SUBSTANCE USE 

DISORDER

Information on 

Recovery Housing 

Prevalence, Selected 

States' Oversight, and 

Funding

Report to Congressional Requesters

March 2018

GAO-18-315

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-315, a report to 

congressional requesters

March 2018

SUBSTANCE USE DISORDER

Information on Recovery Housing Prevalence, 

Selected States’ Oversight, and Funding

What GAO Found

Nationwide prevalence of recovery housing—peer-run or peer-managed drugand alcohol-free supportive housing for individuals in recovery from substance 

use disorder (SUD)—is unknown, as complete data are not available. National 

organizations collect data on the prevalence and characteristics of recovery 

housing but only for a subset of recovery homes. For example, the National 

Alliance for Recovery Residences, a national nonprofit and recovery community 

organization that promotes quality standards for recovery housing, collects data 

only on recovery homes that seek certification by one of its 15 state affiliates that 

actively certify homes. The number of homes that are not certified by this 

organization is unknown.

Four of the five states that GAO reviewed—Florida, Massachusetts, Ohio, and 

Utah—have conducted, or are in the process of conducting, investigations of 

recovery housing activities in their states, and three of these four states have 

taken formal steps to enhance oversight. The fifth state, Texas, had not 

conducted any such investigations at the time of GAO’s review. Fraudulent 

activities identified by state investigators included schemes in which recovery 

housing operators recruited individuals with SUD to specific recovery homes and 

treatment providers, who then billed patients’ insurance for extensive and 

unnecessary drug testing for the purposes of profit. For example, officials from 

the Florida state attorney’s office told GAO that SUD treatment providers were 

paying $300 to $500 or more per week to recovery housing operators for every 

patient they referred for treatment and were billing patients’ insurance for 

hundreds of thousands of dollars in unnecessary drug testing over the course of 

several months. Some of these investigations have resulted in arrests and other 

actions, such as changes to insurance payment policies. Florida, Massachusetts, 

and Utah established state certification or licensure programs for recovery 

housing in 2014 and 2015 to formally increase oversight. The other two states in 

GAO’s review—Ohio and Texas—had not passed such legislation but were

providing training and technical assistance to recovery housing managers.

The Substance Abuse and Mental Health Services Administration (SAMHSA), 

within the Department of Health and Human Services (HHS), administers two 

federal health care grants for SUD prevention and treatment that states may use 

to establish recovery homes and for related activities. First, under its Substance 

Abuse Prevention and Treatment block grant, SAMHSA makes at least $100,000 

available annually to each state to provide loans to organizations seeking to 

establish recovery homes. Second, states have discretion to use SAMHSA 

funding available under a 2-year grant for 2017 and 2018 primarily for opioid use 

disorder treatment services, to establish recovery homes or for recovery 

housing-related activities. Of the five states GAO reviewed, only two, Texas and 

Ohio, have used any of their SAMHSA grant funds for these purposes. Four of 

the five states—Florida, Massachusetts, Ohio, and Texas—have also used state 

general revenue funds to establish additional recovery homes.

HHS had no comments on this report. View GAO-18-315. For more information, 

contact Katherine M. Iritani at (202) 512-7114 

or iritanik@gao.gov.

Why GAO Did This Study

Substance abuse and illicit drug use, 

including the use of heroin and the 

misuse of or dependence on alcohol 

and prescription opioids, is a growing 

problem in the United States. 

Individuals with SUD may face 

challenges in remaining drug- and 

alcohol-free. Recovery housing can 

offer safe, supportive, drug- and 

alcohol-free housing to help these 

individuals maintain their sobriety

and can be an important resource for 

individuals recovering from SUD. 

However, the media has reported 

allegations about potentially 

fraudulent practices on the part of 

some recovery homes in some 

states.

GAO was asked to examine recovery 

housing in the United States. This 

report examines (1) what is known 

about the prevalence and

characteristics of recovery housing

across the United States; (2) 

investigations and actions selected 

states have undertaken to oversee

such housing; and (3) SAMHSA

funding for recovery housing, and 

how states have used this or any 

available state funding. GAO 

reviewed national and state data, 

federal funding guidance, and 

interviewed officials from SAMHSA, 

national associations, and five 

states—Florida, Massachusetts, 

Ohio, Texas, and Utah—selected 

based on rates of opioid overdose 

deaths, dependence on or abuse of 

alcohol and other drugs, and other 

criteria. State information is intended 

to be illustrative and is not

generalizable to all states.
Page i GAO-18-315 Substance Use Disorder

Letter 1

Background 3

Nationwide Prevalence of Recovery Housing Is Unknown, but 

National Organizations Collect Data on the Number and 

Characteristics of a Subset of Recovery Homes 6

Most States We Reviewed Have Investigated Potential Fraud 

Related to Recovery Housing and Taken Steps to Enhance 

Oversight 7

Certain SAMHSA Grant Funding Can Be Used for Recovery 

Housing, and Selected States Have Used SAMHSA and State 

Funding to Support Recovery Housing 17

Agency Comments 23

Appendix I State Agencies and Related Entities GAO Interviewed 26

Appendix II GAO Contact and Staff Acknowledgments 28

Tables

Table 1: Features of Three State-Established Oversight Programs 

for Recovery Housing 14

Table 2: Selected States’ Use of Federal and State Funding for 

Recovery Housing and Oversight Activities, Fiscal Years 

2013 through 2017 21

Contents
Page ii GAO-18-315 Substance Use Disorder

Abbreviations

HHS Department of Health and Human Services

NARR National Alliance for Recovery Residences

SAMHSA Substance Abuse and Mental Health Services 

Administration

SUD substance use disorder

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-18-315 Substance Use Disorder

441 G St. N.W.

Washington, DC 20548

March 22, 2018

Congressional Requesters

Substance abuse and illicit drug use, including the use of heroin and the 

misuse of alcohol and prescription opioids, is a growing problem in the 

United States. Individuals recovering from substance use disorder (SUD) 

may face challenges remaining alcohol- or drug-free. Recovery housing—

peer-run or peer-managed supportive residences—can offer safe, 

supportive, stable living environments to help individuals recovering from 

SUD maintain an alcohol- and drug-free lifestyle. In addition, such 

housing can also help improve individuals’ ability to work, their physical 

health, and their relationships with friends and family, and help them gain 

skills and resources to sustain their recovery. There are no federal laws 

or regulations governing the operation of recovery housing, and there is 

no federal agency responsible for overseeing recovery housing.1 Within 

the Department of Health and Human Services (HHS), the Substance 

Abuse and Mental Health Services Administration (SAMHSA)—

responsible for promoting SUD prevention, treatment, and recovery to 

reduce the impact of SUD on communities—makes some funding 

available to states to support recovery housing.

The media has reported allegations that some unscrupulous recovery 

housing operators and associated SUD treatment providers have 

engaged in fraudulent and misleading practices and exploited residents 

for the purposes of profit. In addition, at least two states—California and 

Florida—have conducted criminal investigations into recovery housing 

and recovery housing operators within their states. Following reported 

allegations, members of Congress have raised questions about the 

oversight of recovery housing.

You asked us to review federal and state oversight of recovery housing. 

This report examines

 1

Federal laws such as the Fair Housing Act prohibit discrimination on the basis of 

disability, which includes individuals in recovery from SUD. Recovery housing 

organizations have described cases in which cities or counties adopted new, or used 

existing, regulations to impose restrictions on recovery homes, only to be found in 

violation of the Fair Housing Act by federal or district courts.

