Medicaid and Supportive Housing
Medicaid Redesign Team Supportive Housing Initiative
In 2011, Governor Cuomo established a Medicaid Redesign Team (MRT) to devise a comprehensive strategy to reduce costs and improve care in New York State’s Medicaid program, focusing much of its attention on the 20% of high-need Medicaid recipients who use up to 75% of all Medicaid spending.
Initially, housing was not a consideration at the outset of this comprehensive reimagining of New York State’s Medicaid program, and no one with housing expertise sat on the deliberative body. The Network therefore organized a comprehensive education effort that brought over 100 members to testify at the MRT’s public hearings and had a series of high-level meetings with the administration which collectively convinced key decision-makers that homelessness was a social determinant of health and that supportive housing was a critically important intervention that could both improve care for high-cost Medicaid recipients and bring down the cost of that care. At the Network’s 2012 annual conference in June, State Medicaid Director and leader of the MRT, Jason Helgerson, credited the Network for educating him and his staff about supportive housing, as seen in this link.
In the summer of 2011, in response to the Network’s education efforts, the NYS Department of Health (DOH) established an MRT Affordable Housing Workgroup, of which the Network was an active member. The workgroup was charged with evaluating the state’s supportive housing portfolio, identifying barriers to the efficient use of available resources for the development and utilization of supportive housing, and making recommendations intended to overcome those barriers.
DOH also established a $75 million annual commitment to expand supportive housing for high cost/high need Medicaid recipients and asked the workgroup to develop a spending plan for these funds and to identify opportunities for investment of additional resources for expanding supportive housing that would result in savings to the Medicaid program.
On December 13, 2011, the MRT voted unanimously to accept the workgroup’s report and recommendations, including the suggested use of $75 million from the Department of Health earmarked for creation of new units of supportive housing as part of MRT implementation. The state Legislature accepted this allotment as part of the 2012 state budget that was passed in April and formally established and funded a new MRT Supportive Housing Program to provide service funding, rent subsidies and capital dollars to create supportive housing for high-cost Medicaid recipients.
The new program was funded with $75 million of State general funds for year one and an anticipated additional $75 million of State general funds allotted in year two. It also allowed the fund to grow to $150 million annually if the State was able to convince the federal Center for Medicare and Medicaid Services (CMS) to provide matching funds.
Since its inception in 2012, the program has continued to grow with state general fund dollars from $75 million in 2012 to $127 million in 2016. NYS has not, however, received approval for a federal Medicaid waiver for supportive housing, so it is important to note that NYS is not using federal Medicaid funding for supportive housing. The financial support for this program comes solely from funding under the State’s Medicaid cap within DOH’s general fund budget.
Over the past five years, $585 million has been committed through the MRT Supportive Housing Program. This funding has supported supportive housing capital programs, services and operating funding for both supportive and long term care programs, seven pilot programs to support potential interventions to reduce Medicaid costs and tracking and evaluation programs.
Supportive Housing Capital - $200 million
Of the total $585 million in committed MRT funding, approximately $200 million has been dedicated as a capital resource to help fund new supportive housing congregate residences in NYS. To date (August 2016), 44 congregate supportive housing projects with approximately 2300 units of supportive housing have been funded with a portion of the resources coming from the MRT Supportive Housing Program. In each of these projects MRT funding constituted part of the projects’ overall funding, blending MRT funds with other state and/or local resources.
Supportive Housing Services & Operating Funding - $23.5 million
In 2012, the Department of Health (DOH) funded approximately $17.5 million to create and/or link to supportive housing for approximately 1,500 formerly homeless individuals struggling with either mental illness, chronic substance abuse or HIV/AIDS throughout New York State. The units were allocated to three New York State agencies that have experience funding supportive housing: the NYS Office of Mental Health (OMH), the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the Department of Health AIDS Institute (DOH AI).
