Attachment_H_–_Community_Supports_Policy_Guide_Volume_2_4.2025.pdf

COMMUNITY SUPPORTS

POLICY GUIDE

VOLUME 2

Community Supports to Support Members Experiencing or At Risk of Homelessness

April 2025

Community Supports Policy Guide Volume 2 | 2

TABLE OF CONTENTS

I. Introduction to Community Supports

II. Community Supports Overview

III. Coordination between MCPs and County Behavioral Health Agencies on Housing Initiatives

IV. Global Cap on Coverage of Room and Board Services

V. Overview of Community Supports to Support Members Experiencing or At Risk of Homelessness

VI. Community Supports – Service Definitions1

1. Housing Transition Navigation Services (HTNS)

2. Housing Deposits

3. Housing Tenancy and Sustaining Services (HTSS)

4. Day Habilitation Programs

5. Recuperative Care (Medical Respite)

6. Short-Term Post-Hospitalization Housing

VII. Transitional Rent

VIII. Engaging Members in Community Supports

IX. Provider Contracting, Enrollment, Credentialing, and Vetting Requirements

X. Data Systems and Data Sharing

XI. Coding, Billing, and Provider Payments

XII. Monitoring, Reporting, and Enforcement

XIII. Appendices

Appendix A: Community Supports to State Plan Service Crosswalk

Appendix B: Summary of Interaction Between Community Supports and ECM 110

Appendix C: Definition of Experiencing or at Risk of Homelessness

1 This volume contains the service definitions for seven of the 15 Community Supports that specifically address the needs of Members experiencing or at risk of homelessness, inclusive of Transitional Rent. Volume 1 contains the service definitions for the eight Community Supports that target Members’ other health-related social needs.

https://www.dhcs.ca.gov/Documents/MCQMD/DHCS-Community-Supports-Policy-Guide.pdf

Community Supports Policy Guide Volume 2 | 3

Appendix D: SMHS, DMC, and DMC-ODS Access Criteria

Appendix E: Full Service Partnership Eligibility Criteria

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I. INTRODUCTION TO COMMUNITY SUPPORTS2

This Community Supports Policy Guide Volume 2 is intended to serve as a resource for Medi-Cal Managed Care health plans (or “Managed Care Plans” (MCPs)) in the implementation of Community Supports that address the needs of Members experiencing or at risk of homelessness.

As of Spring 2025, the Department of Health Care Services (DHCS) has reorganized the Community Supports Policy Guide into two volumes to accommodate new policies specific to Transitional Rent and other Community Supports related to supporting Members experiencing or at risk of homelessness.

» Volume 1 contains the service definitions for eight of the 15 Community Supports that address Members’ health-related social needs.

» Volume 2 contains the service definitions for the seven Community Supports that specifically address the needs of Members experiencing or at risk of homelessness, inclusive of Transitional Rent.

This Policy Guide provides a comprehensive overview of DHCS’ Community Supports to support Members experiencing or at risk of homelessness, as well as operational guidance for MCPs. It is also intended to serve as a resource for Community Supports Providers.

Beginning in January 2022, DHCS launched California Advancing and Innovating Medi- Cal (CalAIM), with the goal of improving quality of care and health outcomes of Medi- Cal Members by implementing delivery system, program, and payment reforms across the Medi-Cal program. A key feature of CalAIM was the statewide introduction, in January 2022, of the Enhanced Care Management (ECM) benefit and a menu of 14 Community Supports. Community Supports, at the option of the MCP and Member, can substitute for covered Medi-Cal services as cost-effective alternatives, potentially decreasing the need for hospital care, nursing facility care, and emergency department (ED) use. MCPs are responsible for administering both ECM and Community Supports in close collaboration with their network of community-based Providers. DHCS expects MCPs to source the majority of referrals for Community Supports from the community and prioritize contracting with locally-based providers who address equity gaps and are culturally responsive to their community.

2 This section duplicates Section I of the Community Supports Policy Guide Volume 1 and is included for ease of reference.

Community Supports Policy Guide Volume 2 | 5

ECM and Community Supports were developed from lessons learned, as well as MCP and Provider experience, in the Whole Person Care (WPC) Pilots and Health Homes Program (HHP). These initiatives pushed the boundaries of a traditional health care delivery approach to begin formally considering the impact of social drivers of health (SDOH) on health outcomes and experience of care in Medi-Cal.

The Medi-Cal ECM and Community Supports Quarterly Implementation Report3 provides a comprehensive overview of ECM and Community Supports implementation to date. It is based on data submitted by MCPs to DHCS, and includes data at the state, county, and plan levels on total Members served, utilization, and provider networks. Since the launch of the program, Community Supports have served over 239,000 Medi-Cal Members.4 For Community Supports to support Members experiencing or at risk of homelessness, over 30,000 Members have used Housing Transition Navigation Services, over 14,000 Members have used Housing Tenancy Sustaining Services, and 2,000 have used Housing Deposits. Every county has at least eight Community Supports available for Members to access.

DHCS is committed to data-driven oversight of Community Supports and expects MCPs to have a data-driven approach to their implementation and monitoring of the program.

