Relocation Supports
-Housing Consultation
-Transition Supports
-Sustaining Supports
-Relocation Supports
Key Administrative Details
State is granting funds to8 family supportive housing agencies in 4 COCs
Delivery System
Provider Type
Payment Methods and Rates
Web Resources
What Health Centers Need to Know to Support Patients
Spring, 2024
As of early 2024, twenty-three states are covering or in the process of implementing Housing Related Services (HRS) to help Medicaid recipients obtain and maintain housing in their community. It is understood that housing status has a significant impact on a person’s ability to effectively connect with the healthcare system and maintain good health and as such, Federally Qualified Health Centers serving individuals experiencing homelessness or housing instability will want to assist their patients with accessing these services. Communities wishing to improve health equity will also need a specific equity strategy to ensure access to services for BIPOC (Black, Indigenous, and People of Color), considering that these populations suffer from higher rates of homelessness, housing instability and institutionalization.
CSH provides regular updates in a state by state Policy Brief with analysis on HRS program implementation. This brief builds on that analysis with focus on accessing these services for health center patients and other health care and community systems now screening for the Social Drivers of Health (SDOH). While waivers may have broad populations listed as eligible, our analysis will focus on state’s implementation plans and what populations are eligible for these services and when.
Most states cover a similar range of services including pre-tenancy or housing navigation services, tenancy sustaining services and move in assistance. Some states are covering short term rental assistance via Health-Related Social Needs Waivers as an additional service.
As health system providers learn of their patient's Health-Related Social Needs, they will want to have on hand easy ways to refer for assistance.
Use the dropdown menu below to learn how to access these services in each state that has been implemented or is in the process of implementation. In states with recently approved waivers, the process may not be in place yet, but CSH will update this summary as state processes are determined and therefore the acronym TBD (To Be Determined) is used. While CSH updates the research regularly, if you are aware of changes needed to this brief, please reach out to CSH at health@csh.org.
Access and Referral Services
Program Name
Housing and Health Opportunities (H2O)
Target Population
People experiencing homelessness, those leaving institutions or congregate care and child welfare involved families.
Eligibility:
State’s initial focus is on people who are experiencing homelessness with serious mental illness.
Services Include
Pre and Post tenancy services, 6 months housing costs including enhanced shelter and outreach
Key Administrative Details
The state is using a Third-Party Administrator.
Recommended referral action
State “GO LIVE” date to offer HRS is 10/1/2024. Contact the TPA AFTER this date for a referral.
Program Name
Target Population
People experiencing homelessness is one of many priority populations
Eligibility
MCPs decide on what services are offered, to what populations and process.
Services Include
Pre and Post tenancy services, 6 months housing costs
Key Administrative Details
State using In Lieu of Services (ILOS) in which MCPs decide what services to offer and to whom.
Recommended referral action
Contact member’s MCP to determine if the person is eligible and how to access services.
Program Name
The CT Housing Engagement and Support Services (CHESS) Initiative
Target Population
Homeless and higher health care utilization than to be expected based on diagnosis
Eligibility
For Patients 18+
HUD Homeless or HUD homeless prior to institutionalization.
Individuals have a higher-than-expected inpatient rate based upon a state predictive analytics score of expected health care usage, called the HEDIS ALL Cause Readmission measure.
1 Critical need or difficulty with Activities of Daily Living (ADL).
Services Include
Pre and post tenancy support services
Key Administrative Details
Administered by Carelon Behavioral Health of Connecticut (ctbhp.com)Carelon Behavioral Health of Connecticut (ctbhp.com)
Recommended referral action
Apply CT CHESS - Home (ctchessdss.com)
For people without an Intensive Case Manager or ICM[JB1] , contact Carelon.
What does this acronym stand for? [JB1]
Web Resources
Program Name
Housing Supportive Services | dhs (dc.gov), including Housing Stabilization Services and Housing Navigation Services
Target Population
Homeless as identified by the city’s Coordinated Entry System
Eligibility:
Patient must require assistance with maintaining housing due to issues with:
- mobility,
- decision making,
- healthy social relationships
- help with one basic need such as self-care or money management AND
Is experiencing or at risk for chronic homelessness, homelessness or housing instability
Services Include
Pre and post tenancy support services
Key Administrative Details
Assessment for the services is integrated into the Coordinated Entry process.
