Joint HHS, HUD, and USDA Informational Bulletin 
DATE:  August 19, 2020 
SUBJECT:   Living at Home in Rural America: 
Improving Accessibility for Older Adults and People with a Disability1 
This Joint Informational Bulletin provides state Medicaid agencies, state and local housing 
agencies, state and local public health agencies, and other health and housing entities with 
information to better understand existing federal resources and programs that are intended to 
improve health and housing outcomes in rural America. These resources may address reducing 
physical environmental barriers in the home, increasing safety, minimizing the risk of falls, and 
supporting a persons ability and desire to remain in his or her own home. 
The information in the Bulletin is intended to support and encourage state agencies to more 
effectively coordinate existing federal resources related to home accessibility across multiple 
sectors within their states as part of their efforts to increase home safety and accessibility for 
older adults and people with disabilities living in rural communities. Given that the population of 
older adults and people with a disability in need of long-term services and supports (LTSS) is 
disproportionately larger in rural versus urban areas2 the Department of Health and Human 
Services (HHS), the U.S. Department of Housing and Urban Development (HUD), and the U.S. 
Department of Agriculture (USDA) are issuing this Informational Bulletin to provide state 
agencies and other interested stakeholders with information about federal resources that may 
help individuals living in rural areas to remain in their homes and communities. 
Multiple federal programs and resources support people with a disability and older adults with 
low incomes to live in and age-in-place in rural America. These aforementioned federal agencies 
and their respective resources and programs can be found in Appendix A-F of this Informational 
Bulletin. 
This Bulletin also supports the HHS Rural Health Task Force, an HHS-wide effort on improving 
health care and access for rural America. This includes the efforts by the Centers for Medicare & 
Medicaid Services (CMS), the Administration for Community Living (ACL), the Centers for 
Disease Control and Prevention (CDC), and the Health Resources and Services Administration 
1 This communication is printed, published, or produced and disseminated at U.S. taxpayer expense. 
2 Andrew Coburn, Eileen Griffin, Deborah Thayer, Zachariah Croll, Erika C. Ziller. Are Rural Older Adults Benefiting from Increased State 
Spending on Medicaid Home and Community Based Services? Maine Rural Health Research Center, June 2016.  (HRSA), to improve health care in rural America, by leveraging collaborative partnerships, 
awareness campaigns, and grant programs both on a federal level, and at a regional, state, and 
local level. 
 
Background 
More than 60 million Americansapproximately 19 percent of the U.S. populationlive in 
rural areas.3,4 Research indicates that individuals living in rural America tend to face greater 
challenges than those living in urban areas, particularly with respect to socio-demographic 
factors, health status, and access to the healthcare delivery system.5 Despite these challenges, 
rural communities have considerable strengths that contribute to overall community well-being. 
According to the Gallup-Sharecare Well-Being Index,6 rural Americans experience a greater 
sense of pride in the community, high feelings of safety and security, and a stronger sense of 
purpose in comparison to urban Americans.7 
 
Older adults and people with a disability represent a significant percentage of rural residents. 
Rural counties make up nearly 85 percent of the 1,104 older-age countiesthose with more 
than 20 percent of their population age 65 or older.8 Those older than 85 years represent the 
fastest growing segment of the U.S. population, and much of that population growth is expected 
to occur in rural areas.9 According to the U.S. Census Bureau's 2013-2017 American Community 
Survey 5-Year Estimates, approximately 9 million people living in rural America  15.1 percent 
of the rural population  are people with a disability.10 
 
Medicare and Medicaid enrollment in rural communities is broad. Medicaid covers nearly one in 
four nonelderly individuals in rural areas.11 Data from the 2018 Medicare Beneficiary Survey 
analyzed by the Medicare Payment Advisory Commission indicated that about one-fifth of 
Medicare beneficiaries live in rural areas.12 Rural Medicare beneficiaries are more likely to be 
dually eligible for Medicare and Medicaid than urban Medicare beneficiaries.13 Demographic 
data indicate that the population of older adults in need of long term services and supports 
(LTSS), including home and community-based services and institutional care, is 
disproportionately larger in rural versus urban areas.14  
                                                            
3 What is Rural America? U.S. Census Bureau. Retrieved from: https://www.census.gov/library/stories/2017/08/rural-america.html 
4 The federal government uses two major definitions of rural, along with many variants that are also available. One is produced by the U.S. 
Census Bureau and the other by the Office of Management and Budget. See: https://www.hrsa.gov/rural-health/about-us/definition/index.html 
5 Healthcare Access in Rural Communities. Retrieved from:  https://www.ruralhealthinfo.org/topics/healthcare-access 
6 The Well-Being Index measures Americans' perceptions of their lives and their daily experiences through five interrelated elements that make 
up well-being: sense of purpose, social relationships, financial security, relationship to community, and physical health. 
https://www.gallup.com/175196/gallup-healthways-index-methodology.aspx 
7 State of American Well-Being, 2017 Community Well-Being Rankings. https://wellbeingindex.sharecare.com/wp-
content/uploads/2018/03/Gallup-Sharecare-State-of-American-Well-Being_2017-Community-Rankings_vFINAL.pdf 
8 Rural America at a Glance 2018, U.S. Department of Agriculture. Retrieved from: https://www.ers.usda.gov/webdocs/publications/90556/eib-
200.pdf 
9 Coburn, A., Lundblad, J., Rural Long-Term Services and Supports: A Primer, Nov 2017. Retrieved from: http://www.rupri.org/wp-
content/uploads/LTSS-RUPRI-Health-Panel-2017.pdf 
10 Retrieved from: https://www.ruralhealthinfo.org/topics/people-with-disabilities#howmany 
11 Foutz, J., Artiga, G., Garfield, R., The Role of Medicaid in Rural America, Issue Brief, Kaiser Family Foundation, April 2017. Retrieved 
from:https://www.kff.org/medicaid/issue-brief/the-role-of-medicaid-in-rural-america/ 
12 Health Care Spending and the Medicare Program, June 2018, Medicare Payment Advisory Commission. Retrieved from: 
http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf 
13 Bennet, K., Robertson, A., Probst, J., Characteristics, Utilization Patterns, and Expenditures of Rural Dual Eligible Medicare Beneficiaries, 
November 2014, South Carolina Rural Health Research Center. 
14 Coburn, A., Lundblad, J., Rural Long-Term Services and Supports: A Primer, Nov 2017. Retrieved from: http://www.rupri.org/wp-
content/uploads/LTSS-RUPRI-Health-Panel-2017.pdf 
2 
   