DHCS regularly reviews inbound MCP data as part of a comprehensive monitoring strategy for Community Supports described in Section XII in this Policy Guide.

DHCS is in continuous communication about Community Supports with MCPs, providers, and other implementation partners. MCPs and other stakeholders may direct their questions to DHCS using the following email address:

CommunitySupports@dhcs.ca.gov.

3 DHCS. Medi-Cal ECM and Community Supports Quarterly Implementation Report. March 2025.

Available at https://storymaps.arcgis.com/collections/a07f998dfefa497fbd7613981e4f6117.

Accessed April 2025.

4 Based on the data from Q2 2024.

https://storymaps.arcgis.com/collections/a07f998dfefa497fbd7613981e4f6117 https://storymaps.arcgis.com/collections/a07f998dfefa497fbd7613981e4f6117 https://storymaps.arcgis.com/collections/a07f998dfefa497fbd7613981e4f6117 mailto:CommunitySupports@dhcs.ca.gov

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II. COMMUNITY SUPPORTS OVERVIEW5

(Updated April 2025) What are Community Supports?

Community Supports are services that help improve the health and well-being of MCP Members by addressing Members’ health-related social needs; helping them live healthier lives; and avoiding higher, costlier levels of care. Community Supports—with the exception of Transitional Rent, which is mandatory for MCPs to offer beginning January 1, 2026—are optional for MCPs to offer and for Members to utilize. MCPs may not require Members to use a Community Support instead of a service or setting listed in the Medicaid State Plan.

Starting on January 1, 2022, MCPs in all counties have been strongly encouraged to offer the following 14 pre-approved Community Supports, which are defined fully in this Policy Guide or Community Supports Policy Guide Volume 1:

» Respite Services (Volume 1)

» Assisted Living Facilities, formerly known as Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for the Elderly and Adult Residential Facilities (Volume 1)

» Community or Home Transition Services, formerly known as Community Transition Services/Nursing Facility Transition to a Home (Volume 1)

» Personal Care and Homemaker Services (Volume 1)

» Environmental Accessibility Adaptations (Home Modifications) (Volume 1)

» Medically Tailored Meals/Medically Supportive Food (Volume 1)

» Sobering Centers (Volume 1)

» Asthma Remediation (Volume 1)

» Housing Transition Navigation Services

» Housing Deposits

» Housing Tenancy and Sustaining Services

» Day Habilitation Programs

5 This section duplicates Section II of the Community Supports Policy Guide Volume 1 and is included for ease of reference.

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» Recuperative Care (Medical Respite)

» Short-Term Post-Hospitalization Housing

Effective July 1, 2025, DHCS is adding Transitional Rent as the fifteenth Community Supports service. MCP coverage of Transitional Rent is initially optional and becomes mandatory for MCPs to offer on January 1, 2026.

Consistent with federal regulations,6 DHCS has determined the preapproved Community Supports to be cost-effective and medically appropriate substitutes for covered Medi- Cal services or settings. MCPs do not need to actively assess or report on cost effectiveness for Community Supports at the MCP or individual level for the purposes of rate setting or compliance with federal requirements. Nothing prohibits MCPs from using utilization management techniques as applicable and as permitted by federal managed care regulations. DHCS is conducting statewide aggregate analyses of the cost effectiveness of each of the approved Community Supports services.

Federal Authorities for Community Supports Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent are authorized under Section 1115 waiver authority. Short-Term Post-Hospitalization Housing and Recuperative Care are authorized under the CalAIM waiver,7 and Transitional Rent is authorized under the BH-CONNECT waiver.8 These services are each subject to the Special Terms and Conditions (STCs) of their respective waivers. The requirements and limitations set forth in the waiver STCs are reflected in the policies provided in this Guide. The other 12 Community Supports are “in lieu of services”

6 National policy continues to evolve; the latest guidance from CMS can be found in the State Medicaid Director Letter (SMDL) from January 2023. (Centers for Medicare and Medicaid Services.

SMDL 23-001. January 2023. Available at https://www.medicaid.gov/federal-policy-guidance.

Accessed April 2025.)

7 Medicaid. CalAIM Demonstration Approval Technical Correction Attachment. January 2025.

Available at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list. Accessed April 2025.

8 Medicaid. Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment (BH-CONNECT) Section 1115(a) Demonstration. January 2025. Available at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list.

Accessed April 2025.

https://www.medicaid.gov/federal-policy-guidance/downloads/smd23001.pdf https://www.medicaid.gov/federal-policy-guidance/downloads/smd23001.pdf https://www.medicaid.gov/federal-policy-guidance https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-dmnstrn-appvl-thncl-crctn-atchmnt-c-aa-01172025.pdf https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-dmnstrn-appvl-thncl-crctn-atchmnt-c-aa-01172025.pdf https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-bh-connect-01102025.pdf https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-bh-connect-01102025.pdf https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-bh-connect-01102025.pdf https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list

Community Supports Policy Guide Volume 2 | 8 established and implemented in accordance with California’s Section 1915(b) waiver and 42 CFR section 438.3(e)(2).9

Each Community Support is additionally subject to the requirements of DHCS’ MCP contract.10 The MCP Contract sets forth the eligibility criteria and clinically oriented service definition for each Community Support. Greater detail, additional requirements, and limitations for each Community Support are provided in this Guide.