Providers are paid by DC Medicaid on a Per Member, Per Month (PMPM) basis. Rate raised to $770.31 in FY 2023.
Taxonomy Code- Case Management, 251B00000X
Procedures Codes H00044 U1- Housing Navigation Services
H00044 U2- Housing Stabilization Services
Recommended referral action
Contact the City’s Coordinated Entry System or collaborate with an agency that offers homeless outreach services.
Web Resources
Housing Supportive Services | dhs (dc.gov)
Program Name
Housing Assistance Waiver
Pilot Program in HHS regions 5 and 7.
Target Population includes
Homelessness
Eligibility
Persons who are homeless or at risk of homeless and suffer from a serious mental illness and/or substance use disorder
Services Include
Pre and post tenancy services
Key Administrative Details
Administered by the Managed Care Organizations (MCOs) in the pilot regions.
State Snapshot of MCOs
Recommended referral action
Ensure the patient is connected to the local behavioral health system services. If you are not sure, contact the local Managing EntityManaging Entity for your county.
Program Name
Community Integration Services (CIS)
Target Population includes
Individuals with a behavioral health, physical illness, or substance use diagnosis and are chronically homeless.
Eligibility
Individuals with a behavioral health, physical illness, or substance use diagnosis and are chronically homeless.
Services Include
Pre and post tenancy services
Key Administrative Details
Administered by state’s Medicaid Managed Care Organizations (MCOs). State MCO listing
State modifying implementation guidelines to improve access for target population.
Program Name
Permanent Supportive Housing (PSH) Initiative
Target Population includes
Low-income populations with disabilities.
Eligibility
Low-income populations with disabilities.
Services Include
Pre and Post tenancy Services
Key Administrative Details
State plan process integrated across housing and services sectors.
Recommended referral action
Process differs for south and north Louisiana. Contact info and process for each is found on the State PSH websiteState PSH website
Web Resources
Program Name
- Community Supports Program for Homeless Individuals (CSP-HI)
- Flexible Services to evolve to Health-Related Social Needs (HRSN) services
Target Population includes
- Chronically Homeless and being expanded to homeless in the new waiver
- TBD by each ACO and their community partners.
Eligibility
- Persons experiencing homelessness or housing instability with behavioral health challenges that interfere with their ability to access health care services.
- TBD by the ACOs (Accountable Care Organizations).
Services Include
Key Administrative Details
- Administered by state’s MCOs
- Administered by MCOs and ACOs to members of their choosing to reduce costs and improve health
Recommended referral action
- Contact MCO or ACO that covers the individual.
- Contact the ACO that covers the individual you are serving.
Web Resources
Program Name
Assistance in Community Integration (ACIS) program
Target Population includes
Homeless or at risk, institution or high risk of institutional placement AND 4 or more hospital visits in a year & 2+ chronic conditions.
Eligibility
Homeless or at risk, institution or high risk of institutional placement AND 4 or more hospital visits in a year & 2+ chronic conditions.
Services Include
Key Administrative Details
Administered by the counties who are responsible to align with housing resources.
Recommended referral action
In Baltimore City, contact the Mayor’s Office of Homeless Services.
In the other three counties, contact the local Health department and ask how to access the ACIS program.
Website Resources
Program Name
Housing Assistance
SDOH In Lieu of Services
Target Population includes
Persons with serious mental illness, serious emotional disturbance and/or intellectual/developmental disabilities.
TBD by MCOs
Eligibility
Persons with serious behavioral health challenges.
Process and other eligibility criteria determined by the PHIPs.
Services Include
TBD
Key Administrative Details
Services are a component of the state’s Behavioral Health Transformation Plan. The benefit is offered through the Prepaid Inpatient Health Plans or PIHPs that manage community behavioral health provider network.
Addressing SDOH needs including potentially Housing Related Services
Recommended referral action
Contact your local Prepaid Inpatient Health plans
Web Resources
Program Name
Housing Stabilization Services
Target Population includes
People with disabilities, homeless or housing unstable.