Letter
Page 2 GAO-18-315 Substance Use Disorder

1. what is known about the prevalence and characteristics of recovery 

housing across the United States;

2. any investigations and actions selected states have undertaken to 

oversee recovery housing; and

3. SAMHSA funding for recovery housing, and how selected states have 

used this or any available state funding.

To address these three objectives, we reviewed available information and 

interviewed officials from national organizations that provide or have 

missions related to recovery housing, state agencies and related entities 

in five selected states, and federal agencies. Specifically, we reviewed 

information and available documentation and interviewed officials from 

the National Alliance for Recovery Residences (NARR) and Oxford 

House, Inc. to obtain information on the prevalence and characteristics of 

recovery housing across the United States.2 To obtain information on 

actions states have taken to investigate and oversee recovery housing 

and how they used federal and any available state funding to support 

such housing from fiscal year 2013 through fiscal year 2017, we also 

interviewed officials from five states we selected for review—Florida, 

Massachusetts, Ohio, Texas, and Utah. We identified the states that met 

at least three of the following criteria: (1) had high rates and numbers of 

opioid overdose deaths in 2015 (the most recent publicly-available 

information), (2) had high rates of dependence on or abuse of illicit drugs 

and alcohol in 2013-2014 (the most recent publicly-available information), 

(3) had an active NARR affiliate, (4) received certain SAMHSA funding for 

recovery services, and (5) were reported in the media or by other sources 

to have enacted legislation pertaining to the regulation or oversight of 

recovery housing.3 We then selected five states from different areas of 

the country. In each state, we interviewed officials from the state 

substance abuse agency, the state Medicaid agency, the state Medicaid 

 2

NARR is a national nonprofit and recovery community organization that aims to support 

individuals in recovery by improving their access to quality recovery residences through 

standards, support services, placement, education, research, and advocacy. Oxford 

House, Inc. is a national nonprofit corporation that serves as an umbrella organization to 

connect individual Oxford Houses and allocates resources to establish additional houses 

where needs arise.

3

For our review, we considered states that received SAMHSA funding for recovery 

support services from fiscal year 2014 through April 2018, the most recent information 

available. 
Page 3 GAO-18-315 Substance Use Disorder

Fraud Control Unit, the state insurance department, and others.4 For a 

complete list of state agencies and related state entities we interviewed, 

see appendix I. We also interviewed officials from two insurance 

companies operating in Florida. The results of our state analyses are 

intended to be illustrative and are not generalizable to all states. To obtain 

information on SAMHSA funding for recovery housing, we also reviewed 

available documentation and interviewed agency officials.

We conducted this performance audit from February 2017 to March 2018 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Definitions of and terms for recovery housing can vary, and recovery 

housing may differ in the types of services offered and resident 

requirements. Alcohol- and drug-free housing for individuals recovering 

from SUD may be referred to as “recovery residences,” “sober homes,” or 

other terms. NARR has defined four levels of recovery housing (I through 

IV) based on the type and intensity of recovery support and staffing they 

offer, up to and including residential, or clinical, treatment centers.5 For 

the purposes of this report, we use the term “recovery housing” to refer to 

peer-run, nonclinical living environments for individuals recovering from 

 4

Medicaid Fraud Control Units, which are typically a part of state attorney general offices, 

investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect in 

health care and related facilities. These units must be separate and distinct from state 

Medicaid agencies.

5

NARR level I and II residences are primarily self-funded, peer-run, single family homes 

where residents have an open-ended length of stay; level II residences typically have a 

paid house manager or senior resident who oversees the house and its residents. Level III 

and IV residences are structured or semi-structured living environments with paid facility 

staff, such as case managers, to assist residents in developing treatment plans and may 

be licensed by the state if they offer clinical services (such as level IV residential treatment 

centers). Although the primary scope of our report is nonclinical recovery housing (i.e., 

levels I and II), the activities of some states in our review may include more structured 

facilities (i.e., levels III and IV).

Background
Page 4 GAO-18-315 Substance Use Disorder

SUD in general, and “recovery homes” to refer to specific homes.6 These 

homes generally are not considered to be residential treatment centers, 

not eligible to be licensed providers for the purposes of billing private 

insurance or public programs—such as Medicaid and Medicare—and 

residents typically have to pay rent and other housing expenses 

themselves. Recovery home residents may separately undergo outpatient 

clinical SUD treatment, which is typically covered by health insurance. In 

addition, recovery homes may encourage residents to participate in 

mutual aid or self-help groups (e.g., 12-step programs such as Alcoholics 

Anonymous) and may require residents to submit to drug screenings to 

verify their sobriety.7 Residents may be referred to recovery homes by 

treatment providers, the criminal justice system, or may voluntarily seek 

out such living environments.

In addition to SAMHSA, two national nonprofit organizations that have 

missions dedicated to recovery housing include NARR and Oxford 

House, Inc. NARR promotes standards for recovery housing, provides 

training and education to recovery housing operators and others, and 

conducts research and advocacy related to recovery housing to support 

individuals in recovery from SUD. As of January 2018, NARR’s 

membership comprised 27 state affiliates that work to promote and 

support NARR’s quality standards for recovery housing and other 

activities in their states. Of the 27 NARR affiliates, 15 were actively 

certifying recovery homes.8 Oxford House, Inc. connects individual Oxford 

Houses across the United States and in other countries. Individual Oxford 

Houses, which operate under charters granted by Oxford House, Inc., are 

democratically run, self-supporting homes. According to the Oxford 

House manual and related documents, all Oxford Houses are rentals, and 

residents are responsible for sharing expenses, paying house bills on 

 6

According to SAMHSA, peers are individuals who share the experiences of addiction and 

recovery. A peer in successful, stable recovery can provide emotional and other support to 

other individuals beginning the recovery process to help reduce the likelihood of relapse. 

Services provided by peers are typically distinguished from those provided by clinical or 

other providers, such as counselors or case managers, in professional treatment 

programs.

7

According to NARR, recovery homes generally verify residents’ sobriety using urine drug 

tests that can be purchased over the counter at retail pharmacies, such as CVS or 

Walgreens, or in bulk from various sellers.

8

As of January 2018, the remaining 12 affiliates, which NARR considers to be 

“developing,” support recovery homes in their states by providing information about 

recovery housing to the public and hearing complaints. NARR was also working to 

develop affiliates in 3 additional states. 
Page 5 GAO-18-315 Substance Use Disorder

time, and immediately evicting residents who drink or use illicit drugs 

while living in the house.9 Oxford House, Inc. maintains a directory of 

houses on its website, and individuals can search this directory for 

vacancies by state. Oxford Houses align with NARR’s definition of level I 

residences; that is, peer-run, self-funded, typically single family homes 

where residents have an open-ended length of stay.

SAMHSA and other organizations recognize recovery housing as an 

important step in SUD treatment and recovery. Research has shown 

positive outcomes of recovery housing on long-term sobriety, such as at 

6-, 12-, and 18-month follow up.10 However, according to SAMHSA and 

NARR officials, much of the available research on effectiveness of 

recovery housing focuses on the Oxford House population, and research 

on other types of recovery homes is limited.11

 9

Houses operate independently but must follow procedures laid out in the Oxford House 

manual and adhere to charter conditions. Residents are to hold regular house meetings at 

least weekly, and each house elects officers, including a president, treasurer, and 

secretary, on a rotating basis. Oxford House, Inc. provides houses with forms that 

residents can use to log house meetings and expenses. Eviction for drug use does not 

include individuals using medications prescribed for behavioral health conditions.

