Innovative ways for Medicaid to promote supportive housing

Federal law prohibits federal matching of state Medicaid room-and-board spending, aside from nursing facility services. However, there are a variety of ways in which Medicaid can contribute to “integrated strategies” to bolster “supportive housing,” or affordable housing combined with support services to encourage health and recovery following living transitions resulting from homelessness, hospitalization, incarceration, or aging out of foster care. A Kaiser Family Foundation (KFF) report analyzed three innovative programs in action today.

A 2015 Center for Medicaid and CHIP Services (CMCS) informational bulleting outlined three housing-related activities covered by Medicaid: individual housing transition services from institutions to community-based housing; individual housing and tenancy sustaining services; and state-level housing services that aid in identifying and securing housing resources, as well as services available via section 1915(b) and (c) waivers, section 1115 demonstration waivers, targeted case management services, and demonstrations established through the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) (see Federal funding available for some Medicaid housing related activities, Health Law Daily, June 29, 2015). KFF suggested that managed care plan initiatives, health homes established by the ACA, State Innovation Models, and accountable care organizations (ACOs) are other vehicles linking Medicaid with supportive housing.

The report analyzed three models of integration. The City of Philadelphia, also a county, established a single-payer system for public behavioral health care of as permitted by law; 85 percent of the population served is Medicaid-eligible. Medicaid provides a source of payment for health services received by eligible individuals house under the Permanent Supportive Housing (PSH) initiative through three separate programs that offer: services to those experiencing chronic homelessness and severe psychiatric disorders; residential substance use disorder treatment to individuals with a history of chronic homelessness and long-term addiction; and temporary shelter during inclement weather while addressing substance use problems. Louisiana used its Medicaid state plan authority to cover tenancy support services to support PSH, which targets low-income, disabled individuals, most of whom are Medicaid beneficiaries. Mercy Maricopa Integrated Care, a Phoenix, Arizona managed care organization (MCO), provides permanent supportive housing services to adults with serious mental illness (SMI), most of whom are Medicaid beneficiaries.

The KFF authors determined that the three models demonstrate that efforts to integrate Medicaid with supportive housing “can be tailored to align with specific policy goals,” such as the reduction of chronic homelessness or the reduction of unnecessary institutionalization of the mentally ill. Integration efforts can improve patterns of health care use and reduce Medicaid costs. However, they face “operational challenges,” such as differing housing administration and Medicaid structures, complexity and fragmentation within systems, and multiple funding streams. Success can only be achieved through strong leaders entering into committed partnerships.

Medicaid plans as shifting as the sands, states weighing options

State Medicaid programs continue to change in response to various factors, from Florida changing its hepatitis C treatment policy to favor patients, to non-expansion states considering the financial impact of potential options. Louisiana just began enrolling the newly eligible this week, and the state projects that many more will seek coverage. South Dakota’s governor is employing some creative techniques to argue that expansion will not cost the state additional funds, and North Carolina is trying to shift plan oversight to outside organizations.

Florida and Hepatitis C

Florida is now providing vital medications to Medicaid patients with hepatitis C at an earlier stage of the disease. In the past, patients have only been offered the drug when they were at fibrosis level three or four, which indicates a high level of scar tissue in the liver and is sometimes the point where patients are in need of a transplant. These drugs are expensive to the program, costing as much as $31,000 each month. Florida amended its program criteria on June 1, 2016, removing the fibrosis level from the criteria.

Louisiana, welcome to Medicaid expansion

Louisiana opened its enrollment process to those newly eligible under the program’s expansion on June 1. The Department of Health and Hospitals (DHH) projects that about 375,000 individuals will eventually receive coverage under the expansion, although the department has been communicating with about 175,000 people about qualification. It is uncertain what effect this will have on other Louisiana health issues, such as doctor training programs. Budgetary problems, including proposed cuts to hospitals, is causing residents to go out of state for training- where they are likely to stay. Safety net hospitals, which treat many poor and uninsured patients, are particularly concerned about the reduction in funding as the state legislature attempts to resolve a budget shortfall.

Utah’s expansion comes with much less fanfare

After Utah’s legislature decided to pass a very reduced expansion plan, one that Democrats bemoaned as a “cruel trick” and “fiscal insanity,” little has been said about the matter–an extreme contrast to years of fighting over the plan of action. The plan will provide coverage to somewhere around 10,000 citizens, a reduced estimate from the original 16,000 tally. Officials expect that the money to be invested in the expansion will not stretch far to cover very many residents due to the high health costs associated with those who have gone without care. Although there has been an opportunity for hearings and public comment, the state has received little input. Some blame the timing of hearings, which would require those interested to come in during a workday, while others believe that the public feels that the legislature is uninterested in their opinions.

North Carolina seeks waiver

North Carolina is requesting that CMS allow it to transfer Medicaid oversight to three managed care organizations and provider-led entities. Although a representative felt that the state provider community has embraced the plan, the state legislature is less than united. The state Senate recently unanimously rejected House changes to its reform bill, which would require the state agency to provide progress reports and disclose a work plan for changes to be made to state health care programs.

South Dakota wants to expand Medicaid without spending more money

South Dakota Governor Dennis Daugaard (R) believes that he can figure out how to expand the state’s Medicaid program to cover about 50,000 more citizens without increasing state spending. Although he believes the math can work if the federal government shoulders more Medicaid costs for Native Americans in the state, the governor is concerned about pushback from the legislature.