Eligibility
- Medicaid eligible
- 18 and older Documented disability
Need assistance with in at least one of the following areas - Mobility
- Communication
Managing Challenging Behaviors or Decision Making
Services Include
Pre and Post tenancy services
Key Administrative Details
Benefit administered by MCOs, approved by the state.
Housing Transition reimbursed at $17.17 per 15-minute increment. The code is H2015 U8.
Housing Sustaining reimbursed at $17.17 per 15-minute increment. Code- H2015 U8/TS.
Recommended referral action
Submit the DHS-7948-ENG (Housing Stabilization Services Eligibility Request) (mn.gov) to DHS
Program Name
Housing Stabilization Services
Target Population includes
Homeless or at risk of homelessness and needing assistance for community living.
Eligibility
Needs assistance in maintaining housing due to a disability and needs assistance in:
1. Mobility
2. Decision Making
3. Relationships
At least one basic need
Services Include
TBD Program capped at 50 people
Key Administrative Details
Administration is TBD but the state’s current Home and Community Based Services programs is administered by Managed Care
Recommended referral action
Not clear at this time.
Web Resources
Program Name
Housing Transition and Tenancy Sustaining Services as part of a Health-Related Social Needs waiver
Target Population includes
Persons with disabilities, formerly incarcerated, formerly homeless or at risk of homelessness, transitioning from institution and/or beneficiaries who are transitioning out of high-risk or unstable housing situations.
Eligibility
- Homeless or at risk of homeless
- Transitioning from Institution to community
- Released from Correctional settings
- At risk of institutionalization due to SMI (Serious Mental Illnesses) or SUD (Substance Use Disorder)
- Transitioning out of unstable housing
- M-LTSS MCOs can identify
Services Include
TBD
Key Administrative Details
TBD
Recommended referral action
GO Live date has not been set as of early, 2024, however will be administered by MCOs, so likely contact the person’s MCO.
Web Resources
Program Name
Supportive Housing Units, including capital funds
Target Population includes
Those with Serious Mental Illness
Eligibility
Persons with Behavioral Health Challenges identified by MCOs
Services Include
Pre and post tenancy services
Key Administrative Details
The services are administered by Managed Care
Recommended referral action
Contact the person’s MCO
Web Resources
Program Name
Social Determinants of Health (SDOH) Initiatives can include Housing Support Services.
Target Population includes
Three regions in the state, all rural, were awarded funding to operate Healthy Opportunities Pilots to offer SDOH services.
Eligibility
Have a qualifying diagnosis and a qualifying social risk factor
Services Include
Key Administrative Details
Lead Pilot Entities (LPE) are operating as Community Care Hubs supporting CBOS administratively.
Recommended referral action
If the person lives in a Healthy Opportunities Pilot Region, contact the local Network Lead
Web Resources
Program Name
Housing Support Services
Target Population includes
People with behavioral health challenges who are experiencing homelessness and housing instability.
Eligibility
Persons with behavioral health challenges
Services Include
Pre and post tenancy services
Key Administrative Details
Providers bill the state for the traditional Medicaid population or an MCO for those who are part of the Medicaid Expansion population.
Recommended referral action
Contact Blue Cross for expansion population members.
For Traditional Medicaid, apply through the State portal.State portal.
Web Resources
Program Name
Health-related services can include housing services. Housing services are optional for Coordinated Care Organizations (CCOs) to fund.
Health Related Social Needs (HRSN) services including Housing Support Services
Target Population includes
The target population is not specified in the waiver. CCOs can choose to include services as an optional benefit under health-related services.
People at risk of homelessness, those leaving institutions or congregate care and child welfare involved families.
Services for those experiencing homelessness do not have a GO LIVE date set.
Eligibility
OHA members who are in a variety of Life Transitions.
Services Include
TBD by the CCOs
Pre and post tenancy services
Rental Assistance
Housing Transition Costs
Key Administrative Details
Coordinated Care Organizations or CCOs are Oregon’s community focused evolution of Managed Care.
State working with CCOs to implement and TPA for individuals who are not CCO members
Recommended referral action
Referral forms will be standard statewide but differ according to HRSN service.
Referral forms for Climate Related Services are available
Go live date for housing services is November 2024.
Program Name
Tenancy Support Services for intellectual or developmental disability/developmental disability (IDD/DD) population
Target Population includes
Those already eligible for IDD waivers. The process remains the same as before the waiver.