10See, for example, D. L. Polcin, R. Korcha, J. Bond, and G. Galloway, “What Did We 

Learn from Our Study on Sober Living Houses and Where Do We Go from Here,” Journal 

of Psychoactive Drugs, vol. 42, no. 4 (2010): 425-433.

11An official from Oxford House, Inc. told us that there have been more than 300 peerreviewed studies conducted on the Oxford House program since 1991.
Page 6 GAO-18-315 Substance Use Disorder

The nationwide prevalence of recovery housing is unknown because 

there are no comprehensive data regarding the number of recovery 

homes in the United States, although NARR and Oxford House, Inc. 

collect data on a subset of recovery homes across the United States. 

Specifically, NARR collects data only on recovery homes that seek 

certification from one of its 15 state affiliates that certify homes. However, 

NARR-certified homes may represent only a portion of existing recovery 

homes, as NARR does not know how many such homes are uncertified. 

As of January 2018, NARR reported that its affiliates had certified almost 

2,000 recovery homes, which had the capacity to provide housing to over 

25,000 individuals; NARR-certified recovery homes include recovery 

housing across all four NARR levels, including residential treatment 

centers that provide clinical services, which are outside the scope of our 

study.12

Oxford House, Inc. collects data annually on the prevalence and 

characteristics of Oxford Houses across the United States. In its 2017 

annual report, Oxford House, Inc. reported that there were 2,287 Oxford 

Houses in 44 states that provided housing to a total of 18,025 

individuals.13 Of the total number of Oxford Houses in 2017, 71 percent 

served men and 29 percent served women, with the average resident 

aged 37 years. The Oxford House, Inc. report also provides information 

on other characteristics of Oxford House residents. For example, of the 

18,025 Oxford House residents in 2017, Oxford House, Inc. reported the 

following:

• 79 percent were addicted to drugs and alcohol; 21 percent were 

addicted to alcohol only.

• 77 percent had been incarcerated.

• 68 percent had previously experienced homelessness.

• 12 percent were veterans.

• 87 percent were employed.

 12A NARR official told us that NARR level IV residences accounted for 2 percent of all 

NARR-certified homes and 3 percent of resident capacity as of January 2018.

13See Oxford House, Inc. Annual Report, Fiscal Year 2017 (Silver Spring, Md.: 2018). 

According to officials from Oxford House, Inc., an average of about eight individuals reside 

in each house, and the average length of stay was about 8 months, according to the 2017 

annual report.

Nationwide 

Prevalence of 

Recovery Housing Is 

Unknown, but 

National 

Organizations Collect 

Data on the Number 

and Characteristics of 

a Subset of Recovery 

Homes
Page 7 GAO-18-315 Substance Use Disorder

• 98 percent regularly attended 12-step meetings, such as Alcoholics 

Anonymous or Narcotics Anonymous.14

• 45 percent attended weekly outpatient counseling in addition to 

attending 12-step meetings

• Average length of sobriety was 13.4 months.15

The five states we selected for review have taken actions to investigate 

and oversee recovery housing. Four of the five states have conducted law 

enforcement investigations of recovery homes in their states and some of 

these investigations have resulted in arrests and changes to public and 

private insurance policies. In addition to actions taken in response to state 

investigations, three of the five states in our review have also taken steps 

to formally enhance their oversight of recovery homes, and the other two 

states have taken other steps intended to increase consistency, 

accountability, and quality across recovery homes.

Officials from four of the five states we reviewed (Florida, Massachusetts, 

Ohio, and Utah) told us that since 2007, state agencies have conducted, 

or are in the process of conducting, law enforcement investigations of 

unscrupulous behavior and potential insurance fraud related to recovery 

housing, and outcomes of some of these investigations included criminal 

charges and changes to health insurance policies. An official from the fifth 

state, Texas, told us that the state had not conducted any recent law 

enforcement investigations related to recovery housing. This official, from 

the Texas Department of Insurance, told us that the department received 

two fraud reports in 2014 and 2016 related to recovery homes and that 

the state was unable to sufficiently corroborate the reports to begin 

investigations.

 14Although Oxford House residents are not required to attend 12-step meetings, officials 

told us that residents generally go to about five meetings a week.

15Oxford House, Inc. officials said that the requirement that residents remain free from 

alcohol and illicit drugs does not include medication-assisted treatment for opioid addiction 

or prescribed medication for co-occurring mental health conditions. Medication-assisted 

treatment is an approach that combines behavioral therapy and the use of certain 

medications, such as methadone and naltrexone, to suppress withdrawal symptoms, 

control cravings, and prevent overdose.

Most States We 

Reviewed Have 

Investigated Potential 

Fraud Related to 

Recovery Housing 

and Taken Steps to 

Enhance Oversight

Four of Five States Have 

Conducted Investigations 

of Recovery Housing
Page 8 GAO-18-315 Substance Use Disorder

Across the four states, officials told us that potential insurance fraud may 

have relied on unscrupulous relationships between SUD treatment

providers, including laboratories, and recovery housing operators,

because recovery homes are not considered eligible providers for the 

purposes of billing health insurance. For example, treatment providers 

may form unscrupulous relationships with recovery housing operators 

who then recruit individuals with SUD in order to refer or require residents 

to see the specific SUD treatment providers.16 This practice is known as 

patient brokering, for which recovery housing operators receive kickbacks 

such as cash or other remuneration from the treatment provider in 

exchange for patient referrals.17 The extent of potential fraud differed

across the four states, as discussed below.

Florida

Officials from several state agencies and related entities described 

investigations into fraud related to recovery housing in southeastern 

Florida as extensive, although the scope of the fraud within the industry is 

unknown.18 In 2016, the state attorney for the 15th judicial circuit (Palm 

Beach County) convened a task force composed of law enforcement 

officials tasked with investigating and prosecuting individuals engaged in 

 16According to officials from the four states, in some cases treatment providers also 

owned recovery homes, rather than partnering with, and paying kickbacks to, other 

individuals who owned or operated the homes. In other cases, treatment providers, 

recovery homes, or laboratories partnered with each other in some combination for the 

purposes of referring patients and billing insurance.

17Kickbacks include remuneration, such as cash, paid or received to reward the referral of 

an individual for treatment or arrangement of items or services to be provided. The federal 

Anti-Kickback Statute prohibits the knowing and willful offer, payment, solicitation, or 

receipt of remuneration to induce or reward referrals or generate business reimbursable 

by federal health care programs, such as Medicaid and Medicare. 42 U.S.C. § 1320a7b(b). Although the federal Anti-Kickback Statute does not apply to private insurance, 

some states have enacted state anti-kickback statutes that apply to private insurance. 

