DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
DATE:   June 26, 2015  
 
FROM:   Vikki Wachino, Director  
Center for Medicaid and CHIP Services 
 
SUBJECT:   Coverage of Housing-Related Activities and Services for Individuals with  
Disabilities  
 
This Informational Bulletin is intended to assist states in designing Medicaid benefits, and to 
clarify the circumstances under which Medicaid reimburses for certain housing-related activities, 
with the goal of promoting community integration for individuals with disabilities, older adults 
needing long term services and supports (LTSS), and those experiencing chronic homelessness1. 
Consistent with statute, CMS does not provide Federal Financial Participation (FFP) for room 
and board2 in home and community based services,3 but can assist states with coverage of certain 
housing-related activities and services.   
 
This Bulletin underscores CMS commitment to help states expand home and community-based 
living opportunities consistent with the Affordable Care Act, the implementation of the Home 
and Community Based Services (HCBS) settings final rule governing Medicaids 1915(c) HCBS 
Waiver program, 1915(i) HCBS State Plan Option, and 1915(k) Community First Choice State 
Plan Option4, as well as the Americans with Disabilities Act and the Supreme Courts decision in 
Olmstead v. L.C.5  The information in this Bulletin is based on evidence from studies 
demonstrating that providing housing-related activities and services facilitates community 
integration and is cost effective. This Bulletin is also intended to help states design benefit 
programs that acknowledge the social determinants of health, and contribute to a holistic focus 
on improvement of individual health and wellness. 
 
Describing Housing-Related Activities and Services  
 
Most broadly, housing-related activities include a range of flexible services and supports 
available to individuals with disabilities and older adults needing LTSS, as well as collaborative 
efforts among key Medicaid and housing agency staffs and stakeholders.  In recent years, the 
                                                           
1 CMS and SAMHSA are working on providing additional guidance to clarify the circumstances under which Medicaid 
reimburses for certain housing-related activities and services for persons experiencing chronic homelessness. 
2 Room and board also includes capital funds used for new construction or rehabilitation of housing. 
3 There are two exceptions that are described in the paragraph on 1915(c) waivers on page 5. 
4 Final Rule - CMS 2249-F  1915(i) State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider 
Payment Reassignment, Setting Requirements for Community First Choice, and CMS 2296-F 1915(c) Home and Community-
Based Services Waivers, published January 10, 2014, available at  http://www.medicaid.gov/HCBS 
5 Americans with Disabilities Act and as interpreted in the U.S. Supreme Courts 1999 decision in Olmstead vs. L.C (Olmstead).   
For details: Statement of the Department of Justice on Enforcement of the Integration Mandate of Title II of the Americans with 
Disabilities Act and Olmstead v. L.C. http://www.ada.gov/Olmstead/q&a_Olmstead.htm  Page 2-CMCS Informational Bulletin 
 
Money Follows the Person (MFP) rebalancing demonstration program6 and the Real Choice 
Systems Change grants7 have provided successful models for Medicaid-supported housing-
related activities and services, particularly for individuals transitioning out of institutions. 
 
Housing-related activities and services are: (1) Individual Housing Transition Services - services 
that support an individuals ability to prepare for and transition to housing; (2) Individual 
Housing & Tenancy Sustaining Services - services that support the individual in being a 
successful tenant in his/her housing arrangement and thus able to sustain tenancy; and (3) State-
level Housing Related Collaborative Activities - services that support collaborative efforts across 
public agencies and the private sector that assist a state in identifying and securing housing 
options for individuals with disabilities, older adults needing LTSS, and those experiencing 
chronic homelessness.  The studies cited below show strong evidence of the benefit of these 
services.  
 
This Bulletin identifies how these housing-related activities and services can be incorporated into 
a Medicaid benefit design for individuals needing LTSS and in states strategies for transforming 
systems to achieve optimal community integration.  Although the focus of this Bulletin is on 
Medicaid reimbursement, other federal resources are also available to states for housing-related 
activities, in collaboration with programs funded by the Department of Housing and Urban 
Development (HUD), the Department of Agriculture (USDA) and other sources.  State Medicaid 
agencies can play an important role in convening state program offices and other partners to 
identify other non-Medicaid funded sources to support these activities and to collaborate in 
HCBS systems transformation. 
  
