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. For the purposes of this report, we use the term “recovery housing” to refer to peer-run, nonclinical living environments for individuals recovering from SUD in general, and “recovery homes” to refer to specific homes. 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. 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. 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 time, and immediately evicting residents who drink or use illicit drugs while living in the house. 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. 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. 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. 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. 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. 98 percent regularly attended 12-step meetings, such as Alcoholics Anonymous or Narcotics Anonymous. 45 percent attended weekly outpatient counseling in addition to Average length of sobriety was 13.4 months. 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. 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. 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. The extent of potential fraud differed across the four states, as discussed below. 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. 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 fraud and abuse in the SUD treatment and recovery housing industries. The task force found that unscrupulous recovery housing operators or associated SUD treatment providers were luring individuals into recovery homes using deceptive marketing tactics. 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. 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 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. 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. 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 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. 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. 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. 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 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 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. 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, and initial fees. See table 1 for additional information on features of state- established oversight programs for recovery housing. 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. 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 resources to recovery homes that were intended to increase consistency, accountability, and quality: 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. 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. 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 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. 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. The loan can be 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. 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. 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 peer mentoring. (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 Oxford House outreach workers. 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. 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 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. See table 2 for states’ use of SAMHSA and state funding for recovery housing activities. 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. 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.

Summary: 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. Nationwide prevalence of recovery housing—peer-run or peer-managed drug- and 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.