18An official with the state’s NARR affiliate told us that the estimated scope of Florida’s 

recovery housing fraud encompassed 110 (recovery or treatment) beds and $1 billion in 

fraudulent private insurance billing in 1 year.
Page 9 GAO-18-315 Substance Use Disorder

fraud and abuse in the SUD treatment and recovery housing industries.19

The task force found that unscrupulous recovery housing operators or 

associated SUD treatment providers were luring individuals into recovery 

homes using deceptive marketing tactics.20 Deceptive marketing practices 

included online or other materials that willfully misdirected individuals or 

their family members to recruiters with the goal of sending these 

individuals to specific treatment providers, in order to receive payments 

from those treatment providers for patient referrals. According to officials 

from the Florida state attorney’s office, these individuals, often from out of 

state, were lured with promises of free airfare, rent, and other amenities 

to recover in southern Florida’s beach climate. Recruiters brokered these 

individuals to SUD treatment providers, who then billed their private 

insurance plans for extensive and medically unnecessary urine drug 

testing and other services.21 Officials from the Florida state attorney’s 

office told us that SUD treatment providers were paying $300 to $500 or 

more per week to recovery housing operators or their staff members for 

every patient they referred for treatment. In addition, these officials cited 

 19In 2016, the Florida legislature appropriated $275,000 to the state attorney for the 15th

Judicial Circuit (Palm Beach County) to conduct a study to strengthen investigation and 

prosecution of criminal and regulatory violations within the substance abuse treatment 

industry. In response, the state attorney’s office formed three task forces in 2016. In 

addition to the law enforcement task force, the other two task forces—composed of 

community and industry members, state agency officials, and other individuals—were 

charged with studying fraud in the recovery housing industry further and making 

recommendations for regulatory changes. Also in 2016, the state attorney empaneled a 

grand jury to investigate how state agencies were addressing the proliferation of fraud and 

abuse within the SUD treatment industry and to make appropriate recommendations on 

how these agencies could better perform their duties to ensure that vulnerable populations 

and communities are protected. In 2017, the state legislature appropriated $300,000 to the 

state attorney’s office to continue its activities.

20Florida State Attorney, 15th Judicial Circuit, Palm Beach County Sober Homes Task 

Force Report: Identification of Problems in the Substance Abuse Treatment and Recovery 

Residence Industries with Recommended Changes to Existing Laws and Regulations

(Palm Beach County, Fla.: January 2017).

21According to the American Society of Addiction Medicine’s April 2017 consensus 

statement on appropriate use of drug testing in clinical addiction treatment, drug testing 

should be tailored to individual patients’ needs and stages of addiction and recovery. For 

the purposes of verifying or ensuring that residents in recovery housing remain free from 

alcohol and illicit drugs, the consensus statement states that weekly testing may be 

appropriate using presumptive testing—that is, lower sensitivity tests, such as urine drug 

tests that can be purchased over the counter. The statement notes that more frequent or 

more sensitive testing (i.e., testing that takes place in a laboratory) is inappropriate and 

does not fit the standard of care. See American Society of Addiction Medicine. Consensus 

Statement: Appropriate Use of Drug Testing in Clinical Addiction Medicine (Rockville, Md.:

April 5, 2017).
Page 10 GAO-18-315 Substance Use Disorder

one case in which a SUD treatment provider billed a patient’s insurance 

for close to $700,000 for urine drug testing in a 7-month period. Officials 

from the state attorney’s office noted that the recovery homes that the 

task force was investigating were not shared housing in the traditional, 

supportive sense, such as Oxford Houses, where residents equally share 

in the rent and division of chores, but rather existed as “warehouses” 

intended to exploit vulnerable individuals.

As a result of these investigations, as of December 2017, law 

enforcement agencies had charged more than 40 individuals primarily 

with patient brokering, with at least 13 of those charged being convicted 

and fined or sentenced to jail time, according to the state attorney’s 

office.22 In addition, the state enacted a law that strengthened penalties 

under Florida’s patient brokering statute and gave the Florida Office of 

Statewide Prosecution, within the Florida Attorney General’s Office, 

authority to investigate and prosecute patient brokering.23

Massachusetts

An official from the Massachusetts Medicaid Fraud Control Unit told us 

that the unit began investigating cases of Medicaid fraud in the state on 

the part of independent clinical laboratories associated with recovery 

homes in 2007. The unit found that, in some cases, the laboratories 

owned recovery homes and were self-referring residents for urine drug 

testing. In other cases, the laboratories were paying kickbacks to 

recovery homes for patient referrals for urine drug testing that was not 

medically necessary. According to the Medicaid Fraud Control Unit 

official, as a result of these investigations the state settled with nine 

laboratories between 2007 and 2015 for more than $40 million in 

 22As of January 2018, task force investigations were ongoing. In addition to task force 

investigations, an official from one insurance company operating in Florida we spoke with 

told us that the company began investigating claims for urine drug testing and other 

services in its individual and family plans after its fraud unit received a large number of 

referrals. This official told us that, as a result of its investigations, as well as its 

participation in the task force investigations, the company made changes to its drug 

testing policy, as well as changes to some of its data analytics processes to allow it to 

identify potentially fraudulent claims more quickly.

23The enacted law specifically denotes patient brokering as a crime, which the Office of 

Statewide Prosecution has the authority to investigate and prosecute. The law also added 

first and second degree felony charges for patient brokering, as well as established fines 

for all felony levels dependent upon the number of patients involved, and made fraudulent 

marketing a third-degree felony. See Ch. 2017-173, Laws of Fla.
Page 11 GAO-18-315 Substance Use Disorder

restitution. In addition, the state enacted a law in 2014 prohibiting clinical 

laboratory self-referrals and revised its Medicaid regulations in 2013 to 

prohibit coverage of urine drug testing for the purposes of residential 

monitoring.24

Ohio

Ohio has also begun to investigate an instance of potential insurance 

fraud related to recovery housing, including patient brokering and 

excessive billing for urine drug testing. Officials from the Ohio Medicaid 

Fraud Control Unit told us that the unit began investigating a Medicaid 

SUD treatment provider for paying kickbacks to recovery homes in 

exchange for patient referrals, excessive billing for urine drug testing, and 

billing for services not rendered, based on an allegation the unit received 

in September 2016.25 As of January 2018, the investigation was ongoing, 

and the Ohio Medicaid Fraud Control Unit had not yet taken legal or other 

action against any providers. Officials from other state agencies and 

related state entities, such as the state substance abuse agency and the 

state NARR affiliate, were not aware of any investigations of potential 

fraud on the part of recovery housing operators or associated treatment 

providers when we spoke with them and stated that this type of fraud was 

not widespread across the state.

Utah

In August 2017, officials from the Utah Insurance Department told us that 

the department is conducting ongoing investigations of private insurance 

fraud similar to the activities occurring in Florida, as a result of a large 

influx of complaints and referrals it received in 2015. These officials told 

us that the department has received complaints and allegations that SUD 

treatment providers are paying recruiters to bring individuals with SUD 

who are being released from jail to treatment facilities or recovery homes; 

billing private insurance for therapeutic services, such as group or equine 

 24See Mass. Gen. Laws ch. 111D, §§ 8(17), 8A (2017); 130 CMR 404.411(b)(5). The 

2014 law also imposed civil and criminal penalties for individuals violating the clinical selfreferral rule, such as civil penalties ranging from $5,000 to $10,000 per violation, plus 

three times the amount of damages sustained, jail or imprisonment for up to 5 years, or a 

combination of both. See Mass. Gen. Laws ch. 111D, § 13 (2017).

