Montana expands Medicaid coverage for housing assistance and transition from prison

The federal agency that oversees Montana's Medicaid program has approved requests from Gov. Greg Gianforte's administration to cover more services for Montanans with mental illnesses and substance use disorders, part of a multiyear effort to leverage state and federal funds to fill gaps in Montana's health care system.

The state Department of Public Health and Human Services on Monday announced the green light from the Centers for Medicare and Medicaid for three distinct expansions of what the public insurance program can fund. Those expansions include housing support services for people with a serious mental illness or substance use disorder; 30 days of pre-release health care for people exiting state prisons; and therapeutic "contingency management," an incentive-based treatment for people addicted to stimulants such as methamphetamine.

The requests were part of Gianforte's broader HEART Initiative - a 2021 plan to improve the state's treatment programs for addiction and mental health. Other aspects of the HEART Initiative have been implemented through CMS-approved waivers to the state's Medicaid program. The three recently accepted prongs have been the subject of regular negotiations between state and federal health officials for many months, the state health department said on Monday.

"Our DPHHS team has put tremendous work into negotiating Montana's HEART waiver on behalf of Gov. Gianforte, and we're proud to announce this significant milestone that opens new treatment doors for individuals," department Director Charlie Brereton said in the written announcement. "Through the HEART Initiative and other reform efforts, we will continue building a sustainable behavioral health system of care for struggling Montanans in need of help."

Medicaid generally has broad restrictions on funding health care services in jails and prisons and on paying directly for housing. In recent years, many states have begun requesting special exceptions to those rules in the form of federal waivers.

According to KFF, a national health research organization, 20 states, including Montana, have waivers in place to expand services for populations involved in the corrections system. As in some other states, Montana's new provision allows for pre-release clinical consultation, case management, opioid use disorder treatment and, upon a prisoner's release, the distribution of a 30-day supply of medication, such as long-lasting anti-psychotic medication and over-the-counter prescriptions. That part of the state's new waiver, along with the reimbursement for contingency management, is slated to go into effect this fall.

Some states have also received waivers to help residents with mental illnesses and addiction find and maintain housing. Montana's waiver applies to people who are at risk of losing their housing, are currently unhoused, have had a recent stay in an institutional setting, are frequent visitors to hospital emergency departments, have a history of incarceration, or have a history of homelessness.

When the housing support program is implemented next year, Medicaid will begin reimbursing providers who help assess people's eligibility for different types of housing, create housing support plans, find financial resources, pay for transition and move-in fees, and assist communications between landlords and tenants.

Tracy Menuez, a program officer who oversees housing initiatives with the Montana Healthcare Foundation, said the expansion will help create a sustainable source of revenue community organizations can use to hire housing navigators and caseworkers - positions that are often funded sporadically through philanthropy or grants.

"Having a stable funding source that is in fact really connected to the health outcomes for that person makes a lot of sense," Menuez said. Once the reimbursement is in place, she continued, "it's just really going to expand the number of places that can constantly offer those services."

The state health department has created a working group to help implement the part of the waiver dedicated to housing assistance, and has invited questions and feedback from interested groups in anticipation of the federal government's approval. Members of the working group include representatives from health care organizations, tribal nations and homeless shelters.

Menuez noted that reimbursement for housing support is just one way to increase housing access through Medicaid - 18 states have housing support waivers in place for various populations, according to KFF - but said that Montana's new approval is a step in the right direction.

Some county-level experts who work to improve health care and transition services for people navigating the criminal justice system also endorsed the expanded coverage for people exiting state prisons. But they pointed out that, as currently written, the waiver approval doesn't extend to people in municipal jails and county detention centers who would also benefit from pre-release services.

"I think what got dropped or what got missed was our detention centers," said Kellie McBride, director of Lewis and Clark County's criminal justice services department. When people get booked into jail, she said, they lose their Medicaid coverage and often have to pay for medication and health services out of pocket in the weeks and months before trial. "It makes it really difficult to provide good quality health care for the person when they're booked in."

A state health department spokesperson said the portion of the waiver covering corrections-involved people currently applies only to eligible people in the state men's and women's prisons, not to those who are in the custody of the state Department of Corrections and housed elsewhere.

McBride noted that a grant of more than $290,000 last year from another part of the HEART Initiative helped cover the costs of jail-based health services in Lewis and Clark County, including a therapist, licensed addictions counselor, case manager and transition coordinator.

"We are grateful for the HEART funds and proud of the services we have been able to provide because of those funds," she said.

In its Monday announcement, the health department said that training will be available in the coming months for providers who are interested in developing and seeking reimbursement for housing supports and contingency management services "before both programs become available to Medicaid members this fall."