According to the AARP 2018 Home and Community Preferences Survey: A National Survey of 
Adults Age-18 Plus: 
  Nearly three-quarters of rural adults say they want to remain in their communities and 
homes as they age. 
  Almost half of rural adults report that they will stay in their current homes and never 
move compared to only a third or less of urban and suburban adults who say they will 
never move from their current homes.  
  Nearly two in five rural homeowners report that major modifications to their homes are 
needed to accommodate aging needs.15 
 
Homeownership is more prevalent in rural communities than in urban communities. Over 83 
percent of rural and older adult households are owner-occupied, compared to approximately 79 
percent of all older adult households and 66 percent of all households nationally. The vast 
majority of rural older adults live in single-family units that were built in earlier decades. These 
structures may not be well suited to meet the needs of aging adults and people with a disability.16  
Homes that are in need of repairs and maintenance and that have use and accessibility issues 
make it harder for older adults and people with a disability to bathe, use stairs, enter and exit, or 
meet other daily needs.17 Falls and their related complications are a hazard for independent 
living and are the leading cause of both fatal and non-fatal injuries among adults over age 65.18 
These barriers may compel older adults and people with a physical disability to move to an 
institutional setting such as a nursing home. Programs and resources that help individuals make 
their homes more accessible and usable facilitate independent living, improve quality of life, and 
promote community integration.  
 
This Informational Bulletin identifies existing federal resources and opportunities that states may 
be interested in utilizing to increase independence and help an individual to remain in his or her 
home. For example, raising or lowering a countertop can help an individual to prepare his or her 
own food; installing a roll-in shower and grab bars may assist an individual to independently 
bathe; installing a ramp, chairlift, or motion detecting lights and widening doorways supports an 
individual by increasing stability, preventing falls, and maximizing independent mobility.19  
Improving home accessibility for older adults and people with a disability represents an 
important step toward building sustainable home and community-based services capacity in rural 
communities. Each of the agencies described in the Appendices is available to provide technical 
assistance to stakeholders in implementing programs to improve home accessibility and health 
outcomes, and to facilitate beneficiary independence. 
 
   
                                                            
15 2018 Home and Community Preferences Survey: A National Survey of Adults Age 18-Plus, A Look at Rural Communities, June 2019, AARP. 
Retrieved from: https://www.aarp.org/content/dam/aarp/research/surveys_statistics/liv-com/2019/home-community-preferences-rural-
communities.doi.10.26419-2Fres.00231.010.pdf 
16 Homes on the Range: Homeownership Rates Are Higher in Rural America, U.S. Census Bureau, Dec. 2016. Retrieved from: 
https://www.census.gov/newsroom/blogs/random-samplings/2016/12/homes_on_the_range.html 
17 Housing an Aging Rural America: Rural Seniors and their Homes, Housing Assistance Council, October 2014.  
18 Important Facts about Falls Centers for Disease Control and Prevention (CDC). Retrieved from: 
https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 
19 Retrieved from: https://eldercare.acl.gov/Public/Resources/Factsheets/Home_Modifications.aspx 
3 
  Appendix A 
Centers for Medicare & Medicaid Services (CMS) 
 
Medicaid 
States have various pathways to improve home accessibility for Medicaid-eligible individuals. 
Below we highlight several options for states to enable individuals to have their medical needs 
met at home while helping to support accessible home environments through their Medicaid 
programs. States have flexibility to cover a variety of optional services under their Medicaid 
state plans; however, a state Medicaid program generally cannot limit coverage exclusively to 
rural areas. A waiver of the statutory statewideness provision generally would be needed to 
limit services to certain geographic areas within a state.20 
 
Federal Medicaid law requires states to provide certain mandatory Medicaid state plan benefits 
under sections 1902(a)(10) and 1905(a) of the Social Security Act (the Act) and 42 Code of 
Federal Regulations (CFR) 440.210 and 440.220. Additionally, pursuant to section 1905(a)(4)(B) 
and (r)(5) of the Act, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 
benefit requires that states provide all medically necessary section 1905(a) services coverable 
under the Medicaid program to certain eligible children under age 21. 
 
States can also choose to provide other optional benefits under state plan authority, as well as 
through waiver authority under section 1915 of the Act, or they can offer additional non-
mandatory benefits under demonstration project authority under section 1115 of the Act. States 
have a certain degree of flexibility in determining which non-mandatory benefits to provide 
under these authorities. In most cases, state flexibility is limited by section 1902(a)(1) of the Act 
and 42 CFR 431.50 (statewideness), section 1902(a)(17) of the Act and 42 CFR 440.230 
(requirements regarding the amount, duration, and scope of covered services), and section 
1902(a)(10)(B) of the Act and 42 CFR 440.240 (comparability of services within and among 
eligibility groups), among other provisions. These requirements apply unless the statute makes 
them non-applicable to the specific benefit or CMS waives the requirement.  
 
Some Medicaid benefits that could help improve home accessibility and health outcomes for 
Medicaid-eligible individuals are described below. 
 
Mandatory Medicaid Benefits  
 
Medicaid Home Health Services. The Medicaid home health benefit is authorized by section 
1905(a)(7) of the Act, and defined in regulations at 42 CFR 440.70. It is a mandatory benefit for 
the categorically needy eligibility groups and for individuals entitled to skilled nursing facility 
services in the medically needy eligibility groups, as described in 42 CFR 440.210(a)(1) and 
440.220(a)(3), respectively. An important stand-alone component of the Medicaid home health 
benefit is medical supplies, equipment, and appliances, under 440.70(b)(3). The regulation 
defines Equipment and appliances as items that are primarily and customarily used to serve a 
medical purpose; generally, are not useful to an individual in the absence of a disability, illness, 
or injury; can withstand repeated use; and can be reusable or removable. This paragraph also 
notes that State Medicaid coverage of equipment and appliances is not restricted to the items 
                                                            
20 Social Security Act  1902(a)(1), 42 U.S.C.  1396a(a)(1). 
4 
  covered as durable medical equipment in the Medicare program. Items that meet the criteria for 
coverage under the home health benefit should be covered as such. Structural or home 
modifications are not covered under the Medicaid home health benefit. Coverage determinations 
for medical supplies, equipment, and appliances are based on medical necessity criteria as 
established by the state and as applied to the individuals particular need. States can have a list of 
preapproved medical equipment and supplies, but are prohibited from having absolute exclusions 
of coverage on medical equipment, supplies, or appliances. 
 
Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC). Medicaid RHC 
and FQHC services are defined in section 1905(a)(2)(B), 1905(a)(2)(C), and 1905(l)(1) and (2) 
of the Act, and include certain services listed in section 1861(aa) of the Act, as described in 
section 1905(l)(1) and (2). FQHCs and RHCs generally serve medically underserved populations 
and areas. Medicaid-covered services provided by FQHCs and RHCs include primary and 
preventive services provided by physicians, nurse practitioners, physician assistants, clinical 
psychologists, and clinical social workers, as well as other ambulatory services included in the 
state plan. If applicable, Medicaid-covered RHC and FQHC services also include part-time or 
intermittent nursing care and related medical supplies (other than drugs and biologicals) 
furnished by a registered professional nurse or licensed practical nurse under a written plan of 
treatment to persons in an area where CMS has certified that there is a shortage of Home Health 
Agencies.  
 
Optional Medicaid Benefits 
 
Physical and Occupational Therapy Services. States have several options for providing physical 
therapy and occupational therapy services. While there are several Medicaid authorities available 
to states, we will highlight a few of the commonly used benefits here.  States may provide these 
services under the therapy benefit authorized under section 1905(a)(11) of the Act and defined at 
42 CFR 440.110. States may also provide these services under rehabilitative services authorized 
under section 1905(a)(13)(C) of the Act and defined at 42 CFR 440.130(d). Lastly, physical and 
occupational therapy services, as well as speech pathology and audiology services, may be 
included in the home health benefit at the states option, as described at 42 CFR 440.70(b)(4).  
 
Case Management and Targeted Case Management. States can choose to furnish case 
management services under sections 1905(a)(19) and 1915(g) of the Act and 42 CFR 440.169, to 
assist Medicaid-eligible individuals in gaining access to needed services. This state plan benefit 
is optional for both categorically needy and medically needy groups, unless the state opts to 
define the ambulatory services it must provide to certain medically needy groups to include it. If 
a state elects to cover case management under the Medicaid state plan, states can also opt to 
provide this benefit without regard to the statewideness and comparability requirements at 
section 1902(a)(1) and (a)(10)(B) of the Act, in which case the benefit is referred to as targeted 
case management (TCM). This means that states can target the benefit to specific populations, as 
described in section 1915(g)(1) of the Act, such as Medicaid-eligible individuals living in rural 
communities. Case management services, as defined in section 1915(g)(2) of the Act and 42 
CFR 440.169, means services that assist eligible individuals to gain access to needed medical, 
social, educational, and other services. Case management services must include all of the 
following: comprehensive assessment and periodic reassessment of an eligible individuals 
5 
  needs; development and periodic revision of a person-centered care plan; referral to services and 
related activities to help the eligible individual obtain needed services; and monitoring activities. 
Case management can also include assisting individuals transitioning from a medical institution 
into a home in the community. Case management can assist individuals with gaining access to 
community-based home accessibility resources, or linking an individual to other needed medical, 
social, and educational services to help an individual live independently in the community. 
 
Section 1915(c) Home and Community Based Services Waiver Programs. States have the option 
to apply for section 1915(c) home and community-based services waivers (HCBS waivers) to 
establish programs intended to enable beneficiaries who meet an institutional level of care to 
receive long-term care services and supports in their home or community, rather than in an 
institutional setting. Section 1915(c) allows states to waive certain Medicaid requirements (i.e., 
statewideness, comparability, and income and resource rules applicable in the community), and 
thus, allows states to furnish services to target populations by age or diagnosis.  
 
Section 1915(c) also allows states to provide benefits in the community to eligibility groups who 
otherwise might receive Medicaid coverage only for institutional services. States may utilize this 
authority to provide home accessibility adaptations to the private residence of the beneficiary or 
his or her family that are required by the beneficiarys service plan and necessary either to ensure 
the beneficiarys health, welfare, and safety or to enable functioning with greater independence 
in the home. Such adaptations could include the installation of ramps and grab-bars, widening of 
doorways, modification of bathroom facilities, or the installation of specialized electric and 
plumbing systems that accommodate the medical equipment and supplies that are necessary for 
the welfare of the beneficiary. Such adaptations may not include those adaptations or 
improvements to the home that are of general utility, and are not of direct medical or remedial 
benefit to the participant.21 Additionally, Medicaid coverage does not extend to supporting room 
and board costs or other benefits that are not directly related to the provision of HCBS. HCBS 
waiver programs can offer service coordination or case management in order to facilitate access 
to home accessibility supports and needed services.  
 
Section 1915(i) State Plan Benefit. A section 1915(i) State Plan Amendment (SPA) allows states 
to provide HCBS to individuals who meet state-defined needs-based criteria that are less 
stringent than institutional criteria (and, if chosen by the state, target group criteria) as set forth in 
42 CFR Part 441 Subpart M. The section 1915(i) benefit also gives states the option of 
establishing additional needs-based criteria for specific HCBS. States could use the section 
1915(i) benefit to offer specific HCBS, including those described above under section 1915(c) 
HCBS waiver programs, to specific target populations by age, disability, diagnosis, and/or 
Medicaid eligibility group.   
 
Section 1915(j) Optional Self-Directed Personal Assistance Services. Section 1915(j) self-
directed personal assistance services (PAS) means personal care and related services, or home 
and community-based services otherwise available under the state plan or a 1915(c) waiver 
program that are provided to an individual who has been determined eligible for the PAS option. 
Self-directed PAS also includes, at the states option, items that increase the individuals 
independence or substitutes (such as a microwave oven or an accessibility ramp) for human 
                                                            
21 1915(c) Waiver Technical Guide: https://wms-mmdl.cms.gov/WMS/help/35/Instructions_TechnicalGuide_V3.6.pdf   
6 
  assistance, to the extent the expenditures would otherwise be made for the human assistance. 
Individuals budgets may be used to purchase goods and services, supports, or supplies related to 
a need or goal identified in the individuals state-approved person-centered service plans. Some 
examples of allowable purchases may include a wheelchair accessible ramp or a home 
modification to widen doorways, or installation of grab bars.22  
 
Section 1915(k) Community First Choice Optional State Plan Benefit. The purpose of the section 
1915(k) Community First Choice (CFC) benefit is to provide certain individuals, who meet an 
institutional level of care, the opportunity to receive necessary personal attendant services and 
supports in a home and community-based setting. There are required services that must be 
included in all CFC programs, as well as additional services that may be included at the states 
option.23 States electing CFC are required to cover the following services, subject to the 
conditions described above: (1) services and supports to assist in accomplishing activities of 
daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks, 
through hands-on assistance, supervision, and/or cueing; (2) acquisition, maintenance, and 
enhancement of skills necessary for the individual to accomplish ADLs and IADLs and health-
related tasks; (3) back-up systems or mechanisms to ensure continuity of services and supports; 
and (4) voluntary training on how to select, manage, and dismiss attendants. The optional 
services states may cover in their CFC benefit include: (1) expenditures for transition costs (such 
as first months rent and utilities or bedding, basic kitchen supplies, etc.) necessary for an 
individual transitioning from an institutional setting to a home and community-based setting and 
(2) expenditures relating to a need that increases an individuals independence or substitutes for 
human assistance, to the extent that Medicaid expenditures would otherwise be made for human 
assistance. 
 
