The Source for Housing Solutions Creating a Medicaid Supportive Housing Services Benefit Washington State Conference on Ending Homelessness. May 22, 2014

Maximizing Public Resources Public Systems CSH creates housing solutions that integrate public service systems to strengthen partnerships and maximize resources. Integrating supportive housing and healthcare is a top priority. Maximized Resources

White Paper  King County Committee to End Homelessness identified lack of mainstream service funds as a major barrier to taking supportive housing to scale.  Chronic Homeless Advisory Council requested federal technical assistance funds to write a white paper on how to make supportive housing services a reimbursable service in Medicaid.  SAMHSA is funding the white paper. (Wants a document that can be used for other states as well.)  CSH is writing the White Paper.  WLIHA is leading state-wide stakeholder engagement.

White Paper I. Background  Homelessness  What supportive housing is  How Medicaid works  Related Efforts in Washington State II. The missing link between supportive housing and healthcare  Homelessness and Health Needs  Supportive Housing’s Impact on Health  Current Barriers to paying for supportive housing services with Medicaid  Creating a Medicaid Supportive Housing Services Benefit

White Paper III. Five Components of Benefit Implementation 1.Eligibility 2.Package of Services 3.State Plan Changes 4.Financing and Reinvestment Strategies 5.Operationalizing the Benefit

Supportive Housing Coordinated Services Housing: Affordable Permanent Independent Support: Flexible Voluntary Tenant-centered Supportive housing combines affordable housing with services that help people who face the most complex challenges to live with stability, autonomy and dignity. Employment Services Case Management Primary Health Services Mental Health Services Substance Abuse Treatment Parenting/ Coaching Life Skills Affordable Housing

Medicaid 1.Medicaid is not a social service program. It is an insurance program. 2.Medicaid must operate within the construct of State agreements with the federal government (Medicaid State Plan) and (often) Managed Care Organizations. 3.Cost savings and member HEALTH outcomes must be measured. 4.Medicaid isn’t the only piece of the puzzle.

Supportive Housing is the Solution. Washington State wants to address the triple aim of Health Care.  Supportive housing improves care.  Supportive Housing improves health.  Supportive housing reduces costs and uses Medicaid dollars more efficiently.  Washington can address its healthcare goals and pay for the supportive housing services that end chronic homelessness. High Quality Health System Reduce Costs Improve Care Improve Health

Medicaid Crosswalk: Gaps (1 of 3) Medicaid can pay for many supportive housing services, but there are barriers to doing so within today’s structure. People with mental illnesses Theoretically, the largest opportunity to pay for supportive housing services exists for this population. However:  Outpatient caseloads cannot provide the depth of services required.  There is not enough funding in the system to pay for the intensive package of services delivered in supportive housing.  Services are not housing-based.

Medicaid Crosswalk: Gaps (2 of 3) People with Chemical Dependency  Paid on fee-for-service basis  Not enough funding to pay for the full range of health and housing services needed People with chronic health conditions that do not have behavioral health needs  No funding for health services outside of behavioral health in supportive housing

Medicaid Crosswalk: Gaps (3 of3) All people who need supportive housing  Outreach and engagement are not covered by Medicaid.  Many transportation costs not covered.  Most services must be delivered face-to-face.  Services can only be provided by licensed behavioral health agencies and credentialed staff. (Many supportive housing providers are not behavioral health agencies.)

Medicaid Supportive Housing Services Benefit  Provides a mechanism through which Medicaid can pay for supportive housing services.  Enables Washington State to use its Medicaid dollars more efficiently to address the serious health conditions of its most vulnerable residents and act on its public policy goal of ending chronic homelessness.

Five Components of Benefit Design EligibilityService Package State Plan Changes Financing and Reinvestment Strategies Operationalizing the Benefit

1. Eligibility Health Conditions Housing Status System Costs

2. Package of Services Tenancy Supports Housing Case Management Services are housing-based. A team of professionals supports the individual in recovery and stabilization.

3. State Plan Changes Home and Community-Based Services: Allows beneficiaries with disabilities to receive services in their own home or community as an alternative to institutional care. 1915i State Plan Amendments  Allows states to implement without a waiver.  Must established needs-based eligibility criteria less than that of institutional care.  Must be state-wide.  Can not limit the number served.  Does not have to be cost-neutral to the federal government.  Must ensure to feds that state funds are available to cover the need.

Home & Community Based Services State Example: Louisiana Multiple waivers and the state plan amendment to address needs after Katrina for people with long-term disabilities in need of housing and services with low-incomes. Will result in 3,000 units of PSH. Primarily scattered-site housing.

1115 Waivers Allows for a wide array of flexibility for States to demonstrate and research service delivery models.  Must be cost neutral to the federal government.  Can target specific populations.  Can cover services not typically reimbursed by Medicaid. State Example: New York Proposed dramatic changes and significant focus on supportive housing. Targeted high cost Medicaid beneficiaries. Wanted to pay for housing- capital and operating. 1 ½ years of negotiation. Answer from CMS? Will reinvest savings into services, operating, and housing.

1115 Waivers State Example: Rhode Island Requested a separate service package for people experiencing chronic homelessness that the state would pay providers to deliver using a bundled or case rate payment. CMS decision anticipated summer 2014.

4. Investment and Reinvestment  Preliminary financial modeling using data only for high-cost beneficiaries suggests a positive ROI for creating the benefit.  The next level of analysis will involve a number of additional factors:  Costs of people already in supportive housing  Predictive cost modeling to identify other beneficiaries in need  Cost impacts for other systems  Affordable housing investments  Flexible dollars available to pay for what Medicaid cannot If cost-savings are to be achieved, they must be reinvested into the supportive housing system to take the effort to end chronic homelessness to scale.

5. Operationalizing the Benefit Relationships between MCOs and Service Providers  Managed care contracts would have a capitated rate, accountability measures, and incentives for reinvesting cost-savings  Managed care pays providers of supportive housing services on a negotiated basis.  Providers would be licensed to provide benefit services. Connections to existing and emerging Medicaid Programs

Contacts & More Information Kate Baber Homelessness Policy & Advocacy Specialist Washington Low Income Housing Alliance Michele Thomas Policy Director Washington Low Income Housing Alliance Thank you. We want your ongoing input! Debbie Thiele Senior Program Manager CSH