Funding Housing Supports with Medicaid 1115 Waivers

December 14, 2023

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:

Intervention Description
1. Rent/temporary housing (+/- utilities) for up to 6 months Limited to: individuals transitioning out of institutional care or congregate settings; individuals who are homeless, at risk of homelessness, or transitioning out of an emergency shelter as defined by 24 CFR 91.5; and/or youth transitioning out of the child welfare system
2. Traditional respite services Temporary, short-term relief for primary caregivers provided by an at-home provider, a health care facility, or an adult day center
3. Day habilitation programs & sobering centers For <24 hours, no room and board
4. Pre-tenancy & tenancy sustaining services Including tenant rights education and eviction prevention
5. Housing transition navigation services Including individualized case management
6. One-time transition & moving costs Including security deposit, first month’s rent, utilities activation fees, movers, relocation expenses, application and inspection fees, fees to meet identification requirements, etc.
7. Medically necessary home accessibility modifications & remediation services Including carpet replacement, mold and pest removal, and ventilation improvements
8. Medically necessary home environment modifications As needed for medical treatment and prevention, including air conditioners, heaters, air filtration devices, and generators

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:

CSG East 1115 Waivers including housing support
State Waiver Name Approved Housing Support
Massachusetts MassHealth 11/03/2023 (i) Pre-tenancy and tenancy sustaining services, (ii) transition navigation services, (iii) one-time transition and moving costs, (iv) medically necessary environment and accessibility modifications.
New Jersey FamilyCare Comprehensive Demonstration 9/13/2023 (i) Medically necessary environment and accessibility modifications, (ii) pre-tenancy and tenancy sustaining services, (iii) transition navigation.
Vermont Global Commitment to Health 11/21/2023 (i) Pre-tenancy and tenancy sustaining services, (ii) transition navigation, (iii) transition and moving costs, (iv) medically necessary environment and accessibility modifications.

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.

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