Section 1115 Demonstrations. States may also utilize section 1115 demonstration authority to 
test home and community-based service strategies. Since section 1115 demonstrations are 
intended to give states the flexibility to pilot new approaches that are likely to assist in promoting 
the objectives of the Medicaid program, states have a great deal of flexibility to design their 
demonstrations accordingly, subject to CMS approval. States could, for example, elect to pilot 
home accessibility services to a specific target population or in a limited geographic area. Some 
states, such as Washington, have used section 1115 demonstration authority to offer home 
accessibility services as part of a broader HCBS strategy targeted to older adults who are at 
risk of requiring Medicaid for long-term care services. The Tailored Supports for Older Adults 
(TSOA) program, funded under Washingtons section 1115 Medicaid Transformation Project 
demonstration, establishes a new eligibility category and benefit package for individuals at risk 
of future Medicaid long-term services and supports who currently do not meet Medicaid 
financial eligibility criteria.24 
 
                                                            
22 For more information on section 1915(j) see https://www.medicaid.gov/medicaid/hcbs/authorities/1915-j/index.html 
 
23 For more information on section 1915(k) see https://www.medicaid.gov/medicaid/hcbs/authorities/1915-k/index.html 
 
24 For more information about the Tailored Supports for Older Adults (TSOA) program, see https://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Waivers/1115/downloads/wa/wa-medicaid-transformation-ca.pdf; Washington State Health Care Authority, Long-term 
Services and Supports Manual, Tailored Supports for Older Adults, https://www.hca.wa.gov/health-care-services-supports/program-
administration/tailored-supports-older-adults-tsoa-0 
7 
  Medicaid Managed Care Strategies for Providing Mandatory and Optional Benefits 
 
When states use a risk-based managed care delivery system, a state can choose to cover any of 
the services described above within the managed care plan contract. In addition, a managed care 
plan may voluntarily choose to provide additional home accessibility services that are not 
covered under the state plan, but the cost and utilization of such additional benefits may not be 
used in developing capitation rates for the managed care plan, unless they explicitly qualify as an 
in-lieu of service as defined in 42 CFR 438.3(e)(2).25  
 
Section 1915(b) waiver programs are used by states to implement a managed care or a fee-for-
service selective contracting delivery system for state plan benefits. States using this authority 
also have the ability to add additional services, beyond those covered in the state plan. Section 
1915(b)(3) authority allows a state to share the savings resulting from the use of more cost-
effective medical care with Medicaid beneficiaries by providing them with additional state plan 
services, or additional services under a concurrent section 1915(c) waiver program. These 
savings must be expended for the benefit of Medicaid beneficiaries enrolled in the section 
1915(b)(3) waiver, and may be used in the provision of home accessibility services for enrollees 
to prevent falls, increase safety and independence, and avoid institutionalization.  
 
Medicare 
 
Medicare is the federal health insurance program for people who are 65 or older, certain people 
under age 65 with disabilities, and people with End-Stage Renal Disease (ESRD), which is 
permanent kidney failure requiring dialysis or a transplant. The different parts of Medicare help 
cover specific services: Medicare Part A (Hospital Insurance) covers inpatient hospital stays, 
care in a skilled nursing facility, hospice care, and some home health care; Medicare Part B 
(Medical Insurance) covers certain doctors services, outpatient care, medical supplies, and 
preventive services; and Medicare Part D provides prescription drug coverage.26 
Medicare Advantage Plans, sometimes called Part C or MA Plans, are an all in one 
alternative to Original Medicare. They are offered by private companies approved by 
Medicare. People who join a Medicare Advantage Plan still have Medicare.  These bundled 
plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), 
and usually Medicare prescription drug coverage (Part D).27  
 
Medicare Advantage plans can offer supplemental benefits that are not covered under Medicare 
Parts A or B if they diagnose, compensate for physical impairments, diminish the impact of 
injuries or health conditions, and/or reduce avoidable emergency room utilization. For example, 
plans may offer non-Medicare-covered safety devices to prevent injuries in the home and/or 
bathroom. Examples of safety devices include: shower stools, hand-held showers, bathroom and 
stair rails, grab bars, raised toilet seats, temporary/portable mobility ramps, night lights, and stair 
treads. The benefit may include a home and/or bathroom safety inspection conducted by a 
                                                            
25 An in-lieu of service is defined as any service or setting that is provided instead of the covered service or setting in the contract. States must 
determine that the alternative service or setting is a medically appropriate and cost effective direct substitute for the covered service and cannot 
require the managed care plan to provide such services.  
26 https://www.medicare.gov/sign-up-change-plans/getting-started-with-medicare 
27 https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-
work 
8 
  qualified health professional, in accordance with applicable state and federal requirements, to 
identify the need for safety devices and/or modifications, as well as the applicability of the 
device or modification to the specific enrollees needs and home.28 
 
Additional Resources 
The CMS Office of Minority Health (OMH) has several resources to help people with disabilities 
access quality health care. The tools include videos, a fact sheet, a resource inventory, and data 
highlights. Specifically, the resource Getting the Care You Need: A Guide for People with 
Disabilities provides information for consumers with disabilities on their rights with regard to 
accessing healthcare, as well as checklists to prepare for and follow up after medical 
appointments. The video series, Navigating Health Care with a Disability: Our Stories, 
features people with disabilities describing their experiences accessing health care. The series 
also explains how health care organizations and providers can improve accessibility and care for 
people with disabilities. 
   
                                                            
28 Medicare Advantage Organizations and Section 1876 Cost Contract Plans, April 27, 2018, CMS. https://www.nahc.org/wp-
content/uploads/2018/05/HPMS-Memo-Primarily-Health-Related-4-27-18.pdf 
9 
  Appendix B 
Administration for Community Living (ACL) 
 
The Administration for Community Living (ACL) helps older adults and people with  
disabilities to live independently and participate fully in their communities. ACLs mission is to 
maximize the independence, well-being, and health of older adults, people with disabilities 
across the lifespan, and their families and caregivers. By funding services and supports, and with 
investments in research and innovation, ACL helps make this mission a reality for millions of 
Americans. 
 