The Case for Housing-Related Activities and Services  
 
Research has demonstrated successful community integration for individuals in need of long 
term services and supports (LTSS) that receive housing-related services. Some of these studies 
and their results include: 
  Under the MFP rebalancing demonstration program, those states providing specific 
housing-related services and activities such as employing housing specialists, paying for 
one-time moving expenses, and incorporating assistance with searching for housing as a 
core function of transition planning had more success and a higher rate of transitioning 
individuals out of more costly nursing homes and other institutions and into community 
living than those programs without these services.8  
  The Real Choice Systems Change grant program showed that building relationships 
between state Medicaid agencies and state and local housing organizations and 
stakeholders resulted in the capacity to take advantage of other federal and state funding 
opportunities to expand community-based housing resources for Medicaid eligible 
                                                           
6 For information on the MFP program: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-
Services-and-Supports/Balancing/Money-Follows-the-Person.html 
7 For information on Real Choice Systems Change grants: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Long-Term-Services-and-Supports/Balancing/Downloads/Final-RCSC-Report.pdf 
8 Lipson, Debra J., Christal Stone Valenzano, and Susan R. Williams. What Determines Progress in State MFP Transition 
Programs? National Evaluation of the Money Follows the Person (MFP) Demonstration Grant Program, Report from the Field, 
No. 8, Washington DC: Mathematica Policy Research, October 2011.  Page 3-CMCS Informational Bulletin 
 
populations, including new rental assistance funds under the Department of Housing & 
Urban Developments Section 811 Project Rental Assistance program for integrated 
supportive housing units.9 
 
States are increasingly using community-based housing-related services as part of a strategy 
when implementing Olmstead plans or settlement agreements to provide integrated community 
living opportunities for people exiting institutional or other segregated settings, as well as those 
at risk of unnecessary institutionalization due to being inappropriately housed.   
 
Housing Related Activities and Services for the Individual:   
 
Three housing-related activities and services are described in this section. Following this section 
is a description of the Medicaid authorities and demonstrations through which states can be 
reimbursed for these services. 
 
1.  Individual Housing Transition Services:   
 
Housing transition services provide direct support to individuals with disabilities, older adults 
needing long term services and supports, and those experiencing chronic homelessness.  These 
services are:   
 
  Conducting a tenant screening and housing assessment that identifies the participants 
preferences and barriers related to successful tenancy.  The assessment may include 
collecting information on potential housing transition barriers, and identification of 
housing retention barriers. 
  Developing an individualized housing support plan based upon the housing assessment 
that addresses identified barriers, includes short and long-term measurable goals for each 
issue, establishes the participants approach to meeting the goal, and identifies when 
other providers or services, both reimbursed and not reimbursed by Medicaid, may be 
required to meet the goal.  
  Assisting with the housing application process. Assisting with the housing search 
process.  
  Identifying resources to cover expenses such as security deposit, moving costs, 
furnishings, adaptive aids, environmental modifications, moving costs and other one-time 
expenses. 
  Ensuring that the living environment is safe and ready for move-in.   
  Assisting in arranging for and supporting the details of the move.  
  Developing a housing support crisis plan that includes prevention and early intervention 
services when housing is jeopardized. 
 
2.  Individual Housing & Tenancy Sustaining Services 
 
                                                           
9 Kehn, Matthew, and Lipson, Debra, The Real Choice Systems Change Grant: Building Sustainable Partnerships for Housing, 
Final Report, Mathematica Policy Research, March 24, 2104, accessed at: http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Long-Term-Services-and-Supports/Balancing/Downloads/Final-RCSC-Report.pdf  Page 4-CMCS Informational Bulletin 
 
This service is made available to support individuals to maintain tenancy once housing is 
secured.  The availability of ongoing housing-related services in addition to other long term 
services and supports promotes housing success, fosters community integration and inclusion, 
and develops natural support networks.  These tenancy support services are:    
 
  Providing early identification and intervention for behaviors that may jeopardize housing, 
such as late rental payment and other lease violations. 
  Education and training on the role, rights and responsibilities of the tenant and landlord.  
  Coaching on developing and maintaining key relationships with landlords/property 
managers with a goal of fostering successful tenancy. 
  Assistance in resolving disputes with landlords and/or neighbors to reduce risk of 
eviction or other adverse action. 
  Advocacy and linkage with community resources to prevent eviction when housing is, or 
may potentially become jeopardized. 
  Assistance with the housing recertification process.   
  Coordinating with the tenant to review, update and modify their housing support and 
crisis plan on a regular basis to reflect current needs and address existing or recurring 
housing retention barriers.   
  Continuing training in being a good tenant and lease compliance, including ongoing 
support with activities related to household management. 
 
