Medicaid and PSH- A Quick History Josh Crites

1. Medicaid and PSH- A Quick History Josh Crites Assistant Director- Housing Authority of Washington County Andrea Bell Homeless Services Manager Oregon Housing and Community Services Lori Kelley SDOH and Housing Manager Oregon Health Authority

2. 2015- A Memo but Not the Beginning • On June 26, 2015, the Centers for Medicare and Medicaid Services (CMS) issued an Informational Bulletin to “assist states in designing Medicaid benefits, and to clarify the circumstances under which Medicaid reimburses for certain housing-related activities, with the goal of promoting community integration for individuals with disabilities, older adults needing long-term services and supports, and those experiencing chronic homelessness.”

3. Housing Transition Individual housing transition services help individuals transition from institutions to community-based housing. These services include, among others, tenant screening and housing assessments that identify enrollees’ preferences and barriers to successful tenancy; development of a housing support plan; assistance with the housing application and search process; assistance with one-time move-in expenses, such as security deposit; arranging for details of the move; and development of a crisis plan that includes prevention and early intervention services when housing is jeopardized.

4. Individual Housing ant Tenancy Sustaining Services • Individual housing and tenancy sustaining services help individuals maintain tenancy after housing is secured. Tenancy support services include education and training on tenants’ and landlords’ role, rights, and responsibilities; assistance in resolving disputes with landlords and neighbors to reduce the risk of eviction; assistance with housing recertification; and others.

5. State Level Housing Services State-level housing services are “strategic, collaborative” activities to assist in identifying and securing housing resources. Among the activities for which Medicaid financing is available are development of agreements with local housing and community development agencies to facilitate access to housing resources, and participation in these agencies’ planning processes

6. Medicaid Funding Explained • Medicaid cannot pay for everyone or everything- • Capitation • Each state defines who can receive certain benefits and how much can be allocated • Fee for service • Value based contracting

7. City/County Philadelphia-Limited to High Utilizers • County manages behavioral health benefit. • Partnered with Medicaid and homeless systems to provide Medicaid benefits for most vulnerable homeless in city/county • Data on Philadelphia’s PSH initiative show that, of the roughly 1,200 chronically homeless participants brought into PSH over the last eight years, 89 percent remain in stable housing and are not using crisis services. • BH costs rose initially when the programs got underway because the use of behavioral health services increased • However, costs dropped substantially after people were housed. For example, the City’s behavioral health costs were $85 per day per person for individuals in the Safe Haven program two years prior to their entry into the program. These costs rose to $112 during the engagement period, then fell to $18 once the person was housed.

8. Louisiana- Post Katrina • After Katrina, the state made a commitment to build PSH units after the Hurricane • They quickly realized that service dollars coming in after the hurricane would dry up and made impressive partnerships with Medicaid to provide services • Limited to persons with significant, long term disability and receiving Medicaid or Ryan White services • This can include individuals with developmental and mental health issues. • Medicaid Department selects organizations that provide tenancy supports. Must receive rigorous training related to tenancy support services before being approved to be a PSH provider.

9. Louisiana- Post Katrina

11. New York- Branding PSH • Re-entry Scatter-Site Permanent Supportive Housing (PSH) Initiative provides rental subsidies, case management and employment counseling to persons with substance abuse problems who are being released on parole to New York City. The Re-Entry PSH Initiative was designed to address the anticipated demand for housing resulting from the Drug Law Reform, with a special focus on parolees returning to their communities.  • Medicaid Re-Design Team (MRT) Permanent Supportive Housing (PSH) Initiative is targeted for individuals with addiction problems who are high frequency, high cost Medicaid consumers in New York State. Increasing the availability of affordable and supportive housing for high-need Medicaid beneficiaries who are homeless, precariously housed or living in institutional settings has been identified as a significant opportunity for reducing Medicaid cost growth. The program components include rental subsidies and other occupancy costs for apartments, program supervision, housing counseling, and employment counseling.

12. New York’s Bureau of Social Determinants of Health • Empire State Supportive Housing Initiative (ESSHI) provides operational and supportive services funding to Providers for the development of new or rehabbed housing units for persons identified as homeless with special needs, conditions, or other life challenges. • The Continuum of Care (CoC) Rental Assistance Program is funded through HUD and is designed to link rental assistance with supportive services for homeless and disabled persons and their families. HUD provides funding for rental assistance through a direct contract with housing provider agencies. Housing Providers deliver or arrange supportive services for individuals and families participating in the program. OASAS provides state-aid funding to Providers that is dedicated exclusively for Case Management and delivery of supportive services to the participants in the CoC Rental Assistance Program. OASAS programs serve persons with a primary diagnosis of substance use disorder. Participants may have co-occurring disabilities such as mental illness and/or HIV/AIDS.

13. Arizona Medicaid Program • AB

14. Partnering with Public Housing to Create PSH- Housing Authorities are well positioned • Three components of PSH are Development, Rental Subsidy and Services • Public Housing Authorities are setup to handle development and rental subsidy but not services. • Services at the PHA level are normally resident services and not meant to assist individuals at a clinical level.

15. Development at a PHA Housing Authorities • Some housing authorities have development departments • This allows the housing authority to create new affordable housing units through a mixture of tax credit funding, bond funding and other sources. • Some housing authorities partner with developers in lieu of actually developing themselves. • Development by a PHA or in partnership with a developer can help increase the number of affordable units in the market

16. Rental Assistance What is it? Why Important? • Housing Authorities control most of the rental assistance within their jurisdictions. • The rental assistance allows low income individuals to pay only what they can afford for rent • Housing Authorities can take the voucher and project base it to deeply affordable units to ensure a development can generate enough cash flow • There are limits on project basing but it is one of the most powerful tools available to ensure low-income units are developed

17. PSH and Services What is Needed • Most Public Housing Authorities do not have capacity to deliver intensive services • Without intense services, building, tenancy and neighbors at risk • Paying rent on time, conflict resolution, cleanliness, noise violations, guests violations

18. Examples of Partnerships Phoenix- Project H2 • Governor’s goal council • Medicaid system braiding funding • Long-term need • Maricopa County PHA, Phoenix PHA and Tempe PHA • Medicaid delivered services

19. Examples of Partnerships Legacy Village- Maricopa County • Housing Authority leading development • Housing Authority providing project based vouchers • Medicaid system through behavioral health system providing services • 15 units dedicated to Medicaid member with SPMI

20. Examples of Partnerships Creston Avenue- New York • $2.6 million gap financing from Medicaid Department • $4.6 million from Homeless Housing Assistance Program • 1/3 of the units supported housing for high need Medicaid users • 2/3 affordable housing • Buying units for capital investments is the strategy for Medicaid in NYC

21. Examples of Partnerships San Mateo County • Skilled Nursing Facility closed with no where to send vulnerable population • The health plan provided transition case management services • Brilliant Corners provided housing navigation to find units • Housing Authority provided project based vouchers • Institute on Aging provided ongoing case management and plans • Ongoing partnership with Housing Authority to set aside 10% of all new units in senior housing projects for this population coming out of skilled nursing facilities.

22. Ways to Engage • Come to the table with clear idea about what gap or need your organization has • Respite beds • End of life services • Transition out of hospital beds • Step down opportunities • What does the housing authority have that might benefit your population • What resources can you bring to the table? • Real estate • Assist in purchasing real estate • Monthly payments • Infusion of cash into capital projects • Two sides should continue talks to see what could be possible