Several ACL programs support efforts to facilitate housing assistance, accessibility, home repair, 
and modifications. For example:  
  State No Wrong Door Systems which include Centers for Independent Living, Area 
Agencies on Aging, Aging and Disability Resource Centers, State Units on Aging, and 
Tribal Organizations provide assistance in securing housing, including home 
modifications, and other services necessary to improve the ability of older adults and 
individuals with disabilities to live and work independently in the community. 
  The National Institute on Disability, Independent Living, and Rehabilitation Research 
(NIDILRR) funds a Rehabilitation Engineering Research Center (RERC) on Universal 
Design and the Built Environment that is working to advance accessibility and universal 
design of housing.   
  The State Assistive Technology (AT) Act programs introduce people to the array of 
assistive technology available to assist them to continue to live at home and engage in 
community life. The AT Act programs also demonstrate how to use the technology, train 
people to use the technology, and offer short term loans of AT to try the technology 
before making a purchase.  
 
Centers for Independent Living 
ACL administers the Centers for Independent Living (CIL) Program, providing 354 discretionary 
grants to CILs, which are consumer-controlled, community-based, cross-disability, 
nonresidential, private nonprofit agencies that provide independent living (IL) services. At a 
minimum, centers funded by the program are required to provide the following IL core services: 
- Information and referral; 
- IL skills training; 
- Peer counseling; 
- Individual and systems advocacy; and 
- Services that facilitate transition from nursing homes or other institutions to community 
living, diversion assistance for people at risk of entering institutions, and the transition of 
youth who have completed their secondary education or otherwise left school, to post-
secondary life. 
 
To learn more about CILs and to access a directory visit https://acl.gov/programs/aging-and-
disability-networks/centers-independent-living. 
   
10 
  Research 
ACL regularly funds projects involving housing, accessibility, safety, and social isolation. 
Currently, ACL funding supports a Rehabilitation Engineering Research Center (RERC) on 
Universal Design and the Built Environment that is working to advance accessibility and 
universal design of housing. Another ACL-funded RERC, Improving Safety and Activity 
Independence in the Home/Community following Traumatic Brain Injury, is designed to improve 
safety, increase activity and participation, lessen family burden, and improve life quality through 
use of self-report measurement paired with technology-based environmental feedback that 
informs on ability, realistic next step goals, treatment, and progress. ACL also funds several 
projects at the University of Montana Rural Institute on Disability. One of these, a Research 
Rehabilitation and Training Center on Disability in Rural Communities, has continued for over 
30 years. This RRTC generates knowledge from research to better understand how to ensure that 
people with disabilities can live effectively in rural communities. Additionally, NIDILRR also 
funds two studies to gather data to develop interventions that will help reduce the effort required 
of people with mobility disabilities to carry out certain activities within the home, and ultimately 
increase community participation. The combined findings of all-rural focused NIDILRR-funded 
studies underscore the business case for mitigating barriers to access and social isolation for 
older adults and people with disabilities. 
 
To learn more about projects funded by NIDILRR visit: 
https://naric.com/?q=en/ProgramDatabase 
 
Older Americans Act Programs (OAA) 
ACL administers the Older Americans Act (OAA) of 1965. The OAA funds a broad array of 
services that enable older adults to remain in their homes and communities for as long as 
possible. These include services to help older people access supports, such as transportation and 
case management, as well as home- and community-based long-term services and supports like 
personal care and adult day care services. The OAA programs can assist older individuals to 
obtain adequate housing, including residential repair and renovation projects designed to enable 
older individuals to maintain their homes. In addition, the OAA National Family Caregiver 
Support Program can assist with home modifications so caregivers are better able to continue 
providing care. The 2020 reauthorization of the OAA contains several provisions to promote the 
ability of older adults to age in place, including the establishment of a committee tasked with 
coordinating efforts to promote safe and accessible living environments and requiring a 
Government Accountability Office study and report focused on home modifications. 
Services under the OAA are provided by a network of federal, state, tribal and community-based 
local agencies.  
 
Area Agencies on Aging, Tribal Organizations, and Aging and Disability Resource Centers can 
provide information and referral services for home modifications including offering home safety 
assessments to identify priority modification needs. These agencies may also provide 
information on public and private financing options to assist with home modifications, and 
provide links to home accessibility programs and qualified contractors. Visit the Eldercare 
Locator at eldercare.acl.gov to locate an agency in your community. 
   
11 
  State Assistive Technology Act Programs 
Assistive technology (AT) is used to modify homes, increase independence and mobility and 
enhance accessibility. There is a wide array of AT available in the market from low-tech items 
like reachers,, door jamb expanders, and ramps to higher tech items such as sensors and 
voice- activated thermostats and lighting, to name a few. ACL administers the State Assistive 
Technology Act (AT) Program funded under section 4 of the Assistive Technology Act of 2004.  
All 50 states, 4 U.S. territories, the District of Columbia and Puerto Rico receive formula grant 
funding to support programs that increase knowledge about, access to and acquisition of assistive 
technology devices and services for individuals with disabilities and older adults. AT Programs 
serve individuals with disabilities of all ages through device demonstrations, device loans, device 
reutilization, training, technical assistance, public awareness, information and referral, and 
assistance with obtaining funding for AT, including home modifications. Most of the AT 
Programs conduct activities that can provide resources for home modifications and accessibility.  
Many states have financial loan programs specifically for AT, home modifications and vehicle 
modifications. Some AT Programs also administer programs or collaborate with other entities 
that provide other types of funding assistance for home modifications and home accessibility. AT 
Programs provide device demonstration centers that can include access to a wide variety of 
devices and equipment related to environmental adaptations to make homes more accessible. AT 
Programs also provide short-term device loans for individuals to borrow devices to try out and 
device reutilization programs that can be a resource to help make homes more accessible for 
persons with disabilities and older adults. 
 
To learn more about the State Assistive Technology Act Program and to access a directory visit 
the Assistive Technology Act Technical Assistance and Training (AT3) Center at 
https://www.at3center.net.  
 
