Using Medicaid for Housing Services

1. Using Medicaid for Housing Services Making the Deal Work: Missouri Housing Summit July 2014 Peggy Bailey CSH Peggy.bailey@csh.org

2. CSH: Who We Are

3. Our Mission Advancing housing solutions that:

4. Maximizing Public Resources CSH collaborates with communities to introduce housing solutions that promote integration among public service systems, leading to strengthened partnerships and maximized resources. • Public Systems • Maximized Resources

5. Building Strong, Healthy Communities Locations where CSH has staff stationed Locations where CSH has helped build strong communities

6. What We Do CSH is a touchstone for new ideas and best practices, a collaborative and pragmatic community partner, and an influential advocate for supportive housing. • Powerful capital funds, specialty loan products and development expertise Research-backed tools, trainings and knowledge sharing Custom community planning and cutting-edge innovations Systems reform, policy collaboration and advocacy

7. Initial Q&A/Discussion

8. Questions • To what degree does Medicaid finance services now? • What are your challenges in addressing health needs of residents? • In what ways does services financing impact housing creation? • To what degree are health care decisions driving affordable/supportive housing without input from housing entities? • Is there coordination between housing based case management and health home care coordinators? • What tools are you looking for to help?

9. Health Homes • Missouri leading the nation • Primary Care • Behavioral Health • Improve and achieve savings • Increasingly hard to serve population • Link care coordination with housing case management (find a way to pay for case mgmt)

10. Motivation

11. Health and Housing Integration • Services financing is difficult • Residents have increasingly complex needs • Mainstream system – not working • Evidence of supportive housing cost savings and health improved outcomes • Passage of Affordable Care Act

12. MedicaidAdvantages • Predictable services funding source • Covers both primary and behavioral health • Strengthens partnership with health system (PSH residents need access to the mainstream system) • Improved chronic disease management

13. Medicaid Limitations • States restrict Medicaid billable providers • General Reimbursement • Can be slow • May not support team oriented care • Requires strong administrative infrastructure • Does not cover all PSH services • Experts estimate that Medicaid has ways to fund between 80 – 90% of services in PSH • Things like housing search, move-in expenses, and related case management are not usually covered MOSTLY THIS IS FIXABLE!!!

14. Medicaid Basics

15. Medicaid Fundamentals

16. Health System Themes

17. Triple AIM

18. Social Determinants of Health

19. Housing as a Social Determinant • Usual means: • Location (no grocery store, lack other neighborhood supports) • Age of the house (lead paint, mold, unsafe water pipes, etc) • Housing overcrowding, etc • For homeless, chronically ill populations - the lack of housing itself dictates health outcomes • This lack of community based housing has impact on health and the health system than a typical social determinant

20. De-Institutionalization • New Medicaid HCBS Rule • Need to separate housing and services • Consumer Choice • States creating implementation plans • Olmstead Enforcement • Improving Assessment and Targeting • Cost Savings Potential

21. Engaging Health System

22. Things to Remember: Medicaid Agency • Medicaid is not a social service program – it is an insurance program • Medicaid agencies have goals – put supportive housing in their terms • Cost savings • Lead with service component of supportive housing • Come with suggestions • Medicaid isn’t the only piece of the puzzle and may not work for all supportive housing providers

23. Things to Remember: Managed Care • Not unlimited flexibility • Must operate within construct of state contract arrangement • Only serve those in their network • Serving more and more high need members • Open to non-traditional partners • Cost savings and member HEALTH outcomes must be measured

24. Messages for Providers • Hospitals • Frequent Users/Emergency Room • Reduce Readmissions • Improving Discharge planning • Community Health Centers and Behavioral Health Clinics • Helping residents make appointments • Adherence to medical advice • Improving Outcomes • Managed Care Networks • Reducing costs • Improving quality and outcomes • Improving access to services

25. Housing Services As Medicaid Benefits

26. Supportive Housing Services

27. Traditional Medicaid • Usually Mental Health Population • Medicaid Rehab Option • Assertive Community Treatment Teams • General behavioral health services • Peer Support • Case management • Crisis Intervention • Outreach and Engagement • Targeted Case Management • Not used often due to narrow population and restrictions on billing • Washington state – for substance use treatment population • 1115 Waivers

28. 1115 Waivers

29. Home and Community Based Services • Louisiana • Several 1915 waivers and 1915i State Plan Amendment • Used Katrina funds to assist with housing component and admin • MCO led – Magellan • Assisted by Technical Assistance Collaborative (TAC) • Targets – Homeless, institutionalized, and multiple chronic conditions • Integrates housing and support services as a package

30. Health Homes, ACOs and Housing

31. Managed Care Specific Initiatives

32. State Investment Recognized Need for Rental Assistance and Capital Investment • New York • FY 2012 – 2013 - $75 million in capital, rental subsidies and services • FY 2013 – 2014 - $86 million • FY 2014 – 2015 - $100 million (in Governor’s proposed budget) • FY 2015 – 2016 - $160 million (in Governor’s proposed budget) • Philadelphia • Longest running example • City operated not for profit MCO • Reinvests Medicaid savings into supportive housing (state only portion)

33. Billing Medicaid

34. Things to Consider • Can you generate revenue that matches your costs? • How many of your SH residents eligible? • Do you provide services that are (should be) Medicaid billable? • Does your staff meet Medicaid provider qualifications? • Does (or can) your agency meet standards necessary to bill Medicaid in your state? (certifications, accounting and data infrastructure, etc) • Are there opportunities in your state to change existing Medicaid eligibility, benefits and provider agencies? • Are there partnerships you can create to access Medicaid reimbursement for your residents?

35. Building Health Partners Directly billing Medicaid is NOT for everyone…. • Hospitals • Community Health Centers/FQHCs • Behavioral Health Clinics • Managed Care Networks • Health Homes • Accountable Care Networks • Managed Care Organizations • Health Homes • Accountable Care Organizations

36. Partnerships

37. Moving the Ball Forward • Issues for payers (States, Managed Care, ACOs, Health Homes) • Intersection of Case Management and Care Coordination • Paying for both with limited resources (before savings are captured) • Developing payment model • Defining roles • Identifying appropriate housing partners • Shortage of affordable housing • Issues for Federal Government • Learned from Money Follows the Person Demonstrations • Important Services Include: • Pre-Tenancy Supports • Tenancy Supports • Case management • Avoiding Long Term Subsidy • HUD still has a responsibility • Ensure subsidy stays if/when service need decreases

38. Contact Info Peggy Bailey Senior Policy Advisor CSH 202-715-3985 ext. 30 Peggy.bailey@csh.org