Eligibility
Persons with Intellectual and Developmental Disabilities and registered with the state system.
Services Include
Key Administrative Details
Web Resources
Program Name
Home Stabilization Services
Target Population includes
Persons with behavioral health or intellectual disabilities and those institutionalized or at risk of institutionalization
Eligibility
Medicaid enrolled patients
Services Include
Home FIND and Home Stabilization Services
Recommended referral action
Complete and submit a Home Stabilization Prior Authorization Form to the state.
Program Name
Supportive Housing Assistance Pilot Program
Target Population includes
Persons who are 18 and older and need assistance with at least one needs-based criteria and have one or more risk factors.
Eligibility
TBD
Services Include
TBD
Key Administrative Details
TBD
Recommended referral action
TBD
Program Name
Foundational Community Supports (FCS) for supportive housing and supportive employment services.
Continuation of the FCS program described above AND expansion of Health-Related Social Needs Services including housing
Target Population includes
People experiencing chronic homelessness, individuals with frequent or lengthy adult residential care stays, individuals with frequent turnover of in-home caregivers, and those at highest risk for expensive care and adverse outcomes.
Populations include chronic homeless, institutionalized or at risk of institutionalization
Eligibility
FCS referral guide
18 and older Medicaid eligible
(1) assessed health needs-based criteria
(1) risk factor including homelessness
Services Include
Pre and Post tenancy services and supported employment services
A variety of Health-Related Social Needs services including pre and post tenancy services, housing transitional costs and rental assistance
Key Administrative Details
The state is using a Third-Party Administrator to simplify administrative processes
Wellpoint (formerly Amerigroup) Provider Manual
Using Billing Codes H0043 Community Support services: daily rate of $112 with a benefit limitation of 30 days over 180 days.
State will continue to use a TPA for FCS, as well as work with their Accountable Communities of Health (ACHs) to roll out the services via Community Based Organizations or CBOs
Recommended referral action
Submit the Foundational Community Supports Referral Form to the Third-Party Administrator, Wellpoint
Web Resources
Medicaid Offices
Spring, 2024
Medicaid Offices
What state Medicaid officials can learn from other early adopter states regarding key policy and implementation details.
Program Name
Housing and Health Opportunities (H2O)
Status
State Planning Post CMS approval
Health-related Social Needs (HRSN) Waiver approved October 14, 2022.
Implementation Plan
Services Protocol
Medicaid Authority
1115 Waiver
Target Population includes
People experiencing homelessness, those leaving institutions or congregate care and child welfare involved families
Delivery System
Third Party Administrator (TPA). Statewide TPA expected to be on board as of 7/1/2024.
Provider Type:
TBD
Taxonomy and HCPCS Codes
TBD
Payment Methods and Rates
TBD
Policy documents
Draft Implementation Protocol
Program Name
MediCal Transformation
Medicaid Authority
1115 waiver and 1915(b) State Plan Amendment
Target Population includes
People experiencing homelessness is one of many priority populations
Deliver System
Managed Care Plans (MCPs).
Provider Type:
Agencies can now enroll as a Community Based Organization (CBO) provider type. Providers will submit enrollment applications through the PAVE Provider Portal (ca.gov) online portal.
Taxonomy and HCPCS Codes
State Guidance recommends a taxonomy code of 251X00000X - Supports Brokerage
State guidance -Housing Transition and Navigation H0043, U6; Housing Deposits H0044, U2; Housing Sustaining Services T2014, U6 or T2051, U6.
Payment Methods and Rates
State Non-Binding ILOS Pricing Guidance
Determined by MCPs.
Most plans are using Per Diem or PMPM but that is decided by MCPs.
Policy documents
DHCS Community Supports Policy Guide (ca.gov)- updated July, 2023
Program Name
State Wide Supportive Housing Expansion (SWSHE)
Medicaid Authority
ARPA HCBS Plan for services and HUD Emergency Housing Vouchers (EHV) for housing subsidies.
Target Population includes
Persons experiencing homelessness, multiple disabling conditions, and high health/crisis system utilization.