3.  State-level Housing Related Collaborative Activities 
 
Several strategic, collaborative activities to assist in identifying and securing housing resources 
are:  
 
  Developing formal and informal agreements and working relationships with state and 
local housing and community development agencies to facilitate access to existing and 
new housing resources. 
  Participating and contributing to the planning processes of state and local housing and 
community development agencies, for example, by providing demographic, housing 
need, and other relevant data for the populations served by the LTSS agencies, among 
other planning activities.  
  Working with housing partners to create and identify opportunities for additional housing 
options for people wishing to transition to community-based housing.   This may include 
coordinating available housing locator systems and developing and/or coordinating data 
tracking systems to include housing. 
 
Medicaid Authorities and Demonstration Programs 
 
States have a number of options under Medicaid and demonstration programs to cover housing-
related services and activities that promote community integration for individuals needing long 
term services and supports, particularly individuals transitioning from institutions.  Housing-
related services will help states to assist individuals with disabilities in accessing settings that 
comply with  the new Home and Community Based Services Settings regulations in 42 CFR 
441.530 for 1915(k), 441.301(c)(4) for 1915(c) and 441.710 for 1915(i). Medicaid funds  Page 5-CMCS Informational Bulletin 
 
cannot be used to pay for a Medicaid beneficiarys room and board in the community.10  
However, the following Medicaid authorities and demonstration programs offer opportunities for 
coverage of some of the housing-related activities and services described above. Some 
authorities offer greater opportunities for coverage, while others are more limited:   
 
1915(c) HCBS Waivers 
 
States can use the 1915(c) HCBS waiver program to cover some housing-related services. As 
part of the waiver case management activity under 1915(c), states can reimburse for housing 
transition and tenancy sustaining services, such as: assessing the participants housing needs and 
presenting options, assisting in securing housing, including the completion of  housing 
applications and securing required documentation (e.g., Social Security card, birth certificate, 
prior rental history), searching for housing, communicating with landlords, coordinating the 
move, providing training on  how to be  a good tenant, and establishing procedures and contacts 
to retain  housing. Environmental modifications to install necessary accommodations for 
accessibility can also be covered.  For persons transitioning out of Medicaid funded institutions 
or other provider-operated living arrangements to a living arrangement in a private residence 
where the person is directly responsible for his or her own living expenses, through CMS 
approved 1915(c) waivers, Medicaid can provide FFP to states for the following Community 
Transition Services  necessary to enable a person to establish a basic household that do not 
constitute room and board: security deposits required to obtain a lease on an apartment or home, 
set-up fees for utilities or service access, including telephone, electricity, heating and water,  
essential household furnishings and moving expenses required to occupy and use a community 
domicile, including furniture, window coverings, food preparation items and bed/bath linens, and 
services necessary for the individuals health and safety such as pest eradication and one-time 
cleaning prior to occupancy    States cannot receive FFP for  room and board except for 
temporary short-term out of home respite services  and for unrelated live-in caregivers.11  
Community Transition Services are furnished only to the extent that they are reasonable and 
necessary as determined through the service plan development process clearly identified in the 
service plan and only when the person is unable to meet such expense or when the services 
cannot be obtained from other sources. Community Transition Services do not include monthly 
rental or mortgage expense, food, regular utility charges, and/or household appliances or items 
that are intended for purely diversional/recreational purposes. 
 