25According to Ohio Medicaid Fraud Unit officials, this investigation is being conducted 

jointly with federal agencies, including the Department of Health and Human Services 

Office of Inspector General and the Federal Bureau of Investigation.
Page 12 GAO-18-315 Substance Use Disorder

therapy, that are not being provided, in addition to billing frequently for 

urine drug testing; and encouraging patients to use drugs prior to 

admission to qualify patients and bill their insurance for more intensive 

treatment. In addition, insurance department officials told us that they 

believed providers are enrolling individuals in private insurance plans 

without telling them and paying their premiums and copays. According to 

these officials, when doing so, providers may lie about patients’ income 

status in order to qualify them for more generous plans. Officials found 

that providers were billing individual patients’ insurance $15,000 to 

$20,000 a month for urine drug testing and other services. Officials noted 

that they suspect that the alleged fraud was primarily being carried out by 

SUD treatment providers and treatment facilities that also own recovery 

homes. Officials told us that the department has not been able to file 

charges against any treatment providers because it has been unable to 

collect the necessary evidence to do so. However, according to insurance 

department officials, the state legislature enacted legislation in 2016 that 

gives insurers and state regulatory agencies, such as the state insurance 

department and state licensing office, the authority to review patient 

records and investigate providers that bill insurers. This authority may 

help the insurance department and other state regulatory agencies better 

conduct investigations in the future.

In addition to actions taken in response to state investigations, three of 

the five states in our review—Florida, Massachusetts, and Utah—have 

taken steps to formally increase oversight of recovery housing by 

establishing state certification or licensure programs. Florida enacted 

legislation in 2015 and Massachusetts enacted legislation in 2014 that 

established voluntary certification programs for recovery housing. Florida 

established a two-part program for both recovery homes and recovery 

housing administrators (i.e., individuals acting as recovery housing 

managers or operators). According to officials from the Florida state 

attorney’s office and Massachusetts Medicaid Fraud Control Unit, their 

states established these programs in part as a result of state law 

enforcement investigations. In 2014, Utah enacted legislation to establish 

a mandatory licensure program for recovery housing. According to 

officials from the Utah substance abuse agency and the state licensing 

office, the state established its licensure program to, in part, protect 

residents’ safety and prevent their exploitation and abuse.

Although state recovery housing programs in Florida and Massachusetts 

are voluntary and recovery homes and their administrators can operate 

without being certified, there are incentives for homes to become certified 

Three States Have 

Established Oversight 

Programs, and Two States 

Are Taking Other Steps to 

Support Recovery 

Housing
Page 13 GAO-18-315 Substance Use Disorder

under these states’ programs, as well as incentives to become licensed 

under Utah’s program. Specifically, all three states require that certain 

providers refer patients only to recovery homes certified or licensed by 

their state program.26 Thus, uncertified and unlicensed homes in Florida, 

Massachusetts, and Utah would be ineligible to receive patient referrals 

from certain treatment providers. Further, state officials told us that state 

agencies are taking steps to ensure providers are making appropriate 

referrals. For example, according to officials from the Florida substance 

abuse agency, treatment providers may refer patients to certified recovery 

homes managed by certified recovery home administrators only and must 

keep referral records. These officials also told us that the state substance 

abuse agency can investigate providers to ensure they are referring 

patients to certified homes and issue fines or revoke providers’ licenses if 

the program finds providers are referring patients to uncertified homes. 

Recovery homes may also view certification as a way to demonstrate that 

they meet quality standards. For example, the official from the 

Massachusetts NARR affiliate told us that some residential treatment 

centers that are required to be licensed by the state are also seeking 

certification to demonstrate that they meet the NARR affiliate’s quality 

standards.

To become state-certified or licensed, recovery homes in Florida, 

Massachusetts, and Utah must meet certain program requirements—

including staff training, documentation submissions (such as housing 

policies and code of ethics), and onsite inspections to demonstrate 

compliance with program standards—though specific requirements differ 

across the three states. For example, while all three state programs 

require recovery housing operators or staff to complete training, the 

number of hours and training topics differ. In addition, for recovery homes 

to be considered certified in Florida, they must have a certified recovery 

housing administrator. Similar to Florida’s certification program for the 

homes, individuals seeking administrator certification must also meet 

certain program requirements, such as training in recovery residence 

operations and administration and legal, professional, and ethical 

responsibilities. Features of the state-established oversight programs may 

also differ across the three states, including program type, type of home 

eligible for certification or licensure, how states administer their programs, 

 26In Massachusetts, this requirement applies to referrals from state agencies and statefunded providers only. In Utah, this requirement applies to referrals from the criminal 

justice system, such as drug courts.
Page 14 GAO-18-315 Substance Use Disorder

and initial fees. See table 1 for additional information on features of stateestablished oversight programs for recovery housing.

Table 1: Features of Three State-Established Oversight Programs for Recovery Housing

Program characteristic Florida Massachusetts Utah

Recovery homes Recovery housing 

administrators

Program type Voluntary certification Voluntary certification Voluntary certification Mandatory licensure

Length of certification or 

licensure

1 year 1 year 1 year 1 year

Type of recovery housing 

eligible for program, 

according to National 

Alliance for Recovery 

Residences (NARR) 

levelsa

I, II, III, and IV n/a IIb II and III

Certifying or licensing 

body

Florida Association of 

Recovery Residences

Florida Certification 

Board

Massachusetts Alliance 

for Sober Housingc Utah Department of Human Services, Office 

of Licensing

Initial feesd $100 application fee plus

$40 certification fee per 

bed for level I and II 

homes, and

$55 certification fee per 

bed for level III and IV 

homese

$100 $150 certification fee

$50 inspection fee per 

home

$1,295

Year program was 

implemented 

2015f 2016f 2017 2014

Number certified or 

licensedg 310h 344h 164 61

Legend: n/a = not applicable

Source: GAO review of state information. | GAO-18-315

Note: This table reflects information from three of the five states we reviewed that established 

oversight programs for recovery housing. The other two states we reviewed—Ohio and Texas—have 

not established such oversight programs, but the states’ NARR affiliates may certify certain recovery 

homes in their states on a voluntary basis according to NARR standards. NARR is a national 

nonprofit and recovery community organization that promotes quality standards for recovery housing.

a

NARR defined four levels of recovery housing (I through IV) based on type, intensity, and duration of 

recovery support and staffing they offer. NARR level I and II residences are primarily self-funded, 

peer-run, single family homes where residents have an open-ended length of stay. Level III and IV 

residences are structured or semi-structured living environments with paid facility staff, such as case 

managers, to assist residents in developing treatment plans and may be licensed by the state.

b

According to officials from the Massachusetts substance abuse agency, facilities operating according 

to NARR levels III and IV are to be licensed by the state as residential treatment centers.

c

According to the official from the Massachusetts Alliance for Sober Housing—the state NARR 

affiliate—while that entity administers the certification program on behalf of the state, another 

organization conducts the inspections required for certification.
Page 15 GAO-18-315 Substance Use Disorder

d

Fees reflect the initial amount that recovery homes and administrators must pay when they first apply 

for certification or licensure. They may be assessed a different fee when applying for recertification or 

license renewal.

e

Certification fees are capped at $2,500 per location for level I and II homes and $3,500 per location 

for level III and IV homes.

f

The implementation date is the year that officials from Florida Association of Recovery Residences 

and the Florida Certification Board told us they began certifying recovery homes and recovery 

housing administrators.

g

Numbers of certified or licensed recovery homes and recovery housing administrators are as of 

December 31, 2017.

h

In Florida, recovery homes must have certified recovery housing administrators to be certified. The 

number of certified homes differs from the number of certified recovery housing administrators 

because a certified recovery home must have one certified recovery housing administrator for every 

three locations.