Delivery System
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
Policy documents
Program Name
The CT Housing Engagement and Support Services (CHESS) Initiative
Medicaid Authority
1915 (i) State Plan Amendment (SPA)
Target Population includes
Homeless and higher health care utilization than to be expected based on diagnosis
Delivery System
Carelon Behavioral Health of Connecticut (ctbhp.com) manages the benefit.
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
Program Name
Housing Supportive Services | dhs (dc.gov), including Housing Stabilization Services and Housing Navigation Services
Medicaid Authority
1915(i) SPA
Target Population includes
Homeless as identified by the city’s Coordinated Entry System
Delivery System
Coordinated Entry is the access point to the benefit.
Coordinated Entry is the system by which all housing referrals are processed within a local Homeless Continuum of Care.
Provider Type
DC created a new Provider Type, Housing Supportive ServicesHousing Supportive Services
Taxonomy and HCPCS Codes
Taxonomy Code Case Management, 251B00000X
Procedures Codes Housing Navigation H0044 U1; Housing Stabilization Services H00044 U2;
Payment Methods and Rates
Taxonomy Code Case Management, 251B00000X
Procedures Codes Housing Navigation H0044 U1; Housing Stabilization Services H00044 U2;
Program Name
Housing Assistance Waiver
Pilot Program in HHS regions 5 and 7.
Medicaid Authority
1115 Waiver Amendment
Target Population includes
Homelessness
Delivery System
Community Mental Health Providers either offer services directly or subcontract with other agencies.
Provider Type
Unclear. State Medicaid provider manual has not been updated online since before the program started.
Taxonomy and HCPCS Codes
Payment Methods and Rates
Program Name
Community Integration Services (CIS)
Medicaid Authority
1115 Waiver
Target Population includes
Individuals with a behavioral health, physical illness, or substance use diagnosis and are chronically homeless.
Delivery System
Delivered via MCO health plans: AlohaCare, HMSA, Kaiser Permanente, ‘Ohana Health Plan, and UnitedHealthcare Community Plan
Provider Type
Atypical Provider Enrollment is allowed and No NPI is required per
CIS PROVIDER ENROLLMENT Training.
Facility, Agency, or Organization (FAO) enrollment is also allowable for CIS services.
CIS Provider Types:
• PT A3 Community Service Agency
• PT 77 Mental Health Rehab Option (MRO)
-CCS provider
• PT 02 Hospital
Hawaii Online Kahu Utility or HOKU Provider Enrollment System
Taxonomy and HCPCS Codes
Recommended CIS NPI Taxonomy Codes:
Primary 251S00000X Community/Behavioral Health Secondary 251B00000X Case Management
Outreach- T1023
Support- H0044
Payment Methods and Rates
Recommended CIS NPI Taxonomy Codes:
Primary 251S00000X Community/Behavioral Health Secondary 251B00000X Case Management
Outreach- T1023
Support- H0044
Program Name
Permanent Supportive Housing (PSH) Initiative
Medicaid Authority
State Plan Services
Target Population includes
Low-income populations with disabilities.
Delivery System
A mix of providers and the state. The state web site explains how to apply.
Provider Type
Permanent Supportive Housing Agency. Provider requirements include that the agency must be a Medicaid enrolled provider of CPST and Psychosocial Rehabilitation services
Taxonomy and HCPCS Codes
No specific taxonomy Code is recommended.
Under HCBS waivers, tenancy supports bill under G9012
State BH plan services
Tenancy Services under CPST- H0036, TG; Tenancy Services under Psychosocial Rehab - H2017, TG;
Payment Methods and Rates
No specific taxonomy Code is recommended.
Under HCBS waivers, tenancy supports bill under G9012
State BH plan services
Tenancy Services under CPST- H0036, TG; Tenancy Services under Psychosocial Rehab - H2017, TG;
Program Name
- Community Supports Program for Homeless Individuals (CSP-HI)
- Flexible Services to evolve to Health-Related Social Needs (HRSN) services
Opertaing
For CSP-HI- Code- H2016 Modifier HK and rate is a per diem of rate of $27.72
CSPECH Cost Savings Report- 2017
New Waiver approved 9/28/2022.
DSRIP HRSN Protocol Approved June, 2023
Target Population includes
- Chronically Homeless and being expanded to homeless in the new waiver
- TBD by each ACO and their community partners.