1915(i) HCBS State Plan Optional Benefit 
 
States can use the 1915(i) state plan service to offer  housing-related services similar to those  
available in the 1915(c) waiver program such as: assessing the participants housing needs and 
presenting options, assisting in securing housing, including the completion of  housing 
applications and securing required documentation (e.g., Social Security card, birth certificate, 
prior rental history), searching for housing, communicating with landlords,  coordinating the 
move, providing training in how to be a good tenant, and establishing procedures and contacts to 
                                                           
10 There are two targeted exceptions to this prohibition that are described in the paragraph on 1915(c) waivers on 
page 5. 
11 Payment for the room and board for the unrelated live-in caregiver is not available if the participant lives in the 
caregivers home or in the residence owned or leased by the provider of waiver services.  Page 6-CMCS Informational Bulletin 
 
retain housing. Environmental modifications to install necessary accommodations for 
accessibility can also be covered.  For persons transitioning out of Medicaid funded institutions 
or other provider-operated living arrangements to a living arrangement in a private residence 
where the person is directly responsible for his or her own living expenses, through CMS 
approved 1915(i) State plan HCBS benefits, Medicaid can provide FFP to states for the 
following Community Transition Services  necessary to enable a person to establish a basic 
household that do not constitute room and board: security deposits required to obtain a lease on 
an apartment or home, set-up fees for utilities or service access, including telephone, electricity, 
heating and water, essential household furnishings and moving expenses required to occupy and 
use a community domicile, including furniture, window coverings, food preparation items and 
bed/bath linens, and services necessary for the individuals health and safety such as pest 
eradication and one-time cleaning prior to occupancy.  States cannot receive FFP for room and 
board except for temporary short-term out of home respite services and for unrelated live-in 
caregivers.12 Community Transition Services are furnished only to the extent that they are 
reasonable and necessary as determined through the service plan development process, clearly 
identified in the service plan and only when the person is unable to meet such expense or when 
the services cannot be obtained from other sources. Community Transition Services do not 
include monthly rental or mortgage expense, food, regular utility charges, and/or household 
appliances or items that are intended for purely diversional/recreational purposes. Individuals do 
not have to meet an institutional level of care to be served through 1915(i), so States can choose 
to serve adults with behavioral health issues or others who could not be served under a 1915(c) 
waiver.  States cannot waive state wideness or limit the number of individuals served.  
 
1915(k) Community First Choice State Plan Optional Benefit 
 
1915(k), also known as Community First Choice (CFC), is a state plan option that reimburses for 
person-centered home and community based attendant services and supports in a home and 
community based setting.  CFC services assist in 1) accomplishing activities of daily living 
(ADLs), instrumental activities of daily living (IADLs), and health-related tasks; 2) acquisition, 
maintenance, and enhancement of skills for the individual to accomplish ADLs, IADLs, and 
health-related tasks; 3) backup systems or mechanisms to ensure continuity of services and 
supports; and 4) voluntary training on how to select, manage and dismiss attendants. States can 
also provide reimbursement for permissible services and supports linked to an individuals 
assessed need in their person-centered plan. Permissible services and supports are: transition 
costs for individuals transitioning from an institution to the community, and/or expenditures that 
increase an individuals independence or substitute for human assistance to the extent that 
expenditures would have been made for human assistance.  Transition costs could also include 
security deposits for an apartment or utilities, purchasing bedding and basic kitchen supplies, 
first months rent, and other one-time expenses required for the transition from an institution to 
community housing.  
 
1915(b) Waivers 
 
                                                           
12 Payment for the room and board for the unrelated live-in caregiver is not available if the participant lives in the 
caregivers home or in the residence owned or leased by the provider of waiver services.  Page 7-CMCS Informational Bulletin 
 
Managed care programs can offer individuals with disabilities, older adults needing long term 
services and supports (LTSS), and those experiencing chronic homelessness housing-related 
activities and services. States may use 1915(b) waivers to authorize a managed care delivery 
system through which services that are otherwise coverable under state plan and waiver 
programs or are medical, health-related or remedial in nature can be reimbursed, such as 
housing-related services. 1915(b)(3) authority permits states to use the savings from services 
covered through its 1915(b) waiver to provide additional services to waiver enrollees.  These 
additional savings may be used to authorize 1915(b)(3) housing-related services specified in this 
bulletin for individuals to identify, transition to, and sustain their housing. 
 
1905(a) State Plan Services 
 
Targeted case management (TCM) services provided under the Medicaid State Plan and 
described at 42 CFR 440.169, may be beneficial for individuals transitioning from institutions 
and/or trying to obtain or maintain their community housing arrangement.  TCM services are 
defined as services furnished to assist individuals in gaining access to needed medical, social, 
educational, and other services.  TCM is a specific service under the state plan that is targeted to 
specific populations, as determined by the state.  As part of identifying the total needs of an 
eligible individual, targeted case management can include linking the individual to needed 
housing resources, activities to help an individual find housing, and assisting with identifying 
resources to support the participant to maintain housing during a crisis.   
 