All Community Supports must supplement and not supplant services received by the Medi-Cal Member through other state, local, or federally -funded programs, in accordance with applicable federal waiver authorities, MCP Contract, APLs, and DHCS guidance.

All Plan Letter (APL) Governing Community Supports MCPs are responsible for ensuring that all Community Supports Providers, Subcontractors, and Network Providers comply with all applicable state and federal laws and regulations, contract requirements, APLs, and other DHCS guidance including, but not limited to, Policy Letters and this Community Supports Policy Guide (inclusive of Volumes 1 and 2) as outlined in APL 21-017 or subsequent updates or superseding APLs.

ECM and Community Supports Action Plan DHCS is committed to adjusting Community Supports program design to reduce administrative burden, promote market awareness, and improve access and uptake of Community Supports across the state. DHCS conducts regular stakeholder feedback on ongoing implementation of Community Supports, which resulted in an ECM and Community Supports Action Plan11 summarizing areas for standardization and efforts to

9 All in lieu of services are subject to the requirements of 42 CFR section 438.3(e)(2). This means that they must be a cost-effective substitute for a service or setting covered under the Medicaid State Plan, voluntary for an MCP to cover and for a Member to utilize, and taken into account in developing the component of the capitation rate that represents the covered State Plan services and settings.

10 DHCS. Medi-Cal Managed Care Boilerplate Contracts. 2024. Available at https://www.dhcs.ca.gov/provgovpart/Pages/MMCDBoilerplateContracts.aspx. Accessed April 2025.

11 DHCS. ECM Community Supports Action Plan Updates. December 2024. Available at https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Resources.aspx. Accessed April 2025.

https://www.dhcs.ca.gov/provgovpart/Pages/MMCDBoilerplateContracts.aspx https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Community-Supports-Action-Plan-Updates-Fall-2024.pdf https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Community-Supports-Action-Plan-Updates-Fall-2024.pdf https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Community-Supports-Action-Plan-Updates-Fall-2024.pdf https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Resources.aspx

Community Supports Policy Guide Volume 2 | 9 streamline access to both services. Since 2023, DHCS has updated select Community Supports service definitions to improve eligibility alignment across the Community Supports and/or clarify eligibility policies. In the spirit of continuous improvement, DHCS updates the Action Plan on a regular basis.

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III. COORDINATION BETWEEN MCPS AND

COUNTY BEHAVIORAL HEALTH AGENCIES

ON HOUSING INITIATIVES

(Added April 2025)

Through the provision of these Community Supports, MCPs play a critical role in addressing the housing needs of Members experiencing or at risk of homelessness, including those with significant behavioral health needs. With the passage of Proposition 1 and the Behavioral Health Services Act (BHSA),12 county behavioral health agencies will also assume a larger role in addressing homelessness among the population they serve.

The BHSA replaces the Mental Health Services Act (MHSA) of 2004. It reforms behavioral health care funding to prioritize services for people with the most significant mental health needs, while adding the treatment of substance use disorders (SUD), expanding requirements for counties to fund and provide housing interventions, and increasing the behavioral health workforce. It also enhances oversight, transparency, and accountability at the state and local levels. Additionally, the BHSA creates pathways to ensure equitable access to care by advancing equity and reducing disparities for individuals with behavioral health needs.

A central reform of the BHSA is a new requirement, effective July 1, 2026, that county behavioral health agencies spend 30 percent of their BHSA funds on Housing Interventions for individuals with significant behavioral health needs who are experiencing or at risk of homelessness. Counties will be permitted to spend Housing Interventions on a range of services including, but not limited to, rental subsidies, operating subsidies, participant assistance funds (e.g., to cover move-in and home set-up expenses, provide utility assistance, cover pet fees, etc.), and landlord outreach and mitigation funds (e.g., for landlord incentives and unit holds, to cover damages caused

12 SB-326 The Behavioral Health Services Act. 2023-2024. Available at https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240SB326. Accessed April 2025. (For information on the passage of Proposition 1 and BHSA, see DHCS’ Behavioral Health Transformation webpage. Available at https://www.dhcs.ca.gov/BHT/Pages/home.aspx.)

https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240SB326 https://www.dhcs.ca.gov/BHT/Pages/home.aspx https://www.dhcs.ca.gov/BHT/Pages/home.aspx https://www.dhcs.ca.gov/BHT/Pages/home.aspx

Community Supports Policy Guide Volume 2 | 11 by a tenant, etc.).13 For Members receiving Transitional Rent who have significant behavioral health needs, the rental subsidies provided under the BHSA Housing Interventions may be the most viable pathway to long-term housing stability following receipt of Transitional Rent.

Importantly, under California Welfare & Institutions (W&I) Code section 5830(c)(2), BHSA “funds shall not be used for housing interventions covered by a Medi-Cal managed care plan.” This means that Members will not be permitted to receive rental subsidies under the BHSA so long as Transitional Rent is available to the Member.