Delivery System
Administered by MCOs
MA ACO (Accountable Care Organization) and MCO (Managed care organizations) listing
Administered by state’s Accountable Care Organizations
Provider Type
Unclear till HRSN implementation plan is approved if CBOs will need to enroll as Medicaid providers, which requires a provider type.
Taxonomy and HCPCS Codes
No specific taxonomy Code is recommended.
HCPCS code- H2016 HK
Unclear till HRSN implementation plan is approved, if CBOS need to enroll in Medicaid and what information CBOs will need to submit for payment including HCPCS codes.
Payment Methods & Rates
No specific taxonomy Code is recommended.
HCPCS code- H2016 HK
Unclear till HRSN implementation plan is approved, if CBOS need to enroll in Medicaid and what information CBOs will need to submit for payment including HCPCS codes.
Program Name
Assistance in Community Integration (ACIS) program
Status
Opertaing
State ACIS Project Website
State Report on program
An updated waiver in 2022 took the program statewide
Medicaid Authority
1115 Waiver
Target Population includes
Homeless or at risk, institution or high risk of institutional placement AND 4 or more hospital visits in a year & 2+ chronic conditions.
Delivery System
Counties/ Lead Entities to administer the program. Only Baltimore City, Cecil, Montgomery and Prince George’s counties are participating.
Provider Type
Providers are not required to enroll in Medicaid, so provider type not required.
Taxonomy and HCPCS Codes
Providers are not required to enroll in Medicaid, so taxonomy codes are not required.
HCPS codes are also not required in the billing between the providers and the lead entities. Providers are submitting invoices to the LE not claims.
Payment Methods and Rates
Providers are not required to enroll in Medicaid, so taxonomy codes are not required.
HCPS codes are also not required in the billing between the providers and the lead entities. Providers are submitting invoices to the LE not claims.
Program Name
Housing Assistance
SDOH In Lieu of Services
Medicaid Authority
1915 (i) SPA as of October 2023
Via Managed Care Contracts
Target Population includes
Persons with serious mental illness, serious emotional disturbance and/or intellectual/developmental disabilities.
TBD by MCOs
Delivery System
Administered by the Prepaid Inpatient Health Plans (PHIPs) and in some cases by the Community Mental Health (CMH) clinics
Provider Type
Provider type is Community Mental Health Center
Taxonomy and HCPCS Codes
No Taxonomy code is recommended in the State Medicaid Provider Manual
HCPCS codes
Housing Assistance is T2038
Community Living Supports is H2015
Payment Methods and Rates
No Taxonomy code is recommended in the State Medicaid Provider Manual
HCPCS codes
Housing Assistance is T2038
Community Living Supports is H2015
Policy documents
Program Name
Housing Stabilization Services
Medicaid Authority
1915 (i) SPA
Target Population includes
People with disabilities, homeless or housing unstable.
Delivery System
Services are authorized by DHS and managed and paid for by the MCOs.
Provider Type
Provider Type 18- HCBS provider
Taxonomy and HCPCS Codes
Taxonomy code: 251B00000X - Case Management
Housing Transition code is H2015 U8.
Housing Sustaining Services code- H2015 U8/TS.
Payment Methods and Rates
Taxonomy code: 251B00000X - Case Management
Housing Transition code is H2015 U8.
Housing Sustaining Services code- H2015 U8/TS.
Housing Stabilization Services (state.mn.us)
Program Name
Medicaid Authority
1115 Waiver
Target Population includes
People with behavioral health challenges who are experiencing homelessness or housing instability.
Delivery System
Provider Type
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
Program Name
Housing Support Services
Status
Opertaing
For a Medicaid funded tenancy support services benefit.
Medicaid Authority
1915(i) SPA
Target Population includes
TBD
Delivery System
Provider Type
TBD
Taxonomy and HCPCS Codes
Payment Methods and Rates
Policy documents
Program Name
Housing Stabilization Services
Status
State Planning post CMS approval
The State Plan Amendment is approved and the state is developing regulations to govern operations
Medicaid Authority
1915(i) SPA, which is a Home and Community Based Services (HCBS) program
Target Population includes
Homeless or at risk of homelessness and needing assistance for community living.