- OMH MRT Scattered-Site Program - OMH awarded 700 units statewide; 438 beds in New York City (350 of which were in Brooklyn) and 262 units throughout the rest of the state. Eligible clients needed to be either enrolled or eligible for a Health Home or have been referred from a psychiatric hospital. Awardees received the OMH Supported Housing rate of $15,043 to support both the rent and housing based services. Supportive housing case managers were encouraged to work with the Health Home Care Coordinators to help coordinate services. Supportive housing providers could take referrals from the partnering Health Home or through a ground up approach – shelters, hospitals etc. OMH took a very hands-on approach to working with both the supportive housing providers, Health Homes and psychiatric centers, convening a monthly joint meeting for a period of time to troubleshoot challenges in filling units. This assistance was extremely helpful in making the program a success.
- OASAS MRT Scattered Site Program - OASAS awarded 300 units throughout the state. To be eligible for the OASAS program, the person had to be Health Home eligible or enrolled and had to have been either in the emergency room five times over the past twelve months, had two inpatient stay’s over the past twelve months, or a combination of four emergency visits and one inpatient stay over the past twelve months. OASAS funding --$20,000 per person -- paid for rent and rent-associated expenses as well as housing-based services. The supportive housing provider took referrals from Health Homes or through a ground up approach. Supportive housing providers were expected to find a person housing, place them into that housing and then provide housing based services. The care coordinator was responsible for coordinating the tenant’s overall care. OASAS also took a very hands-on approach to helping troubleshoot program challenges including helping determine whether potential tenants met the eligibility criteria and held monthly conference calls to address issues. Awardees felt this approach, along with the agency’s ability to be flexible and accessible, attributed greatly to the program’s success.
- DOH AIDS Institute Program - The Department of Health AIDS Institute (DOH AI) created two different programs under MRT, one for NYC and another for the rest of state. In NYC, the agency provided funding to connect unstably housed individuals with AIDS who had been referred by Health Homes to housing – because the City provides housing to people with AIDS through the City’s HIV/AIDS Services Administration (HASA). Outside NYC, DOH AI provided funding for scattered site supportive housing for Health Home eligibles/enrollees that were both homeless and had AIDS. Downstate, DOH AI estimates the program has served some 500 people through these services; upstate they estimate just under 100 people were served. All awardees were allocated a $140,000 contract.
It should be noted that all three programs faced significant challenges finding suitable apartments at the contract rates. The Network convened upstate and NYC providers under all three programs to discuss lessons learned and offer recommendations for future iterations. Click HERE to read them. For a brochure the Network created to help disseminate information about the various programs, click HERE.
Supportive Housing Health Home Pilot Program - $4 million
In addition, the MRT Supportive Housing Program also funded several long term care and pilot programs aimed at reducing Medicaid expenditures and improving care for various vulnerable populations. One pilot program funded under the MRT Supportive Housing Program specific to supportive housing is the Supportive Housing Health Home Pilot Program. In September of 2014, the Health Home Supportive Housing Pilot awarded ten contracts statewide under the Medicaid Redesign Team Supportive Housing Program (MRTSHP). The awards were made to nonprofit supportive housing providers working in tandem with one or more health homes. The awards allow these providers to create modest scattered site programs (for the most part, each provider envisions housing some twenty individuals), but the program’s primary distinction is that it allows Health Homes to refer clients directly into supportive housing, and thus eliminates the requirement that clients be vetted by the Department of Homeless Services (DHS) or the Human Resources Administration (HRA). Previously, DOH’s MRT program had funded multiple supportive housing programs, but this pilot is the first in which Health Homes control the “front door” to the housing (i.e., the first in which Health Homes can determine the best candidates for supportive housing based on their clinical perspective). For more information please visit the NYS DOH website.
Targeting High Cost Medicaid Users for Supportive Housing
A fundamental element of MRTSHP is its integration of high-cost Medicaid users (HCMUs) into the supportive housing model. In order to maintain the state’s investment while simultaneously sustaining the integrity of the model, it is essential to demonstrate reduced health care costs and improved quality of life. At present, eligibility for MRTSHP-funded housing is based on either (a) Serious and Persistent Mental Illness (SPMI) or on (b) the presence of two chronic conditions, criteria that were developed by DOH as tantamount to high cost/utilization of Medicaid services.