Likewise, while counties may fund services such as navigation, tenancy sustaining services, short-term post-hospitalization housing, recuperative care, or housing deposits through BHSA Housing Interventions, they may not fund these services for Members who are eligible to receive them as Community Supports through their MCP.

Counties can use BHSA Housing Interventions to cover items or services that are not covered under Medi-Cal managed care or not covered by the individual’s MCP.

Examples include, but are not limited to, ongoing utility assistance, coverage of pet deposits and other move-in and home set-up costs not covered under Housing Deposits, landlord incentives, landlord mitigation funds, and operating subsidies.

13 For additional information on BHSA Housing Interventions, see the BHSA County Policy Manual. (DHCS. BHSA County Policy Manual. April 2025. Available at https://www.dhcs.ca.gov/BHT/Pages/Policy-Manual.aspx. Accessed April 2025.)

https://www.dhcs.ca.gov/BHT/Pages/Policy-Manual.aspx https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=WIC&division=5.&title=&part=3.2.&chapter=&article=

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Figure 1. Example Scenario of a Member Eligible to Receive Both Transitional Rent and BHSA Housing Interventions Funding

To ensure meaningful access to Community Supports that assist Members experiencing or at risk of homelessness—and to improve long-term housing outcomes for the behavioral health population—MCPs and county behavioral health agencies must establish stronger partnerships, coordination, and communication. Many of the policies outlined in the following sections are designed to support this goal, including efforts to encourage counties and/or their contracted behavioral health providers to contract with MCPs as Community Supports Providers, including for services like Transitional Rent, so they can continue serving clients seamlessly even as funding sources change. Additional policies aim to support the development of Flexible Housing Subsidy Pools (“Flex Pools”), which allow a single entity to manage landlord engagement across contributing funders.

BHSA Housing Interventions BHSA Housing Interventions

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IV. GLOBAL CAP ON COVERAGE OF ROOM AND

BOARD SERVICES

(Added April 2025)

Short-Term Post-Hospitalization Housing and Recuperative Care are authorized under California’s CalAIM waiver, and Transitional Rent is authorized under the BH-CONNECT waiver. These waivers establish a “global cap” on coverage of Short-Term Post- Hospitalization Housing, Recuperative Care, and Transitional Rent, all three of which are referred to in the waivers as “Room and Board” services. Under the cap, coverage is limited to six months of Room and Board services per Member within a rolling 12-month period. This means that a Member may not receive more than a combined six months of Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent during any rolling 12-month period.

MCPs must count the rolling 12-month period starting from the Member’s first date of utilization of Short-Term Post-Hospitalization Housing, Recuperative Care, or Transitional Rent—not from the date of authorization.

In addition to the global cap, which is applicable to all three Room and Board services, Transitional Rent—as a Room and Board-only intervention without accompanying clinical services—is subject to an additional cap of six months per household, per demonstration.

The table below reflects the duration and frequency restrictions per Room and Board service and across the three services.

Service Limits per Service14 Limits across the Services15

Recuperative Care 6-month limit per rolling 12-month period (per Member) 6-month limit per rolling 12-month period (per Member) Short-Term Post Hospitalization Housing

6-month limit per rolling 12-month period (per Member)

14 The 12-month rolling timeframe begins on the first day the Member uses any of these services.

15 The 12-month rolling timeframe begins on the first day the Member uses any of these services.

https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-dmnstrn-appvl-thncl-crctn-atchmnt-c-aa-01172025.pdf

Community Supports Policy Guide Volume 2 | 14

Service Limits per Service14 Limits across the Services15

Transitional Rent 6-months of service per 5-year demonstration (per household) also applies across all three Room and Board services.

When operationalizing this requirement, MCPs must track Member utilization in days and limit coverage to 182 combined days of Short-Term Post-Hospitalization Housing, Recuperative Care, and/or Transitional Rent in any given 12-month period.

A Member whose household receives Transitional Rent that is attributed to another individual in the household can still receive Short-Term Post-Hospitalization Housing and/or Recuperative Care within the same rolling 12-month period as the Transitional Rent.

Implementation Principles for MCPs on the Global Cap on Coverage of Room and Board Services

(1) Room and Board Holds. In some cases, a Member will be required or choose to leave a setting before the expiration of the authorized Room and Board period. That exit may be voluntary (e.g., the Member decides to move in with a friend or relative) or involuntary (e.g., the Member is incarcerated) and short-term (e.g., brief hospitalization) or long-term (e.g., admission for an extended stay in a nursing facility). The MCP must count toward the global cap any Room and Board days the MCP is obligated to pay for under its Network Agreement with the Community Supports Provider. The Network Agreement should outline the financial responsibility pertaining to “Room and Board holds.”

» If the Network Agreement states that the MCP is not obligated to pay for days in which the Member is not physically residing in the setting, days in which the Member is not residing in the setting must not be counted toward the global cap.

» If the Network Agreement states that the MCP will pay for Room and Board holds, then the MCP is required to count the days spent in the institution or hospital in calculating its payment for the stay in the Short-Term Post-Hospitalization Housing, Recuperative Care, or Transitional Rent setting, and it must count the days spent outside of the setting toward the global cap.