Delivery System
State Medicaid Office, Department of Health and Human Services (DHHS)
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
Policy documents
Program Name
Housing Transition and Tenancy Sustaining Services as part of a Health-Related Social Needs program
Status
State Planning post-CMS approval
The HRSN 1115 waiver is approved as of 3/30/2023 and the state is developing regulations to govern operations.
Medicaid Authority
1115 Waiver
Target Population includes
Persons with disabilities, formerly incarcerated, formerly homeless or at risk of homelessness, transitioning from institution and/or beneficiaries who are transitioning out of high-risk or unstable housing situations.
Delivery System
Managed Care
Provider Type
TBD in the implementation Plan
Taxonomy and HCPCS Codes
TBD in the implementation Plan
Payment Methods and Rates
TBD in the implementation Plan
Policy documents
Program Name
Supportive Housing Units, including capital funds
Status
Operating
Program is called Linkages and provides state funded rental assistance with Medicaid services for those with Behavioral health Challenges
Updated Centennial Care 2.0 waiver includes growing the program
Medicaid Authority
1115 waiver
Target Population include
Those with Serious Mental Illness
Delivery System
Managed care
Provider Type
Limited to Behavioral Health Services Division and state approved providers
Taxonomy and HCPCS Codes
State Linkages Policy Manual recommends Certified Peer Support Workers (CPSW) using a H0044 code but the Behavioral Health Billing Manual uses H00043.
Payment Methods and Rates
State Linkages Policy Manual recommends Certified Peer Support Workers (CPSW) using a H0044 code but the Behavioral Health Billing Manual uses H00043.
Policy documents
Program Name
Social Determinants of Health (SDOH) Initiatives can include Housing Support Services.
Status
Operating
State Program Website
Services Definitions and Fee Schedules updated March, 2023
Medicaid Authority
1115 Waiver
Target Population include
Three regions in the state, all rural, were awarded funding to operate Healthy Opportunities Pilots to offer SDOH services.
Delivery System
Pilot program administered by regional Healthy Opportunities Network Leads
Provider Type
Taxonomy and HCPCS Codes
Taxonomy and HCPCS codes not included in the state’s Service Definition and Fee Schedules
Payment Methods and Rates
Taxonomy and HCPCS codes not included in the state’s Service Definition and Fee Schedules
Policy documents
Program Name
Housing Support Services
Status
Operating
The state has an approved 1915(i) SPA. Services began on February 2, 2021.
The rate is $10.49 per 15-minute increment. The code is H2021 U4.
Medicaid Authority
1915 (i) SPA
Target Population include
People with behavioral health challenges who are experiencing homelessness and housing instability.
Delivery System
Administered by the state for the Traditional Medicaid population and the MCO for the expansion population
Taxonomy and HCPCS Codes
Taxonomy Code 251B00000X
Provider Type
Provider type 25, Provider Type 25- Agency
Payment Methods and Rates
Policy documents
Program Name
Health-related services can include housing services. Housing services are optional for Coordinated Care Organizations (CCOs) to fund.
Health Related Social Needs (HRSN) services including Housing Support Services
Status
Operating
The state is working to incentivize CCOS to offer tenancy supports to pair with new housing-related resources that are coming online.
State Health-Related Services Overview
State Planning post CMS approval
Housing Services GO LIVE, November 2024 for those at risk of Homelessness.
State submitted Implementation Plan in August 2023.
Waiver approved 9/28/22
Medicaid Authority
1115 Waiver that creates Coordinated Care Organizations (CCOs)
1115 Waiver
Target Population include
The target population is not specified in the waiver. CCOs can choose to include services as an optional benefit under health-related services.
People at risk of homelessness, those leaving institutions or congregate care and child welfare involved families
Services for those experiencing homelessness do not have a GO LIVE date set
Provider Type
TBD, needs additional state/CMS plans to be approved.
Taxonomy and HCPCS Codes
TBD, needs additional state/CMS plans to be approved.
Payment Methods and Rates
TBD, needs additional state/CMS plans to be approved.
HCPCS codes- H0043 U1
$20.24 for a 15 minute increment
Program Name
Tenancy Support Services for intellectual or developmental disability/developmental disability (IDD/DD) population
Status
Operating
The state has added tenancy support services to the menu of services for persons eligible for the IDD waiver.