Section 1115 Research and Demonstration Programs 
Section 1115 of the Social Security Act gives the Secretary of HHS authority to approve 
experimental, pilot, or demonstration projects that further the objectives of Medicaid and the 
Childrens Health Insurance Program (CHIP).  These demonstrations give states additional 
flexibility to design and improve their programs, to demonstrate and evaluate policy approaches, 
such as using innovative service delivery systems that improve care, increase efficiency, and 
reduce costs.  Some section 1115 demonstrations include housing-related services consistent 
with the statutory authorities described in this bulletin.  For example, states can provide services 
to individuals already in the community, by helping the individual problem solve, advocate with 
landlords, access community resources to assist with back rent, and assist individuals to 
complete forms for subsidized housing.  For people leaving institutions, states assist with 
locating  housing, completing forms for subsidies, moving, and household set ups. In general, 
section 1115 demonstrations are approved for a five-year period and can be renewed, typically 
for an additional three years.  Demonstrations must be budget neutral to the federal 
government, which means that during the course of the project federal Medicaid expenditures 
will not be more than federal spending without the demonstration.   
Money Follows the Person Rebalancing Demonstration 
 
For states participating in the MFP Rebalancing Demonstration Grant, the grant provides an 
opportunity for states to offer housing-related services to individuals transitioning from 
qualifying institutions to qualifying home and community based settings.  Most MFP programs 
have hired and/or contracted with housing specialists, housing coordinators, transition  Page 8-CMCS Informational Bulletin 
 
coordinators, and case/care managers to provide an array of housing-related services and 
activities.  These include state-level housing related collaborative activities to create, identify and 
secure affordable, accessible, rental housing resources that meet MFP qualified residence 
requirements.  In collaboration with housing agencies, landlords, and developers, MFP programs 
have also funded housing-related transition services to assist individuals in locating, applying for 
and moving into housing, as well as housing stabilization, tenancy supports and services related 
to assisting individuals remain in their housing.  
 
State Examples 
 
States that have used the various opportunities noted above to fund housing-related services and 
activities include:  
 
  MFP program: 
  Washington States Roads to Community Living program uses MFP 
o
administrative and demonstration services funds to support housing-related 
transition and sustaining services, as well as collaborative efforts across human 
service agencies and with state and local housing agencies to develop housing 
resources. 
  Texas has used MFP administrative funding in collaboration activities with state 
o
housing and local agencies.  
 
  Some states  have used 1915(b) waivers to cover housing-related services for housing 
transition and to sustain housing for individuals: 
  Iowas Behavioral Health Waiver 
o
  Michigans Specialty Inpatient Health Plans, Children with Serious Emotional 
o
Disturbances, and Childrens Waiver Program Waivers 
  North Carolinas Cardinal Innovations Waiver 
o
  Wisconsins Family Care Waiver 
o
  Nebraskas Health Connection Waiver 
o
  Ohios Integrated Care Delivery System Waiver 
o
 
  Transition to Housing, Crisis Intervention and Housing Stabilization provided under  
1915(c) waiver authority in Louisiana enables individuals who are transitioning into a 
unit, including those transitioning from institutions, to secure their own housing.  It also 
provides assistance at any time the individuals housing is placed at risk (e.g., eviction, 
loss of roommate or income).  The service includes the following components:  
  Conduct a housing assessment identifying individuals preferences related to 
o
housing and needs for support to maintain housing, budgeting for housing/living 
expenses, accessing sources of income necessary for rent, home management, 
establishing credit and understanding and meeting obligations of tenancy.     
  Assist individual to view and acquire housing, secure supporting documents, 
o
completing/submitting applications, securing deposits, locate furnishings.   
  Develop an individualized housing support plan based upon the housing 
o
assessment.    Page 9-CMCS Informational Bulletin 
 
  Participate in the development of the plan of care, incorporating elements of the 
o
housing support plan.  
  Communicate with the landlord or property manager regarding the individuals 
o
disability, accommodations needed, and components of emergency procedures 
involving the property manager. 
 
For More Information 
 
CMS is committed to assisting states in providing housing-related services and activities and to 
expand home and community-based living opportunities. Please contact Martha Egan at 
martha.egan@cms.hhs.gov for questions about this Bulletin.