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(2) Monthly Payments. If an MCP pays in advance for a full month of housing in a permanent setting, the MCP must count the full month toward the global cap, even if the Member moves out of the unit prior to the expiration of the month, except when the MCP recovers a prorated portion of the full-month’s payment for days for which the Member is not physically residing in the setting. The Transitional Rent Provider must not issue payment to the landlord for the month following the Member’s exit from the unit.

(3) MCPs’ obligations if Member switches Plan elections. If a Member switches MCPs and the new MCP has covered the Member for less than 12 months and the Member needs Short-Term Post-Hospitalization Housing, Recuperative Care, or Transitional Rent, the MCP must determine whether the Member utilized one of these Room and Board services from the previous MCP and if so, for how long. Specifically, the newly elected MCP must:

(a) Request information from the prior MCP to obtain information about the Room and Board service provided and dates of coverage;

(b) Request information from the Member whether the Member utilized any of the Room and Board services in the prior 12-month period;

(c) If the Member had been a Member of the new MCP in any prior period, review any prior utilization data to validate whether the Member was provided any of the Room and Board services; and

(d) Ensure that providers delivering Room and Board services provide information to MCPs about Room and Board service utilization, the Providers delivering the service and the dates of service.16

16 As established in the Community Supports Member Information Sharing Guidance. (DHCS.

Community Supports Member Information Sharing Guidance. December 2024. Available at https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Resources.aspx. Accessed April 2025.)

https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Resources.aspx

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V. OVERVIEW OF COMMUNITY SUPPORTS TO

SUPPORT MEMBERS EXPERIENCING OR AT

RISK OF HOMELESSNESS

(Added April 2025)

The disparities in health outcomes between individuals who are housed and those experiencing homelessness are stark. Non-elderly individuals experiencing homelessness have 3.5 times the mortality risk of those who are housed and a 40-year-old person experiencing homelessness faces a similar mortality risk to a housed person nearly 20 years older.17 Individuals experiencing homelessness also have significantly higher rates of chronic conditions and behavioral health needs than the housed population, along with higher rates of acute and emergent health services utilization.

With coverage of the Community Supports to support Members experiencing or at risk of homelessness, DHCS seeks to help Members experiencing or at risk of homelessness realize the significant improvements in health that have been shown to result from stable housing.

A. Community Supports to Support Members Experiencing or At Risk of Homelessness There are seven Community Supports to support Members experiencing or at risk of homelessness:

(1) Housing Transition Navigation Services (HTNS)

(2) Housing Deposits

(3) Housing Tenancy and Sustaining Services (HTSS)

(4) Day Habilitation

(5) Recuperative Care (Medical Respite)

(6) Short-Term Post-Hospitalization Housing

(7) Transitional Rent

17 Meyer B. D., Wyse A. & Logani I. (2023). Life and Death at the Margins of Society: The Mortality of the U.S. Homeless Population (No. w31843). National Bureau of Economic Research.

Available at https://www.nber.org/papers/w31843. Accessed April 2025.

https://www.nber.org/papers/w31843

Community Supports Policy Guide Volume 2 | 17

MCP coverage of HTNS, Housing Deposits, HTSS, Short-Term Post-Hospitalization Housing, Recuperative Care, and Day Habilitation is strongly encouraged but remains optional. MCPs have had the option to cover these services since January 1, 2022.

Transitional Rent will become a mandatory service beginning January 1, 2026, and will be implemented in phases for select eligible populations (see Section VII on Transitional Rent). MCPs may also opt to cover Transitional Rent as early as July 1, 2025.

When MCPs launch coverage of Transitional Rent, their continued coverage of other Community Supports for Members experiencing or at risk of homelessness—particularly HTNS, Housing Deposits, and HTSS (collectively referred to as the Housing Trio)—is critical to helping Members identify, secure, and sustain permanent housing.

B. Housing Support Plan A Member’s housing support plan sets forth a plan for achieving the individual’s housing goals that is based on the individual’s needs, preferences, and barriers to housing. It is a key tool that acts as a personalized roadmap to help a Member on their journey from homelessness or housing instability into long-term housing stability. A housing support plan can help ensure that time-limited Room and Board services18 will be provided in ways that best contribute to the long-term housing stability of the Member. The development and maintenance of a housing support plan has always been part of the expectation for the Housing Trio; with the addition of Transitional Rent, DHCS is emphasizing the key role that it plays across the services.

When a Housing Support Plan is Required DHCS requires MCPs to ensure that a Member has a housing support plan in place as a condition for authorizing a Member for Transitional Rent, whether the Member is placed in an interim or permanent setting (see Section VII.F for detail on Transitional Rent authorization). In many or most cases, the Member being referred for Transitional Rent/Housing Deposits has received or is receiving HTNS, and thus has a housing support plan that has been developed by the Member’s HTNS Provider in conjunction with the Member.19 However, DHCS recognizes that similar housing navigation may be provided outside Community Supports. In addition, a Member is not specifically required to have received HTNS as a condition of being able to receive Transitional Rent

18 See details on the six-month global cap on Room and Board services in Section IV.

19 Development of a housing support plan is one of the HTNS activities in the HTNS service description (see Section VI.1).

