Funding Housing Supports with Medicaid 1115 Waivers

Federal Medicaid funding is available for states to invest in housing supports using 1115 demonstration waivers. Medicaid 1115 Waivers grant states flexibility to design experimental pilot projects if they serve the general objectives of the Medicaid program. Although 1115 waivers may allow the most flexibility over program design, housing supports can be funded through a variety of Medicaid authorities, and states should determine which options best serve their intended outcomes.

• The Department of Housing and Urban Development advises states to consider the selection of target populations and the scope of housing services that will be provided under a Medicaid benefit.
• The Centers for Medicare and Medicaid Services (CMS) published guidance on which housing services can be provided under the various programs.

Since 2020, CMS has increased its efforts to address social determinants of health (SDOH) and health-related social needs (HRSN), which includes housing stability. “These needs, when unmet, can drive lapses in coverage and access to care, higher downstream medical costs, worse health outcomes, and perpetuation of health inequities,” according to the agency. CMS also created the Healthy Adult Opportunity (HAO), under authority of section 1115(a)(2), providing states with more flexibility to provide coverage to some populations not otherwise eligible for Medicaid benefits.

Guidance from CMS on “Addressing Health-Related Social Needs in Section 1115 Demonstrations” includes the following list of available services and basic descriptions:

States with Approved 1115 Waivers to Fund Housing Supports

CMS maintains a State Waivers List for approved and pending 1115 waivers, including application and approval documentation, along with other supporting materials. Approvals nationwide can also be found using KFF’s Medicaid Waiver Tracker.

A few states in the Northeast have recently been approved for housing support services:

New Provisions for HRSN services

Approvals for Massachusetts and New Jersey allowed both states to fund expanded services for health-related social needs, including housing supports. In each of the approval letters, specific services are described (see p. 118 for MA and p. 85 for NJ). Only specific populations are eligible, and strict protocols must be followed to implement and monitor the program.

Vermont’s Supportive Housing Assistance Pilot

The approval of Vermont’s waiver allowed the state to establish its Supportive Housing Assistance Pilot. The new program will fund assistance with locating and applying for housing, assistance with maintaining benefits, development of living skills, eviction protection services, help with security and utility deposits, and other additional services (see p. 134).

Vermont Legal Aid, a group in support of the program, called upon the legislature to offer perspectives on program design, help to track progress of program implementation, and, if necessary, help to make additional resources available in the program’s initial stages.

Applying for 1115 Waivers

The Centers for Medicare and Medicaid Services provides detailed guidance on the application process, while precise application procedures can be found in Sec. 431.412 of Medicaid’s Review and Approval Process for Section 1115 Demonstrations. In brief, applications must include:

1. Comprehensive descriptions of the program, goals, and delivery system.
2. Current enrollment data and projections.
3. Research hypotheses in support of proposed changes.
4. Evidence of budget neutrality.
5. Compliance with public notice requirements.

States may also submit a pre-application concept paper or confer with CMS prior to submitting the application.

For state officials interested in applying for Medicaid 1115 Waivers, the first step is to contact your State Medicaid Agency.