State-established oversight programs in Florida, Massachusetts, and 

Utah also include processes to monitor certified or licensed recovery 

homes and take action when homes do not comply with program 

standards. For example, an official from the Florida Association of 

Recovery Residences—the state NARR affiliate and organization that 

certifies recovery homes in Florida—told us that the entity conducts 

random inspections to ensure that recovery homes maintain compliance 

with program standards. State-established oversight programs in the 

three states also have processes for investigating grievances filed against 

certified or licensed recovery homes. Further, officials from certifying or 

licensing bodies in all three states—the Florida Association of Recovery 

Residences, Massachusetts Alliance for Sober Housing, and the Utah 

Office of Licensing—told us their organizations may take a range of 

actions when they receive complaints or identify homes that do not 

comply with program standards, from issuing recommendations for 

bringing homes into compliance to revoking certificates or licenses.27

According to officials from the certifying body in Florida, the entity has 

revoked certificates of recovery homes that have acted egregiously or 

have been nonresponsive to corrective action plans. Officials from the 

certifying and licensing bodies in Massachusetts and Utah told us that 

these entities had not revoked certificates or licenses when we spoke to 

them for this review, but may have assisted homes with coming into 

compliance with certification standards or licensure requirements.

Officials from Ohio and Texas told us that their states had not established 

state oversight programs like those that exist in Florida, Massachusetts, 

and Utah, but their states had provided technical assistance and other 

 27The Massachusetts Alliance for Sober Housing is the Massachusetts NARR affiliate.
Page 16 GAO-18-315 Substance Use Disorder

resources to recovery homes that were intended to increase consistency, 

accountability, and quality:28

• Officials from the Ohio substance abuse agency told us that since 

2013 the state has revised its regulatory code to define recovery 

housing and minimum requirements for such housing.29 Officials also 

told us that the agency does not have authority to establish a state 

certification or licensure program for recovery housing. According to 

these officials, the state legislature wanted to ensure that Ohio’s 

recovery housing community maintained its grassroots efforts and did 

not want a certification or licensure program to serve as a roadblock 

to establishing additional homes. However, officials from the Ohio 

substance abuse agency told us that the agency encourages recovery 

homes to seek certification by the state NARR affiliate—Ohio 

Recovery Housing—to demonstrate quality. In addition, these officials 

told us that the state substance abuse agency also provided start-up 

funds for Ohio Recovery Housing and has continued to fund the 

affiliate for it to provide training and technical assistance, as well as to 

continue certifying recovery homes.30 According to officials from Ohio 

Recovery Housing, the NARR affiliate regularly provides the state 

substance abuse agency with a list of newly-certified recovery homes, 

as well as updates on previously-certified homes, as part of ongoing 

efforts to develop a recovery housing locator under its contract with 

the agency.

• Officials from the Texas substance abuse agency noted that 

establishing a voluntary certification program, such as one that 

certifies homes according to NARR’s quality standards, would be 

beneficial. However, the state legislature has not enacted any 

legislation establishing such a program to date. The agency is in the 

 28Although Ohio and Texas have not established state certification or licensure programs, 

both states have active NARR affiliates that certify recovery housing according to the 

NARR standards.

29Officials from the state substance abuse agency also told us that recovery homes must 

meet state, local, and county building codes and obtain certificates of occupancy. 

30Officials from Ohio Recovery Housing told us that the state provided funding as part of 

its response to an examination of recovery housing in Ohio supported by the Ohio 

substance abuse agency and published in 2013 that made several recommendations to 

address the challenges and the lack of resources for recovery housing in the state. See K. 

Paquette, N. Greene, L. Sepahi, K. Thom, and L. Winn, Recovery Housing in the State of 

Ohio: Findings and Recommendations from an Environmental Scan (Columbus, Ohio.: 

June 2013). According to officials from Ohio Recovery Housing, such steps have 

successfully expanded recovery housing networks in the state.
Page 17 GAO-18-315 Substance Use Disorder

process of developing guidance for providers on where and how to 

refer their patients to recovery housing, which includes a 

recommendation to send patients to homes certified by the Texas 

NARR affiliate, but officials could not tell us when they expected the 

guidance to be finalized.

SAMHSA provides some funding for states to establish recovery homes. 

Of the five states we reviewed, two used SAMHSA funding and four used 

state funding to help support recovery housing from fiscal year 2013 

through fiscal year 2017.

SAMHSA makes funding available to states for recovery housing through 

certain grant programs for SUD prevention and treatment. Specifically, 

under its Substance Abuse Prevention and Treatment block grant, which 

totaled approximately $1.9 billion in fiscal year 2017, SAMHSA makes at 

least $100,000 available annually to each state to provide loans for 

recovery housing.31 States that choose to use this funding may provide up 

to $4,000 in loans to each group that requests to establish alcohol- and 

drug-free housing for individuals recovering from SUD.32 The loan can be 

 31See 42 U.S.C. § 300x-25; 45 C.F.R. § 96.129 (2017). The objective of SAMHSA’s 

Substance Abuse Prevention and Treatment block grant is to help states plan, implement, 

and evaluate programs and activities related to preventing and treating SUD, such as 

providing information on prevention and treatment services and technical assistance to 

community-based agencies. The total block grant amount was the same in fiscal years 

2017 and 2018.

32By statute, the purpose of this funding is to make loans for the cost of establishing 

programs for the provision of homes where groups of at least six individuals recovering 

from SUD may reside. States may directly establish the loan funding or contract with a 

private, nonprofit entity to manage it. Loans are to be repaid in monthly installments, and 

states are to assess penalties for failure to pay installments by dates specified in loan 

agreements. 

Certain SAMHSA 

Grant Funding Can 

Be Used for Recovery 

Housing, and 

Selected States Have 

Used SAMHSA and 

State Funding to 

Support Recovery 

Housing

SAMHSA Provides 

Funding for Recovery 

Housing and Has 

Undertaken Other 

Initiatives to Support 

Recovery Housing
Page 18 GAO-18-315 Substance Use Disorder

used for start-up costs such as security deposits and must be repaid 

within 2 years. Loans are to be made only to nonprofit entities that agree 

to requirements for the operation of the recovery homes outlined in the 

authorizing statute, namely that (1) the homes must prohibit the use of 

alcohol and illegal drugs; (2) the homes must expel residents who do not 

comply with this prohibition; (3) housing costs, such as rent and utilities, 

are to be paid by the residents; and (4) residents are to democratically 

establish policies to operate the homes.33 According to SAMHSA officials, 

states are prohibited from using block grant funding other than the loan 

funding for recovery housing. However, the block grant application does 

not require states to provide a description of whether and how they will 

use the loan.

SAMHSA has also made funding for recovery housing available under the 

agency’s State Targeted Response to the Opioid Crisis grant (opioid 

grant), a 2-year grant program under which SAMHSA anticipated 

awarding up to $485 million for each of fiscal years 2017 and 2018.34 The 

opioid grant is intended to supplement states’ existing opioid prevention, 

treatment, and recovery support activities, and SAMHSA requires most of 

states’ funding to be used for opioid use disorder treatment services, such 

as expanding access to clinically appropriate, evidence-based treatment. 

States may also use their opioid grant funding for recovery housing and 

recovery support services—which SAMHSA recognizes as part of the 

continuum of care—such as establishing recovery homes and providing 

 33Oxford House, Inc. officials told us that as of January 2018, Oxford House, Inc. had 

contracts with 13 states and the District of Columbia to manage the loans available 

through the SAMHSA block grant and to provide outreach workers for technical 

assistance. Oxford House, Inc. gives the start-up funds that it receives from the state to 

individuals who are interested in starting Oxford Houses. Each house opens a bank 

account to repay the loan electronically.