Community Supports Policy Guide Volume 2 | 18 or Housing Deposits.20 As long as a housing support plan is in place that meets the requirements below, it may have been developed by another Community Supports Provider, a flex pool or hub organization that coordinates supportive services, or other Housing Providers, including county behavioral health agencies, regardless of their participation in Medi-Cal or as a contracted Provider.

The housing support plan can and should be updated as a Member’s needs and other relevant circumstances change. For example, once a Member successfully secures tenancy through Transitional Rent and/or receives Housing Deposits, the Member may begin receiving HTSS, and the HTSS Provider will be responsible for maintaining and updating the housing support plan in partnership with the member to reflect their evolving needs.

A housing support plan is not required as a condition for a Member to receive Recuperative Care or Short-Term Post-Hospitalization Housing. However, when Members are receiving Recuperative Care or Short-Term Post-Hospitalization Housing, they should be offered HTNS, so that the HTNS Provider can conduct a housing assessment and develop a housing support plan with the Member to help identify preferences and barriers related to successful housing tenancy after transitioning from Recuperative Care or Short-Term Post-Hospitalization Housing.

Content of a Housing Support Plan Below are the elements that DHCS expects to be in a Member’s housing support plan.

The housing support plan must:

1. Identify the permanent housing strategy and solution for the Member, including the payment sources and mechanisms, that will support the Member in maintaining housing after the Room and Board services covered under the Medi- Cal managed care delivery system are exhausted (e.g., the Member’s income, BHSA Housing Interventions, or other long-term subsidies).

2. Identify the full range of permanent housing supports that will support the Member in sustaining tenancy (e.g., tenancy sustaining service, utilities).

3. Be informed by Member preferences and needs, and reviewed and revised as needed based on changes in Member circumstances.

20 As of the April 2025 updated version of this Community Supports Policy Guide, DHCS is no longer requiring a Member to receive HTNS as a condition of receiving Housing Deposits (see Section VI.2 on Housing Deposits).

Community Supports Policy Guide Volume 2 | 19

4. Be based on a housing assessment that addresses identified barriers, includes short- and long-term measurable goals for each issue, establishes the Member’s approach to meeting the goal, and identifies when other providers or services, both reimbursed and not reimbursed by Medi-Cal, may be required to meet the goal.

5. Be developed in a way that is culturally appropriate and trauma-informed.

The housing support plan can and should be updated as a Member’s needs and other relevant circumstances change.

When receiving Transitional Rent, a Member can be placed in an interim or permanent setting. Ultimately, DHCS recognizes that the details provided in the housing support plan may differ depending on the type of setting a Member is seeking authorization for;

specifically:

» For interim settings: For a Member transitioning from homelessness into an interim setting, a housing support plan should address all major elements identified above, though it may be less complete, given that establishing trust, along with identifying a Member’s housing strategy and solution, and payment sources and mechanisms can take time. However, as outlined in Section VII.F, DHCS is also requiring documentation from the Member’s county behavioral health agency that the Member will be able to transition to BHSA Housing Interventions at the expiration of Transitional Rent. This documentation fulfills the requirement of the Member’s housing solution in their housing support plan (i.e., if the Member is otherwise not able to secure a U.S. Housing and Urban Development (HUD) Housing Choice Voucher, permanent supportive housing subsidy, or other long-term rental subsidy to transition to at the expiration of coverage under Transitional Rent).

» For permanent settings: By the time a Member is seeking Transitional Rent in a permanent setting, they will be further along in making progress with their Housing Support Plan. In this version of the housing support plan, it will also address all major elements identified above, but the content and overall level of detail will look different than when the housing support plan had been initially created; i.e., goals have been identified, barriers overcome (e.g., documents have been obtained), and a housing search has taken place. So a housing support plan should appear to be more complete.

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C. Interaction Between Community Supports to Support Members Experiencing or At Risk of Homelessness and ECM Through CalAIM, DHCS has developed a comprehensive set of supports to address the needs of Members experiencing or at risk of homelessness. In addition to the seven Community Supports to support Members experiencing or at risk of homelessness, MCPs must cover the ECM benefit, which provides systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered for Members with the most complex medical and social needs, including for individuals and families experiencing homelessness.21 With ECM, Members receive connections to needed physical and behavioral health care services, as well as social supports. To support housing needs specifically, ECM Providers can place referrals for these Community Supports that assist their Members with finding, securing, and maintaining housing. Establishing this connection to the Community Supports for Members experiencing or at risk of homelessness, with the goal of long-term housing stability, further promotes the aim of ECM, which is to improve Member health and functioning.

Figure 2: Interaction Between ECM and Community Supports

21 For more information, see the ECM Policy Guide. (DHCS. ECM Policy Guide. August 2024.

Available at https://www.dhcs.ca.gov/CalAIM/ECM/Documents/ECM-Policy-Guide.pdf. Accessed April 2025.)

https://www.dhcs.ca.gov/CalAIM/ECM/Documents/ECM-Policy-Guide.pdf

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For many Members, participation in ECM and the Housing Trio serves as a referral point into the Community Supports services with a Room and Board component (i.e., Transitional Rent, Recuperative Care, Short-Term Post-Hospitalization Housing). For Members who are not already receiving ECM and Housing Trio services when they are referred to Transitional Rent or another Room and Board service, immediate access to and engagement in ECM and the Housing Trio is also important.