State Councils on Developmental Disabilities 
ACL provides funding to support State Councils on Developmental Disabilities across the United 
States and its territories that work to address identified needs by conducting advocacy, systems 
change, and capacity building efforts that promote self-determination, integration, and inclusion. 
Key activities include conducting outreach, providing training and technical assistance, removing 
barriers, developing coalitions, encouraging citizen participation, and keeping policymakers 
informed about disability issues. For example, Georgias State Council on Developmental 
Disabilities has a Real Homes priority which focuses on promoting accessible, affordable 
housing, including the production of visitable homes including one no-step entrance, 32 clear 
passage through all interior doors and at least a half bathroom that a wheelchair user can 
maneuver in. This initiative promotes making these three features standard through voluntary 
implementation, market forces and advocacy. To learn more about State Councils on 
Developmental Disabilities visit https://acl.gov/programs/aging-and-disability-networks/state-
councils-developmental-disabilities. 
 
State Protection and Advocacy Systems  
Under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act), each 
state and U.S. territory has a protection and advocacy system (P&A) designated by the states 
governor. The DD Act and other authorizing statutes give the P&As authority to advocate for the 
rights of individuals with disabilities. The DD Act states that each P&A must have the authority 
12 
  to pursue legal, administrative, and other appropriate remedies or approaches to ensure the 
protection of, and advocacy for, the rights of such individuals within the State. 42 U.S.C. 
15043. The P&As use a range of remedies to advocate for individuals with developmental 
disabilities, including self-advocacy assistance, negotiation and litigation. Federal law authorizes 
P&As entities to protect the rights of individuals with developmental and other disabilities using 
different tools, including advocacy, investigation of abuse, and monitoring of settings where 
people with disabilities receive services. For instance, Disability Rights New Jersey assisted a 
59-year old man with Aspergers Disorder and insulin-dependent diabetes who was residing in a 
nursing facility. His discharge consideration included Managed Long Term Services and 
Supports (MLTSS), a separate program under the states HCBS waiver program. Disability 
Rights New Jersey held multiple meetings to discuss options for discharge. This man eventually 
received appropriate support including access to a housing subsidy. There are 57 P&As - one in 
every state and U.S. territory as well as one serving the Native American population in the four 
corners region. For more information on the P&As, please visit https://acl.gov/programs/aging-
and-disability-networks/state-protection-advocacy-systems. 
 
University Centers for Excellence in Developmental Disabilities Education, Research & 
Service 
ACL supports University Centers for Excellence in Developmental Disabilities Education, 
Research, and Service (UCEDDs), a nationwide network of independent but interlinked centers, 
representing an expansive national resource for addressing issues, finding solutions, and 
advancing research related to the needs of individuals with developmental disabilities and their 
families. UCEDDs provide training in support of the goals of maintaining housing and 
preventing homelessness for people with disabilities in the community. For example, Hawaiis 
UCEDD has formed the Hawaii Visitable Housing Coalition, which operates a website that 
serves as a one-stop shop for visitable housing resources in Hawaii, as well as a listserv to 
connect those working on visitability in Hawaii, develops educational resources and sessions on 
the topic, and educates the public and legislators on the benefits of visitable housing.  
To learn more about UCEDDs and to access a directory visit https://acl.gov/programs/aging-and-
disability-networks/national-network-university 
13 
  Appendix C 
Centers for Disease Control and Prevention (CDC) 
 
The Centers for Disease Control and Prevention (CDC) serves as the national focus for 
developing and applying disease prevention and control, environmental health, and health 
promotion and health education activities designed to improve the health of the people of the 
United States. CDC has several programs to support older adults throughout the United States, 
and in rural America. These programs and resources help make individuals homes safer, 
increase independence, ensure safety, minimize the risk for falls and support individuals ability 
and desire to remain in their homes and participate in community living.   
 
The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative helps healthcare 
providers develop a standardized process on how to screen patients for fall risk, assess the at-risk 
patients modifiable risk factors, and intervene to reduce identified risks using effective risk 
factor-specific interventions to reduce older adult falls in communities.  
 
STEADI resources for patients include: Stay Independent Brochure; What You Can Do to 
Prevent Falls Brochure; and Check for Safety Brochure, which includes a checklist for 
individuals to find and fix home hazards. 
 
STEADI resources for providers include: Algorithm for Fall Risk Screening, Assessment, and 
Intervention, which walks through how to assess a patients fall risk, educate patients, selecting 
interventions, and follow up; Preventing Falls in Older Patients: Provider Pocket Guide, an easy 
to use tool that summarizes key points of fall prevention; Talking About Falls Prevention with 
Your Patients; Fall Risk Checklist;  Fall Prevention Patient Referral Form; Integrating Fall 
Prevention into Practice; Recommended Programs Form to refer older adults to community 
programs that can help increase strength and balance; and A CDC Compendium of Effective 
Falls Interventions: What Works for Community Dwelling Older Adults, a collection of effective 
fall interventions to address older adult falls in communities.   
 
The Coordinated Care Plan to Prevent Older Adult Falls (CCP), offers primary care providers, 
practices, and healthcare systems a framework for implementing a Stopping Elderly Accidents, 
Deaths, and Injuries, or STEADI-based clinical fall prevention program in primary care settings 
to manage older patients fall risk. Although developed for primary care, the CCP and STEADI-
based programs can be implemented in different healthcare settings; and the CDC STEADI: 
Evaluation Guide for Older Adult Clinical Fall Prevention Programs describes key steps to 
measuring and reporting on the success of implementing a STEADI-based clinical fall 
prevention program. Evaluating the implementation and use of STEADI-based programs can 
help providers and organizations increase the quality of care provided to their older patients, and 
demonstrate program related successes and areas for improvement. CDC recommends providers 
use the CCP and Evaluation Guide simultaneously to ensure effective reporting on the clinical 
fall prevention programs overall success.   
 
STEADI-Rx, offers community pharmacists instruction on how to screen, assess, and intervene 
to reduce fall risk among their clients. STEADI-Rx is based on CDCs STEADI initiative and 
incorporates the Joint Commission of Pharmacy Practitioners Pharmacists Patient Care 
14 
  Process. STEADI-Rx includes a 3-step framework, or algorithm, for integrating fall screening 
and prevention into pharmaceutical care and a suite of tools that can be used to assist pharmacy 
staff in completing each step. It was developed by geriatric pharmacists, healthcare providers, 
and fall prevention experts committed to helping reduce fall injuries among older adults. 
The MyMobility Plan is a tool developed to encourage older adults to take action now to remain 
safe, mobile and independent as they age. The MyMobility Plan provides resources for older 
adults to help manage their health to maintain mobility, make their homes safer to prevent falls, 
and consider alternative transportation as they age. Related content includes a supporting fact 
sheet about medicines and their potential side effects that may increase fall or motor vehicle 
crash risk and promotional and social media materials to share and promote the planning tool.   
   