In order to better understand for whom supportive housing is a ‘prescription’ for improved medical and cost outcomes, the Network convened a half-day learning session with experts and innovators from the US and Canada in the field of providing supportive housing to the highest-cost/highest-need homeless people in 2014. Experts from Toronto, San Francisco, Chicago, Boston and New York shared lessons learned, and discussed emerging and ongoing issues around targeting.
The Network published a report on this learning session: High Cost Medicaid Users in Supportive Housing: Best Practices/Think Tank to help disseminate current best practices and challenges nationally in order to help inform this innovative policy work. Additionally, the Network convened a subset of these experts to discuss targeting at our 2015 Conference and our 2016 Conference.
Federal Medicaid Waiver and Supportive Housing
The Network worked closely with the State in the summer of 2012 to write the supportive housing component of the State’s $10 billion federal Medicaid waiver application. If approved, the waiver would allocate hundreds of millions of federal Medicaid resources over five years to expand supportive housing for the high-cost Medicaid recipient population. The funds would be used for capital and operating costs to create and subsidize the housing. In addition to an enormous surge of new supportive housing development in New York, this precedent-setting allocation could transform the way that Medicaid and supportive housing are used across the country. Read the State’s waiver application here (the supportive housing section begins on page 57):
This waiver application has not been approved by the federal government and therefore the state continues to invest solely state general fund dollars into the MRT Supportive Housing Program, without any federal match from Medicaid.
Medicaid, Managed Care and Supportive Housing in NYS
In 2015, NYS shifted the way its behavioral health system was run, by making Managed Care Organizations (MCOs) responsible for authorizing and overseeing all behavioral health care services for Medicaid recipients. As part of this overhaul, the State required MCOs to create Health and Recovery Program (HARP) packages, a raft of special services that would be made available to the very neediest recipients, those coping with complex health and behavioral health challenges. The services offered under these plans are Home and Community Based Services.
Home and Community Based Services
People with the most complex behavioral needs – or HARP-eligible individuals – can access HCBS services from service providers that have been previously vetted by the Office of Mental Health. The path to accessing these services requires the potential recipient to first undergo a lengthy assessment conducted by that person’s Health Home. The resulting plan of care then needs to be ok’d by the person’s MCO, sent back to the Health Home for recommendations as to which two service providers the client can choose from to administer these services, then, once the client decides this, the Health Home contacts the service provider to deliver the approved service. Each service has a maximum number of hours that service can be delivered in a year. Approximately 100 Network members across the state have applied for and been designated to offer at least one of fourteen HCBS services. The Network is therefore working to help our community better understand the emerging landscape so that providers can make the most of Medicaid-funded service opportunities without endangering existing programs or the health and stability of their tenants.
HCBS Workshop & TA - NYC Providers
In the fall of 2015, Cindy Freidmutter, from CLF Consulting, conducted two trainings for NYC providers interested in providing HCBS services and offered limited follow up financial modeling and technical assistance to member organizations.
The powerpoint slides from the Network’s 2015 NYC September Trainings is here.
In addition the Network, a number of members designated to provide HCBS and Ms. Freidmutter worked to model the costs of providing a number of HCBS services. They found that the approved rates for two types of Respite services as well as two types of Housing Based Recovery Services failed to cover even best-case-scenario cost projections. The Network, members and our consultant fed this information back to the Office of Mental Health which, in turn, has asked CMS for permission to raise these rates.
For more information on HCBS financial modeling that was done, please contact Maclain Berhaupt, at the Network’s Albany office.
HCBS Workshop and TA - Upstate and Long Island Providers
The Network hosted a webinar for over 100 SHNNY upstate and Long Island members in August, 2016 to help prepare for the October 1 launch date for these regions.
Network consultant, Cindy Freidmutter, covered the following issues in her presentation:
- Opportunities and challenges for supportive housing providers in offering HCBS
- Strategies for starting-up HCBS services that minimize financial risk
- Infrastructure that needs to be in place to offer HCBS
- Financial viability of HCBS services and how to align costs and revenues
The webinar can be viewed here. (When you click on the link to access the webinar, it will take you to a registration page – fill in your name and email address and it will take you to the recorded webinar.)
The powerpoint slides from the webinar are located here.
The Network thanks the New York Community Trust for funding our and Ms. Freidmutter’s work on HCBS.