34The State Targeted Response to the Opioid Crisis grant was established by the 21st

Century Cures Act. See Pub.L. No. 114-255 § 1003, 130 Stat. 1033, 1044-46 (2016). 

SAMHSA awarded the opioid grants to states and territories using a formula based on 

unmet need for opioid use disorder treatment and drug overdose deaths.
Page 19 GAO-18-315 Substance Use Disorder

peer mentoring.35 (See the next section of this report for information on 

how states have used SAMHSA funding.)

In addition to providing funding, SAMHSA has undertaken other initiatives 

related to recovery housing, including an assessment of needs for 

certifying recovery housing in the future. In 2017, SAMHSA held two 

recovery housing meetings that covered topics including research on 

emerging best practices in recovery housing, state recovery housing 

programs, available funding for recovery housing, and challenges that 

state entities have experienced regulating recovery homes in their states. 

SAMHSA contracted with NARR at the end of fiscal year 2017 to provide 

technical assistance and training to recovery housing organizations, 

managers, and state officials on NARR’s quality standards and 

certification process, including presentations at three to four national and 

regional SUD conferences, such as those held by the National 

Association of State Alcohol and Drug Abuse Directors and other 

associations. NARR is also required to submit a final report to SAMHSA 

before the 1-year contract ends with recommendations for future needs 

for certifying recovery housing and establishing additional NARR state 

affiliates. SAMHSA officials told us that this is the agency’s first contract 

with NARR, and SAMHSA plans to conduct an internal assessment at the 

end of fiscal year 2018 to determine next steps.

Two of the five states we reviewed used SAMHSA funding to help support 

recovery housing in their states from fiscal years 2013 through 2017, 

according to state officials. Texas was the only state in our review that 

used the loan funding available under SAMHSA’s block grant. Officials 

from the Texas substance abuse agency told us that from fiscal years 

2013 through 2017, the state used at least $150,000 of this funding 

annually to increase the number of Oxford Houses in the state and hire 

 35According to SAMHSA, recovery support services include a full range of culturally and 

linguistically appropriate social, legal, and other services that assist individuals with SUD 

and their families. Recovery support services include employment assistance, education, 

housing, community treatment, illness management, and peer-operated services. There 

are other SAMHSA funds available for recovery support services that may help individuals 

access emergency or temporary housing but cannot be used to establish recovery homes. 

For example, SAMHSA’s Access to Recovery grant, which SAMHSA officials said the 

agency is terminating April 30, 2018, provided funding to eligible states to carry out a 

voucher program for SUD recovery support services, such as peer coaching, 

transportation to medical treatment, and other services to help individuals improve life 

skills or find employment. The grant also provided vouchers for individuals to pay for 

emergency housing for up to 1 week and transitional housing for up to 6 months.

Selected States Have 

Used SAMHSA and State 

Funding for Recovery 

Housing
Page 20 GAO-18-315 Substance Use Disorder

Oxford House outreach workers.36 Texas and Ohio also used a portion of 

their SAMHSA opioid grant funding for recovery housing. For example, in 

fiscal year 2017, officials from Ohio’s substance abuse agency told us 

that the state used $25,000 of its approximately $26 million in opioid grant 

funding to support and train recovery housing operators, with the goal of 

increasing the number of recovery homes that accept individuals who 

receive medication-assisted treatment. The other states we reviewed—

Florida, Massachusetts, and Utah—did not opt to use the loan funding

available under the SAMHSA block grant and did not use their SAMHSA 

opioid grant funding for recovery housing services, according to state 

officials.

Four of the five states in our review—Florida, Massachusetts, Ohio, and 

Texas—have used state funding to establish and support recovery 

housing and recovery housing-related activities. For example, officials 

from the Texas substance abuse agency told us that, since 2013, the 

state legislature has authorized at least $520,000 annually for recovery 

housing. In fiscal years 2015 through 2017, the state used this funding for 

personnel costs and related expenditures, such as hiring seven Oxford 

House outreach workers and establishing a state loan fund of $200,000 to 

supplement the SAMHSA loan funding to support the establishment of an 

additional 25 new Oxford Houses.37 Officials from the Massachusetts 

substance abuse agency told us that the agency has received annual 

state appropriations in the amount of $500,000 since fiscal year 2015 to 

contract with the entities that inspect and certify recovery homes for the 

state certification program and to contract with the state NARR affiliate for 

technical assistance with developing recovery housing certification 

standards and supporting the certification process. State substance 

 36Officials from the Texas substance abuse agency told us that Texas contracts with 

Oxford House, Inc. to administer the loans and to hire outreach workers. Oxford House 

outreach workers assist individuals in finding recovery homes, negotiate leases, and help 

individuals or groups that want to open new homes apply for Oxford House charters. As of 

November 2, 2017, there were 215 Oxford Houses in Texas, according to officials from 

the Texas substance abuse agency, but they could not provide us with the total number of 

recovery homes in the state.

37During this period, Texas also used these funds to provide $5,000 in stipends to help 

individuals recovering from SUD find housing. According to officials from the Texas 

substance abuse agency, the stipend is a one-time amount of about $150 per individual 

and is intended to help those individuals secure housing and employment to enable them 

to subsequently pay for their own housing. Officials noted that the substance abuse 

agency initially used funding from SAMHSA’s Substance Abuse Prevention and Treatment 

block grant to provide the stipend, but the state legislature thought it was a good program 

and allocated money for it from state general funds. 
Page 21 GAO-18-315 Substance Use Disorder

abuse agency officials from the fifth state, Utah, told us that the state did 

not use state funding to establish recovery homes during fiscal years 

2013 through 2017.38 See table 2 for states’ use of SAMHSA and state 

funding for recovery housing activities.

Table 2: Selected States’ Use of Federal and State Funding for Recovery Housing and Oversight Activities, Fiscal Years 2013 

through 2017

State and funding source 

Fiscal Year (FY) 

2013

(dollars)

FY 2014

(dollars)

FY 2015

(dollars)

FY 2016

(dollars)

FY 2017

(dollars)

Florida

State funding (Florida 

Association of Recovery 

Residences certification 

activities)

— — $100,000a — $100,000b

State funding (Florida 

Certification Board 

certification activities)c

— 100,000 — —

Massachusetts

State funding (voluntary 

recovery housing certification 

program)d

— — 500,000 500,000 500,000

Ohio

Substance Abuse and Mental 

Health Services 

Administration (SAMHSA) 

State Targeted Response to 

the Opioid Crisis grant

fundinge

— — — — 25,000

State fundingf — — 5,000,000 2,500,000 2,500,000

Capital bond fundingg — — 5,000,000 — —

Texas

SAMHSA Substance Abuse 

Prevention and Treatment 

block grant loan funding

202,000 174,000 151,000 151,000 151,000

 38Although the state did not use any state funding to establish recovery homes, officials 

from the Utah substance abuse agency told us that Utah uses state funding for recovery 

support services, including housing assistance for individuals transitioning from the 

criminal justice system (e.g., drug courts or correctional facilities) to the community.
Page 22 GAO-18-315 Substance Use Disorder

State and funding source 

Fiscal Year (FY) 

2013

(dollars)

FY 2014

(dollars)

FY 2015

(dollars)

FY 2016

(dollars)

FY 2017

(dollars)

Texas

SAMHSA State Targeted 

Response to the Opioid Crisis 

grant fundinge

— — — — 418,635

State funding 620,000 620,000 520,000 520,000

Utah

SAMHSA funding — — — — —

State fundingh — — — — —

Legend: — = The state did not receive funds that year.