15 
  Appendix D 
 Health Resources and Services Administration (HRSA) 
 
The Health Resources and Services Administration (HRSA) provides resources and research on 
public health supports and interventions to help older adults living in rural areas age in place. 
The Federal Office of Rural Health Policy (FORHP) administers many of these rural programs 
and advises the U.S. Department of Health and Human Services on rural policy issues.  
 
The HRSA FORHP-funded Rural Health Information Hub is a national clearinghouse on rural 
health issues designed to support health care delivery and population health in rural 
communities. States can find resources regarding evidence-based programs and promising 
practices to prevent falls and support community living for older adults on Rural Health 
Information Hub pages such as Rural Aging  Models and Innovations and Rural Aging  
Resources.  
 
FORHP also supports the Rural Health Research Gateway to increase the amount of impartial, 
policy-relevant research on health and related issues in rural communities. FORHP-funded Rural 
Health Research Centers have published dozens of policy briefs, white papers, reports, and 
scholarly journal articles on issues related to rural aging in place. 
 
States may also find other HRSA programs useful for addressing the health needs of community-
residing older adults in rural areas.  
 
Additionally, HRSA funds health centers and other community-based organizations that deliver 
high-quality and comprehensive primary care services. HRSA-funded health centers also provide 
case management and enabling services. These services may be designed to meet patients 
ongoing needs, including assessment of varied factors affecting health (e.g., housing, education, 
etc.), counseling, referrals to address assessed needs, and periodic follow up. These case 
management responsibilities can help health centers connect rural older adults to housing and 
other resources necessary to maintain their safe community living arrangements. In fact, care 
coordination for older adults is one of several health center promising practices that HRSA tracks 
to support continuous quality improvement at funded health centers.  
 
Some FQHCs specialize in serving special populations through the Health Care for the Homeless 
Program. The Health Care for the Homeless Program provides funding to health centers that 
serve people experiencing homelessness. These programs furnish intensive services to meet the 
specific needs of medically complex individuals. Health Care for the Homeless grantees are 
required to provide substance use disorder services in addition to the required primary health 
services. 
 
HRSAs Ryan White HIV/AIDS Program provides a comprehensive system of HIV primary 
medical care, essential support services, and medications for low-income people with HIV who 
are uninsured and underserved. Home health care is the provision of services in the home that are 
appropriate to an eligible clients needs, including clients in rural areas, and are performed by 
licensed professionals. Activities must relate to the clients HIV disease and may include 
preventive and specialty care. 
16 
   
Rehabilitation services may include physical, occupational, and speech therapy that are provided 
to improve or maintain a clients quality of life and optimal capacity for self-care in accordance 
with an individualized plan of HIV care. 
 
Non-Medical Case Management Services (NMCM) is the provision of a range of client-centered 
activities focused on improving access to and retention in needed core medical and support 
services. NMCM provides coordination, guidance, and assistance in accessing medical, social, 
community, legal, financial, employment, vocational, and/or other needed services. NMCM may 
also include assisting eligible clients to obtain access to other public and private programs for 
which they may be eligible. 
 
The Geriatrics Workforce Enhancement Program (GWEP) improves health care for older adults 
by transforming clinical training environments and maximizing patient and family engagement 
in health care decisions. This program integrates geriatrics and primary care delivery sites and 
systems by requiring grant recipients to incorporate the principles of the Age-Friendly Health 
Systems Initiative (what matters most to the older adult, medications, mentation, and mobility), 
value-based care, and alternative-payment models. A key component of the success of this 
program is the development of reciprocal partnerships between academia, primary care, and 
community-based organizations to address social determinants and other gaps in health care for 
older adults. The program provides training across the educational continuum focusing on 
geriatrics training in inter-professional and team-based care to increase quality of care and 
provider satisfaction.   
 
Faculty with expertise in geriatrics are needed to train the workforce and provide specialized care 
to improve health outcomes for older adults. HRSA funds the Geriatrics Academic Career 
Awards (GACA) Program to support the career development of junior faculty in geriatrics. The 
goals of the program are for the GACA grant recipient to develop the necessary skills to lead 
health care transformation in a variety of settings, including in rural and/or medically 
underserved setting, as well as age-friendly settings that provide inter-professional training in 
clinical geriatrics. 
 
HRSA also has developed training on dementia to assist practicing health professionals, 
caregivers, families and patients in better understanding dementia and its impact, HRSA 
developed two education and training curricula on dementia. The Alzheimers Disease and 
Related Dementias curriculum offers continuing education credits for health professions faculty, 
students, primary care practitioners, members of the inter-professional geriatrics care team and 
direct service workers. The modules in the caregiving curriculum are designed to assist primary 
care providers in addressing caregiver needs of persons living with dementia and to help family 
and other caregivers of persons living with dementia take care of their own health and better 
cope with the challenges of caregiving. Both curricula are open access and the materials can be 
downloaded and modified to be used to meet local training needs. 
 
 
   
17 
  Appendix E 
U.S. Department of Housing and Urban Development (HUD) 
 
The U.S. Department of Housing and Urban Development (HUD) provides resources and 
programs for home repair and rehabilitation to help older adults and individuals with disabilities 
living in rural areas to age in place or remain at home.  
 
Title I Property Improvement Loan Program  insures loans up to $25,000 for light or 
moderate rehabilitation of properties.   
Section 203(k) Rehabilitation Mortgage Insurance  enables homebuyers and homeowners to 
finance the purchase (or refinancing) of a home and the cost of its rehabilitation through a single 
mortgage or to finance the rehabilitation of their existing home.  
Section 184 Indian Home Loan Guarantee Program  can be used, both on and off native 
lands, for new construction, rehabilitation, purchase of an existing home, or refinance. 
HOME Investment Partnerships Program (HOME)  allows participating jurisdictions to 
assist existing low-income homeowners with the repair, rehabilitation, or reconstruction of 
owner-occupied units through a grant or loan, and to rehabilitate or newly construct housing for 
low-income homebuyers, and for down-payment or other financing to assist homebuyers to 
purchase homes as their principal residence. 
Community Development Block Grant (CDBG)  can be used by states and units for local 
government to provide  grants, loans, loan guarantees, interest subsidies, or other forms of 
assistance to homeowners for the purpose of repairs, rehabilitation, or reconstruction. 
Section 202 Housing for the Elderly  state agencies could encourage nonprofits to apply for 
Capital Advance Funds in response to a Notice of Funding Availability (NOFA), and there are 
many existing properties in rural areas that are well suited for aging in place. 
Section 811 Housing for Persons with Disabilities -  state agencies could encourage nonprofits 
to apply for Capital Advance funds in response to a NOFA, or they could apply to participate in 
the State Project Rental Assistance Program, and there are existing properties in rural areas that 
are in the community and accessible. 
FHA Multifamily Mortgage Insurance -  loan guarantees available for rehabilitating rental 
properties. 
 