Each of the individual service definitions below includes a summary of the related policies for Members receiving that service or authorized for that service (e.g., Members authorized for Transitional Rent must also be authorized for ECM). The full summary of “Interaction Policies” is included as Appendix B.

Below in Figure 3 is an example of a Member’s journey interacting with these services, in which the Member is at first experiencing homelessness and needs an acute hospitalization.

Figure 3. Housing Community Supports and ECM Across a Member’s Journey

» In this example, the Member’s journey begins with an acute hospitalization for injury or illness. The Member also meets the criteria for access to Medi-Cal Specialty Mental Health Services (SMHS) and is experiencing homelessness.

» Following DHCS’ requirements for Transitional Care Services,22 the hospital discharge team coordinates with the Member’s MCP prior to discharge and

22 See requirements in in the Population Health Management (PHM) Policy Guide. (DHCS. PHM Policy Guide. May 2024. Available at https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy- Guide.pdf. Accessed April 2025.)

Recuperative Care Transitional Rent https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-Guide.pdf https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-Guide.pdf https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-Guide.pdf https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-Guide.pdf

Community Supports Policy Guide Volume 2 | 22 discovers that the Member would benefit from a Recuperative Care stay and is not already receiving ECM.

» The MCP arranges for the Member to be discharged to Recuperative Care and assigns an ECM Provider. Because this Member is already engaged in SMHS and the local county behavioral health agency is under contract with the MCP as an ECM Provider, the Member’s ECM Provider is a care manager employed by the county behavioral health agency.

» Once receiving ECM, the Member’s ECM Lead Care Manager refers the Member to HTNS for support in finding and securing housing (the county behavioral health agency is also contracted with the MCP to provide HTNS, HTSS, Housing Deposits, and Transitional Rent, so serves as the HTNS Provider).

» The HTNS Provider works with the Member to develop a housing support plan and identifies an apartment.

» The Member is then authorized for Housing Deposits to provide one-time services and modifications necessary to establish a basic household and Transitional Rent for temporary rental assistance.

» The Member moves into an apartment unit. Housing Deposits covers the security deposit and other move-in expenses. The Transitional Rent Provider begins issuing checks to the landlord to cover the Member’s rent each month.

» The Member transitions from HTNS to HTSS for ongoing support in maintaining safe and stable tenancy.

» Through connection to the Housing Trio, Transitional Rent, and ECM, and close coordination between the MCP and the county behavioral health agency, the Member is able to remain in their apartment and transition to a long-term housing subsidy funded under the BHSA. The plan for how the Member will maintain housing through BHSA Housing Interventions is documented in the housing support plan.

This journey is illustrative. Members may have varying needs that require them to use different combinations of services at different times. Additionally, a Member may not receive more than a combined six months of Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent during any rolling 12-month period. See Section IV for more information on the global cap for Room and Board services.

DHCS recognizes that multiple Network Providers may be involved in a Member’s care.

For example, a federally qualified health center may provide ECM, while a community-

Community Supports Policy Guide Volume 2 | 23 based organization with experience in housing provides Housing Trio services and Transitional Rent. In other cases, a single entity may fulfill multiple Network Provider roles spanning ECM and the housing-related Community Supports. DHCS expects MCPs to coordinate among Network Providers to ensure Members receive comprehensive, person-centered care. The Community Supports services provided should utilize best practices for Members who are experiencing or at risk of homelessness and who have complex health, disability, and/or behavioral health conditions. Examples of best practices include Housing First, Harm Reduction, and Motivational Interviewing.

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VI. COMMUNITY SUPPORTS – SERVICE

DEFINITIONS23

The Community Supports service definitions for the following services are detailed in the section below:

» Housing Transition Navigation Services

» Housing Deposits

» Housing Tenancy and Sustaining Services

» Day Habilitation Programs

» Recuperative Care (Medical Respite)

» Short-Term Post-Hospitalization Housing

The service definitions for Respite Services, Assisted Living Facility Transitions, Community or Home Transition Services, Personal Care and Homemaker Services, Environmental Accessibility Adaptations (Home Modifications), Medically Tailored Meals/Medically Supportive Food, Sobering Centers, and Asthma Remediation can be found in Volume 1 of the Community Supports Policy Guide.

23 This section includes the service definition for all Community Supports to support Members experiencing or at risk of homelessness except Transitional Rent, which is in Section VII.

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Housing Transition Navigation Services (HTNS)

Description/Overview (Updated April 2025) Housing Transition Navigation Services (HTNS) assist Members with finding, applying for, and obtaining housing.24 The services provided to a Member must be based on an individualized assessment of needs and documented in the Member’s housing support plan. As such, a Member may only require a subset of the following activities.

