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Housing As A Health-Related Social Need: Lessons From North Carolina’s Healthy Opportunities Pilot

Rows of homes.

In recent years, the Centers for Medicare and Medicaid Services (CMS) has opened the door for states to use Medicaid funding to cover an array of services that support people in getting and keeping housing, from case management services and navigation help to identify housing options to coverage of up to six months of rent as a bridge to long-term housing subsidies such as Department of Housing and Urban Development (HUD) vouchers. These efforts are part of a broader initiative to advance the use of Medicaid funds to address a wide array of health-related social needs, underscored by CMS’s November 2023 release of guidance and a framework describing allowable services and supports.

Among the states leading the way in this work is North Carolina. And other states interested in learning from its experience might start by reading an important new article in the February 2024 issue of Health Affairs: “Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina’s Healthy Opportunities Pilots Program.” Authors Katie Huber and colleagues highlight how the housing-related social needs (HRSN) concept works on the ground outside of written policies and guidance. Findings from the article provide new evidence about the impact of these services on health and well-being, alongside critical takeaways about what works and, equally important, what doesn’t work when implementing HRSN services in Medicaid. This analysis can provide unique insight that contributes to the evolution of HRSN policies at the federal and state level.

The North Carolina Department of Health and Human Services (NCDHHS) has been testing the health impacts of services that support access to and retention of housing along with other HRSN services to qualifying Medicaid enrollees through its Healthy Opportunities Pilots (the Pilots).

Authorized by CMS during the Trump administration as part of a Section 1115 Demonstration Waiver, the Pilots were among the first in the nation to allow a Medicaid program to fund a wide range of health-related services—addressing housing, nutrition, transportation, and interpersonal violence/toxic stress—to a broad range of eligible populations. Housing services offered through the program range from housing-related case management services, home remediation to abate health risks in the home (for example, mold), payment for first month’s rent, security deposits, utilities, and more.

More recently, North Carolina applied to CMS to renew its 1115 waiver demonstration and expand the Pilots to operate statewide, building on lessons learned from the first few years of the Pilots.

With this Forefront article, we aim to build on the lessons outlined by Huber and colleagues in their article. Specifically, we offer three key additional takeaways stemming from North Carolina’s particular experience. We hope that stakeholders and partners in other states will benefit from the following insights.

Hub Organizations Provide Essential Support To Housing CBOs

One of the biggest challenges to addressing housing needs via Medicaid is for payers to develop a sufficient network of service providers—including housing navigators, nutrition service providers, and others—to meet beneficiaries’ needs. Community-based organizations (CBOs)—especially those providers of housing support services—are essential partners, offering unique and trusted relationships with communities and individuals. But CBOS also have to learn new functions required to participate in Medicaid and that requires significant investment in capacity building, hands-on training, and technical assistance.

As described in the August 2022 Health Affairs Forefront article, “Medicaid Is Emerging As A Big Player In Housing, But Success Depends On New Partnerships(authored by one of us, Reyneri), CBOs may need to bill for individual services delivered, work with health plans, become Medicaid enrolled providers, among other new functions. That is asking a lot, especially of a nonprofit organization, which may already be stretched thin in terms both financial and human resources.

At the same time, it’s crucial for states to avoid overmedicalizing the unique services and relationships that CBOs bring to the table. Maintaining the unique capabilities of CBOs is important to ensure their ability to form trusted relationships with individuals in the community that can benefit from Pilot services.

North Carolina’s answer to these challenges was to establish network leads responsible for building and overseeing a robust network of CBOs that are prepared to provide the full range of Pilot services, including the spectrum of housing-related supports—from home modifications to utilities support.

This approach alleviates the need for “many to many” contracting relationships between CBOs and plans. Network leads are based in the communities they serve, which allows them to tailor their networks of CBOs to the needs of their populations, which, as researchers raised, vary significantly across Pilot communities. Network leads work with their networks of CBOs, community members, and other leaders to identify and solve, through trainings, convenings, and direct technical assistance, regionally specific needs and challenges. They also provide valuable feedback to the state on Pilot implementation and design.

Network leads have been instrumental in: navigating issues of timely service authorization; thinking creatively about how to manage network capacity issues; and ensuring timely payment for housing supports to protect CBOs from additional financial strain. Network leads have escalated these issues to the state and advocated for key changes to expedite payment and reduce administrative burden.

Start Small And Scale

The Pilots were strategically launched with a limited scope in March 2022, focusing first on food and nutrition services before expanding to housing-related services and transportation and, most recently, services targeted to address interpersonal violence/toxic stress.

The phased approach allowed the state, network leads, and CBOs to address and learn from the unique design challenges for each type of HRSN “domain” in their regions before expanding to the next. Thanks to regular convenings, consistent engagement with Pilot partners, robust monitoring and evaluation systems, and the collection and analysis of real-time data, NCDHHS could make real-time modifications to ensure that the Pilots were operating effectively and efficiently. These modifications preceded each decision to expand the scope of services.

Medicaid Can’t And Shouldn’t Do It Alone

Recent federal actions offer a short-term bridge to stable and sustainable longer-term subsidies through housing programs. Medicaid historically has prohibited the use of federal matching dollars to pay for “room and board” housing services. However, in recognition of the impact of housing on individual’s health, CMS’s new HRSN framework allows Medicaid to pay for short-term, temporary housing for qualifying individuals through 1115 waiver authority. This is an exciting expansion of what was previously considered allowable via Medicaid, but the benefit is still temporary and time limited.

To take advantage of the substantial federal support that comes with this new policy and provide comprehensive care for Medicaid enrollees facing housing insecurity, health and housing agencies, providers, CBOs, and others must create new ways to collaborate. To date, North Carolina has taken the initial steps to ensure connections to other entitlement programs—including by promoting enrollment in other programs such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) at the time of assessment for Pilot eligibility.

North Carolina has recognized the need to double down on these partnerships and will be participating alongside eight other states in the Housing and Services Partnership Accelerator organized collaboratively by the Department of Health and Human Services (HHS) and HUD. This partnership will support states in developing or expanding innovative housing-related supports and services for Medicaid-eligible people with disabilities and older adults who are experiencing or at risk of homelessness. As the name suggests, the Accelerator will focus on helping states improve collaboration and coordination between organizations and systems that help people find—and keep—stable, healthy housing.

The Road Ahead

Through its recent guidance supporting state efforts to meet patients’ health-related social needs, CMS has opened the door for states to innovate and fund creative solutions to some of the most pressing issues impacting Medicaid beneficiaries. As state approaches to addressing HRSNs continue to proliferate, the focus on housing-related services and their impact on health will be front and center. For North Carolina, the years ahead will be critical.

The state is currently seeking to renew, expand, and make key changes to its Healthy Opportunities Pilot program for another five-year period. These new changes include expanding the Pilots to operate statewide and expanding eligibility criteria and service offerings in ways that build on lessons learned and successes to date. The Pilots rely on partnerships among organizations with different missions, cultures, and business models that have historically existed in separate silos for health and social care.

Together with the lessons we’ve highlighted here, the authors of “Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina’s Healthy Opportunities Pilots Program” provide essential, real-time findings that can inform CMS’s framework as it moves from theory into practice. Giving state and local partners the flexibility to meet the needs of their communities is essential to the success and scale up of HRSN initiatives.

Authors’ Note

Manatt Health Strategies has supported North Carolina DHHS on the design and implementation of the Healthy Opportunities Pilot program since 2017. Additionally, Manatt team members including Melinda Dutton and Mandy Ferguson provided feedback on the Health Affairs journal article by Katie Huber and colleagues.

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