Reasonable Accommodations 
Both privately owned and publicly assisted housing must meet certain housing accessibility 
requirements. Further, participants in federally-assisted housing must meet requirements for 
nondiscrimination on the basis of disability. The reasonable accommodation process is the 
primary method by which a person with a disability who is a tenant in federally-assisted housing 
can request a home modification or other reasonable accommodation such as having a service 
animal. 
Section 504:  Frequently Asked Questions 
(https://www.hud.gov/program_offices/fair_housing_equal_opp/disabilities/sect504faq#_Reason
able_Accommodation) 
 
HUD-DOJ Statement on Reasonable Modifications under the Fair Housing Act 
(https://www.hud.gov/sites/documents/DOC_7502.PDF) 
18 
  Appendix F 
U.S. Department of Agriculture (USDA)  
 
USDA offers loans and grants to low and very low-income applicants to modernize, repair and 
make accessible alterations to homes in rural areas for both single family housing and affordable 
multi-family rental housing. Program eligibility requirements must be met for applicants to 
receive assistance. In many instances, USDA can leverage funds with other agencies or non-
profit organizations to make the necessary repairs or modifications.  
 
USDA programs for providing home repair, rehabilitation and home modifications are 
administered through the Rural Housing Services (RHS), a division within the USDA  Rural 
Development agency. These programs include the Rural Home Loans (Section 502 Direct), 
Single Family Home Loan Guarantees (Section 502 Guarantee), Single Family Housing Repair 
Loans & Grants (Section 504), Housing Preservation Grants, Multi-Family Housing Loan 
Guarantees, Housing Preservation & Revitalization Demonstration Loans & Grants and Farm 
Labor Housing Direct Loans & Grants. Below are short descriptions of each program with a link 
to Fact Sheets for further details. 
 
Single Family Section 502 Direct Home Loan Program 
Assists low- and very-low-income applicants obtain decent, safe and sanitary housing in eligible 
rural areas by providing payment assistance to increase an applicants repayment ability. To be 
eligible, at a minimum, applicants must have an adjusted income that is at or below the 
applicable low-income limit for the area where they wish to buy a house and they must 
demonstrate a willingness and ability to repay debt.  
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-
sheet/508_RD_FS_RHS_SFH502Direct.pdf   
 
Generally, rural areas with a population less than 35,000 are eligible. The USDA Income and 
Property eligibility website, https://eligibility.sc.egov.usda.gov/eligibility/welcomeAction.do, 
can be access for complete details.  
 
Applicants should contact local Rural Development Offices https://www.rd.usda.gov/contact-
us/state-offices about eligibility requirements. 
 
Single Family Section 502 Home Loan Guarantees 
Assists approved lenders in providing low- and moderate-income households the opportunity to 
own adequate, modest, decent, safe and sanitary dwellings as their primary residence in eligible 
rural areas. Eligible applicants may build, rehabilitate, improve or relocate a dwelling in an 
eligible rural area. The program provides a 90% loan note guarantee to approved lenders in order 
to reduce the risk of extending 100% loans to eligible rural homebuyers.  
 
Applicants must contact an approved lender. Information about approved lenders may be 
obtained by contacting a Guaranteed Loan Coordinator, https://www.rd.usda.gov/contact-
us/state-offices, in the appropriate state.  
 
Single Family Housing Repair Loans & Grants 
19 
  Programs provide loans to very-low-income homeowners to repair, improve, or modernize their 
homes or provides grants to elderly very-low-income homeowners to remove health and safety 
hazards.  
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-
sheet/508_RD_FS_RHS_SFH504HomeRepair.pdf 
 
Generally, rural areas with a population less than 35,000 are eligible. Applicants may check the 
address of their home, https://eligibility.sc.egov.usda.gov/eligibility/welcomeAction.do, to 
determine eligibility online.  
 
Housing Preservation Grants 
Provides grants to sponsoring organizations for the repair or rehabilitation of housing occupied 
by low- and very-low-income individuals and families. Applications are accepted on an annual 
basis through a NOFA in the Federal Register.  
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-sheet/508_RD_FS_RHS_HPG.pdf  
 
Generally, rural areas and towns with 20,000 or fewer people are eligible. Check eligible 
addresses, https://eligibility.sc.egov.usda.gov/eligibility/welcomeAction.do.  
 
Multi-Family Housing Loan Guarantees 
Program works with qualified private-sector lenders to provide financing to qualified borrowers 
to increase the supply of affordable rental housing for low- and moderate-income individuals and 
families in eligible rural areas and towns. Private lenders may apply for a loan guarantee on 
loans made to an eligible borrower who is unable to obtain commercial credit on reasonable 
terms without the guarantee. Loans guaranteed through this program are serviced through the 
private lender that makes the loan, just as they would be without a guarantee. 
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-
sheet/508_RD_FS_RHS_MFGuarantee.pdf   
 
Housing Preservation & Revitalization Demonstration Loans & Grants 
Restructures loans for existing Rural Rental Housing projects to help improve a projects 
physical condition and preserve the availability of safe affordable rental housing for low income 
residents. Preserve and improve existing Rural Rental Housing projects in order to extend their 
affordable use without displacing tenants through increased rents.  
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-
sheet/508_RD_FS_RHS_PreservationRevitalization.pdf 
 
A two-phase application process starts with pre-applications accepted on an annual basis through 
a NOFA in the Federal Register. Selected pre-applications are invited to submit final 
applications. 
 
Mutual Self-Help Housing Technical Assistance Grants 
20 
  Provides grants to qualified organizations to help them carry out local self-help housing 
construction projects. Grant recipients supervise groups of very-low- and low-income individuals 
and families as they construct their own homes in rural areas. The group members provide most 
of the construction labor on each others homes, with technical assistance from the organization 
overseeing the project. 
 
Program Fact Sheet: https://www.rd.usda.gov/sites/default/files/fact-
sheet/508_RD_FS_RHS_MSHHousingTechAsst.pdf 
 
Generally, rural areas with a population less than 35,000 are eligible. The USDA Income and 
Property eligibility website, https://eligibility.sc.egov.usda.gov/eligibility/welcomeAction.do, 
can be accessed for complete details.  
 
Applicants should contact local Rural Development Offices https://www.rd.usda.gov/contact-
us/state-offices about eligibility requirements. 
21