Source: GAO based on information reported by selected states. | GAO-18-315

Note: This table reflects information provided by the five states we reviewed on their use of SAMHSA 

and state funding for recovery housing for fiscal years 2013 through 2017.

a

This funding was used to develop the infrastructure needed to meet national standards for initial and 

ongoing recovery housing certification during fiscal years 2015 and 2016 for the state’s voluntary 

certification program for recovery homes.

b

This funding was used for the state’s certification and training program.

c

This funding was used to develop the certification program to measure the professional competence 

of recovery housing administrators under the state’s voluntary certification program that called for the 

certification of both recovery homes and recovery housing administrators (e.g., managers or 

operators).

d

This funding was used to cover expenses for the state’s voluntary certification program that was 

established by state law in 2014. According to state officials, expenses included training for recovery 

housing owners and operators.

e

SAMHSA State Targeted Response to the Opioid Crisis grant funding in this table refers to amounts 

that officials from state substance abuse agencies told us were used specifically for recovery housing. 

The opioid grant is 2-year grant for fiscal years 2017 and 2018 authorized under the 21st Century 

Cures Act and is intended to supplement existing opioid prevention, treatment, and recovery support 

activities. Of the $485 million available for each of the 2 years, most of the funding is to be used for 

opioid use disorder treatment services.

f

The state may have used additional state funding for recovery support services that could include 

housing (e.g., rental assistance or transitional housing) but because amounts used specifically for 

recovery housing could not be separated from total amounts for support services or other types of 

housing, according to officials from the state substance abuse agency, this information is not reflected 

in the above table.

g

The Ohio capital bond funding was used for the purchase, renovation, or new construction of 

recovery homes. According to officials from the state substance abuse agency, the capital funds 

covered recovery housing projects for multiple units and increased recovery housing capacity in the 

state to more than 1,000 beds.

h

Although the state did not use any state funding to establish recovery homes in our study period, 

officials from the state substance abuse agency told us that the state used a total of about $38,000 

across all 5 years to assist individuals with substance use disorder who were on parole and at 

immediate risk for relapse as a result of their current housing situation to enter recovery housing.
Page 23 GAO-18-315 Substance Use Disorder

We provided a draft of this report to HHS. HHS did not have any 

comments.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of Health 

and Human Services, appropriate congressional committees, and other 

interested parties. In addition, the report will be available at no charge on 

the GAO website at http://www.gao.gov.

If you or your staff have any questions concerning this report, please 

contact Katherine M. Iritani, Director, Health Care at (202) 512-7114 or 

iritanik@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report.

GAO staff who made key contributions to this report are listed in appendix 

II.

Katherine M. Iritani

Director, Health Care

Agency Comments
Page 24 GAO-18-315 Substance Use Disorder

List of Requesters

The Honorable Orrin Hatch

Chairman

Committee on Finance

United States Senate

The Honorable Trey Gowdy

Chairman

Committee on Oversight and Government Reform

House of Representatives

The Honorable Richard Blumenthal

United States Senate

The Honorable Dianne Feinstein

United States Senate

The Honorable Margaret Wood Hassan

United States Senate

The Honorable Tim Kaine

United States Senate

The Honorable John McCain

United States Senate

The Honorable Christopher S. Murphy

United States Senate

The Honorable Marco Rubio

United States Senate

The Honorable Elizabeth Warren

United States Senate

The Honorable Rob Bishop

House of Representatives

The Honorable Ken Calvert

House of Representatives
Page 25 GAO-18-315 Substance Use Disorder

The Honorable Katherine M. Clark

House of Representatives

The Honorable Carlos Curbelo

House of Representatives

The Honorable Theodore E. Deutch

House of Representatives

The Honorable Lois Frankel

House of Representatives

The Honorable Alcee L. Hastings

House of Representatives

The Honorable Darrell Issa

House of Representatives

The Honorable William R. Keating

House of Representatives

The Honorable Mia Love

House of Representatives

The Honorable James P. McGovern

House of Representatives

The Honorable Seth Moulton

House of Representatives

The Honorable Dana Rohrbacher

House of Representatives

The Honorable Edward R. Royce

House of Representatives

The Honorable Chris Stewart

House of Representatives

The Honorable Frederica S. Wilson

House of Representatives
Appendix I: State Agencies and Related 

Entities GAO Interviewed

Page 26 GAO-18-315 Substance Use Disorder

We interviewed officials from the following agencies and related entities in 

the five states we selected for review.

Florida

• Agency for Health Care Administration, Division of Medicaid

• Department of Children and Families, Substance Abuse and Mental 

Health Program

• Department of Financial Services, Division of Investigative and 

Forensic Servicesa

• Florida Association of Recovery Residencesb

• Florida Certification Board

• Attorney General, Medicaid Fraud Control Unit and Office of 

Statewide Prosecution

• State Attorney, 15th Judicial Circuit (Palm Beach County)

Massachusetts

• Bureau of Substance Addiction Services, Massachusetts Department 

of Public Health

• Division of Insurance

• MassHealth (state Medicaid office)

• Massachusetts Alliance for Sober Housingb

• Medicaid Fraud Control Unit

Ohio

• Department of Insurancec

• Department of Medicaid

• Department of Mental Health and Addiction Services

• Attorney General, Health Care Fraud Section (includes the Medicaid 

Fraud Control Unit)

• Ohio Recovery Housingb

Appendix I: State Agencies and Related 

Entities GAO Interviewed
Appendix I: State Agencies and Related 

Entities GAO Interviewed

Page 27 GAO-18-315 Substance Use Disorder

Texas

• Department of Insurancec

• Health and Human Services Commission, Mental Health and 

Substance Abuse Division

• Health and Human Services Commission, Medicaid and CHIP

• Medicaid Fraud Control Unitc

• Texas Recovery-Oriented Housing Networkb

Utah

• Department of Health, Division of Medicaid and Health Financingc

• Department of Human Services, Division of Substance Abuse and 

Mental Health

• Department of Human Services, Office of Licensing

• Insurance Department

• Medicaid Fraud Control Unit

• Utah Association of Addiction Treatment Providersb,d

Source: GAO. | GAO-18-315

Notes:

a

This division investigates potential insurance fraud in Florida.

b

State affiliate of the National Alliance for Recovery Residences (NARR). 

c

This organization provided written responses to our queries.

d

As of January 2018, NARR classified the Utah affiliate as “developing.” Officials from the Utah 

Association of Addiction Treatment Providers told us that its recovery residence activities were 

conducted by one of the association’s committees, and the committee was not actively certifying 

recovery houses in Utah according to the NARR standards.
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 28 GAO-18-315 Substance Use Disorder

Katherine M. Iritani, (202) 512-7114 or iritanik@gao.gov

In addition to the contact named above, Tom Conahan, Assistant 

Director; Shana R. Deitch, Analyst-in-Charge; Kristin Ekelund; and 

Carmen Rivera-Lowitt made key contributions to this report. Also 

contributing were Lori Achman, Jennie Apter, Colleen Candrl, and Emily 

Wilson.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101689)
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