Medicaid Authority
1915 (i) SPA
Target Population include
Those already eligible for IDD waivers. The process remains the same as before the waiver
Delivery System
Via Managed Long-Term Services and Supports
Taxonomy and HCPCS Codes
State does not weigh in on this, but
Case Management or Care Coordinator- (171M00000X) OR
In Home Supportive Care Agency (253Z00000X) seem most appropriate
Payment Methods and Rates
HCPCS codes- H0043 U1
$20.24 for a 15 minute increment
Policy documents
Program Name
Home Stabilization Services
Medicaid Authority
1115 waiver
Target Population include
Persons with behavioral health or intellectual disabilities and those institutionalized or at risk of institutionalization
Delivery System
Services are provided in a Fee for Service System and providers bill the state.
Provider Type
Not required.
Taxonomy and HCPCS Codes
No state recommended Taxonomy Code
HCPCS- H0044 for Home Tenancy and H0044 u1 for Home Find
Payment Methods and Rates
The per month rate per member is $331.84
Program Name
Supported Home Living
Medicaid Authority
1915(i) SPA
Target Population include
Persons with serious mental illness.
Delivery System
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
TBD
Policy documents
Program Name
Housing Related Services and Supports
Status
Operating
Waiver Approved 6/30/2022
Medicaid Authority
1115 Waiver
Target Population include
Generally, has a Behavioral Health challenge and is homeless or at risk of homelessness.
Delivery System
Provider Type
TBD
Taxonomy and HCPCS Codes
Payment Methods and Rates
TBD
Policy documents
Program Name
Supportive Housing Assistance Pilot Program
Medicaid Authority
1115 Waiver
Target Population include
Persons who are 18 and older and need assistance with at least one needs-based criteria and have one or more risk factors.
Delivery System
TBD- state operates most of the Medicaid program with a single state controlled MCO.
Provider Type
TBD
Taxonomy and HCPCS Codes
TBD
Payment Methods and Rates
TBD
Program Name
High Needs Support Benefit
Status
Planning
CMS approved the waiver as of July 9, 2020.
The state timeline for implementation is TBD.
High Needs Support (virginia.gov)
Medicaid Authority
1115 Waiver
Target Population include
State to develop target criteria that include health-related needs-based measures and risk factors
Delivery System
Provider Type
Policy documents
Program Name
Foundational Community Supports (FCS) for supportive housing and supportive employment services.
Status
Operating
The waiver was approved and implemented as of January 1, 2018.
State Program Website
State Planning post-CMS approval
Waiver renewal approved June 30, 2023
Medicaid Authority
1115 Waiver
1115 Waiver Renewal
Target Population include
People experiencing chronic homelessness, individuals with frequent or lengthy adult residential care stays, individuals with frequent turnover of in-home caregivers, and those at highest risk for expensive care and adverse outcomes.
Populations include chronic homeless, institutionalized or at risk of institutionalization
Delivery System
The state is using a Third-Party Administrator to manage the program. Amerigroup won a competitive bid for this contract. Amerigroup is now called Wellpoint.
Wellpoint Provider Manual
Provider Type
Provider One Enrollment Guide
FCS Providers enroll as a facility, agency, organization or institution (FAOI) provider
The state’s third party administrator has a FCS Provider Application that that does not require a Provider Type but does require a Washington Medicaid Provider ID
Taxonomy and HCPCS Codes
Taxonomy Code- Case Management 251B0000X
HCPCS codes- Using Billing Codes H0043 Community Support services:
Payment Methods and Rates
Per Diem rate of $112 with a benefit limitation of 30 days over 180 days.
Policy documents
Program Name
CHIP Housing Support Initiative
Housing Support Services
Medicaid Authority
Children’s Health Insurance Program (CHIP)
1915(i) SPA
Target Population include
Low-income families experiencing homelessness to address equity issues in both health and homeless assistance systems.
Medicaid beneficiaries with Behavioral Health needs, who are experiencing homelessness or at imminent risk of homelessness
Delivery System
Provider Type
Taxonomy and HCPCS Codes
Payment Methods and Rates
Policy documents