HTNS activities include:

1. (Updated April 2025) Conducting a housing assessment that identifies the Member’s preferences and barriers related to successful tenancy.25 The assessment may include collecting information on the Member’s housing needs and preferences, potential housing transition strengths and barriers, and identification of housing retention strengths and barriers.26

2. (Updated April 2025) Developing a housing support plan based upon the housing assessment.27 See additional details about what a housing support plan must contain in Section V.B.

3. (Updated April 2025) Assisting in searching for housing and presenting options.28

4. Assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history).

5. Assisting with benefits advocacy, including assistance with obtaining identification and documentation for Supplemental Security Income (SSI)

24 DHCS added the language “finding, applying for” to precede “obtaining housing” to this service component.

25 DHCS removed tenant screening as an HTNS activity, as this is typically performed by landlords or housing providers to assess prospective tenants before renting out a property.

26 DHCS added the language “preferences” and “strengths” to this service component.

27 DHCS removed tenant screening as an HTNS activity, as this is typically performed by landlords or housing providers to assess prospective tenants before renting out a property.

28 DHCS added the language “assisting” to make it clear that the HTNS Provider is responsible for helping the Member with conducting the housing search.

Community Supports Policy Guide Volume 2 | 26 eligibility and supporting the SSI application process. Such service can be subcontracted out to retain any needed specialized skillset.

6. (Updated April 2025) Identifying and securing available resources to assist with attaining housing—such as Transitional Rent, HUD Housing Choice Voucher, and other state and local assistance programs—and matching available resources to Members.29

7. Identifying and securing resources including but not limited to Housing Deposits30, to cover expenses such as security deposit, moving costs, adaptive aids, environmental modifications, moving costs, and other one-time expenses.

(see Section VI.2. Housing Deposits Community Support).

8. (Updated April 2025) Providing education to the Member about Fair Housing and anti-discrimination practices, including making requests for necessary reasonable accommodation if necessary.31

9. Landlord education and engagement.

10. Ensuring that the living environment is safe and ready for move-in.

11. Communicating and advocating on behalf of the Member with landlords.

12. Assisting in, arranging for, and supporting the details of the move.

13. Establishing procedures and contacts to retain housing, including developing a housing support crisis plan that includes prevention and early intervention services when housing is jeopardized.32

14. Identifying, coordinating, securing, or funding non-emergency, non-medical transportation to assist Members’ mobility to ensure reasonable accommodations and access to housing options prior to transition and on move in day.

29 DHCS modified the language in this service component to allow for the inclusion of Transitional Rent.

30 DHCS modified the language in this service component to include Housing Deposits, which is another Community Supports service that can be used to cover expenses related to lease-up and move-in such as a security deposit.

31 DHCS added the language “Providing education to the Member about Fair Housing and anti-discrimination practices, including making” to this service component.

32 The services associated with the crisis plan are a separate Community Support under HTSS.

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15. Identifying, coordinating, securing, or funding environmental modifications to install necessary accommodations for accessibility (see Environmental Accessibility Adaptations in Community Supports Policy Guide Volume 1).

Eligibility (Population Subset)

(1) (Updated April 2025) Individuals who meet the following social and clinical risk factor requirements:

a) Social Risk Factor Requirement: Experiencing or at risk of homelessness.33

b) Clinical Risk Factor Requirement: Must have one or more of the following qualifying clinical risk factors:34

(i) Meets the access criteria for Medi-Cal Specialty Mental Health Services (SMHS);

(ii) Meets the access criteria for Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS);

(iii) One or more serious chronic physical health conditions;

(iv) One or more physical, intellectual, or developmental disabilities; or

(v) Individuals who are pregnant up through 12-months postpartum.

OR

(2) (Added April 2025) Individuals who are determined eligible for Transitional Rent.

These individuals are automatically eligible for HTNS.35

OR

(3) Individuals who are prioritized for a permanent supportive housing unit or rental subsidy resource through the local homeless Coordinated Entry System or similar system designed to use information to identify highly vulnerable individuals with disabilities and/or one or more serious chronic conditions and/or serious mental illness, institutionalization or requiring residential services because of a substance use disorder and/or is exiting incarceration.

33 The definition of an individual experiencing or at risk of homelessness is based on HUD’s definitions with three modifications as detailed in Appendix C.

34 See Appendix D for the SMHS, DMC, and DMC-ODS access criteria.

35 See Section VII on Transitional Rent for additional information.

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MCPs may accept an attestation by the Member or the provider on behalf of the Member of the need for housing to satisfy any documentation requirements regarding the Member’s housing status.

Restrictions/Limitations Services do not include the provision of Room and Board or payment of rental assistance.

Services are not subject to the Room and Board provisions in Section IV.

Actions to be taken under HTNS must be identified as reasonable and necessary in the Member’s housing support plan.

Service duration can be as long as necessary and there is no limit on how many times an eligible Member may be authorized for this service.

While it is appropriate and optimal for Members to receive HTNS prior to Housing Deposits and/or Transitional Rent, it is not a prerequisite.

Delivery with Other Community Supports and ECM HTNS with ECM: MCPs must ensure that Members who meet the eligibility requirements for HTNS are offered ECM, and Members are highly encouraged to receive both services.