By Erica C. Barnett
A report commissioned by the King County Regional Homelessness Authority, but never publicly released, highlights some of the challenges the regional agency will face as it attempts to use federal Medicaid funding to pay for Partnership for Zero, a marquee program that aims to eliminate homelessness in downtown Seattle by connecting people directly with housing.
The report, from the nonprofit Corporation for Supportive Housing, also lays out a potential road map for navigating the Medicaid reimbursement process, which is so byzantine that many King County providers have avoided using the program.
Currently, homeless service providers can seek funding through a Medicaid-based program called Foundational Community Supports, which provides benefits and services for people experiencing homelessness who are eligible for Medicaid and have chronic health conditions. The program, which has been around since 2018, treats homelessness as a health care issue and housing as a form of health care—a meaningful step that many advocates have applauded.
“FCS is a really unique revenue source, because it’s not a short-term grant or contract—it really is based on a person’s health and will stay with them as long as they need these services,” said Debbie Thiele, CSH’s western managing director. “It’s been a major breakthrough to have the health care system seeing supportive housing services as a part of health.”
But establishing clients’ eligibility for the program and securing payment for ongoing services has been a daunting and sometimes money-losing challenge for service providers, who often have to hire specialized administrative staff and train case managers to meticulously document encounters with clients. In conversations with PubliCola earlier this year, providers explained how challenging it can be to translate notes by front-line case managers into billable Medicaid hours; a case worker who isn’t fully trained and dogged in their efforts to enroll clients and “constantly generate [billable] service contacts” can cost an agency significantly more than they bring in, one provider said.
Back in April, Dones said the KCRHA was about to start billing some services to Medicaid in a series of experimental “dry runs” that will “give us ample time to correct anything that is going wrong” before transitioning Partnership for Zero into a mostly Medicaid-funded program next year. Those dry runs haven’t happened, and the reasons for the delay remain somewhat opaque.
“Once providers are up and running with Medicaid FCS, it is projected to cover gaps with increase revenue, but to get to that point, providers report their start-up costs to be far more than they can afford, in some cases in the hundreds of thousands of dollars,” the report says.
Thiele says one solution would be funding to help organizations, particularly smaller and BIPOC-led groups, set up the billing and other infrastructure they need. “If you want the nonprofit sector, which is reliant on grants and contracts and doing this incredibly challenging work in community, to make a major internal change to the way they operate, then they need investment in order to do that,” Thiele said. “With staff turnover being what it is right now, it’s a big risk for nonprofits to do new things,” she added.
The CSH report breaks down some of the primary issues that prevent homeless service providers from getting the most out of Medicaid funds, including administrative hurdles that force staff to work extra hours manually inputting data and doing duplicative work; denials and disenrollments for reasons that can feel capricious, such as minor technical errors; and difficulty knowing what services FCS will consider “supplemental” or new, as opposed to “supplanting” funding for services that already exists.
Many of the issues that exist at nonprofits are also relevant for KCRHA, which will have to train its system advocates—case managers with personal experience of homelessness who navigate Partnership for Zero clients into services and housing—to do all the things nonprofit service providers have identified as major challenges.
Earlier this year, KCRHA’s then-CEO Marc Dones told the agency’s implementation board that securing funds through FCS should be relatively simple, and expressed confidence that Partnership for Zero, which has fallen significantly behind schedule, would be at least 85 percent Medicaid-funded by next year. In fact, Dones called the agency’s 85 percent prediction “conservative,” adding that “if we are able to exceed that, then we will close the budget gap just on Medicaid reimbursement.” KCRHA baked this optimism into its 2024 budget, which assumes that Medicaid, through FCS, will provide about $5 million for Partnership for Zero, with KCRHA making up an estimated $900,000 gap.
Dones resigned earlier this year. The city of Seattle is currently paying them $250 an hour to come up with recommendations for using Medicaid funds “to maximize the region’s resources available to address homelessness”—a portfolio that seems quite similar to the the work CSH is doing for KCRHA.
Back in April, Dones said the KCRHA was about to start billing some services to Medicaid in a series of experimental “dry runs” that will “give us ample time to correct anything that is going wrong” before transitioning Partnership for Zero into a mostly Medicaid-funded program next year. Those dry runs haven’t happened, and the reasons for the delay remain somewhat opaque.
According to Thiele, CSH was supposed to move into Phase 2 of their “engagement” with KCRHA as soon as they finished the initial report earlier this year: The “dry run, and convenings across King County.” But, she said, “we’ve been waiting on our contract with them for some time. … They did recently give us a small contract to get started, but we were seeing this as probably a good 18 months of process work” before Medicaid billing can start in earnest. “It’s in motion, but I just can’t tell how far we’ll get with it.”
KCRHA spokeswoman Anne Martens said the agency is “on track for a ‘dry run’ this fall. … My guess is that there will be some kinks to work out, and we’ll have to adjust and evaluate as we go.” Later, Martens clarified that the “dry run… is still expected to happen before the end of the year. So we’re still in the process of setting up the system, policies, tech configurations, and trainings required to test how Medicaid billing would work in practice.”
Partnership for Zero is funded by corporate and philanthropic donors through the nonprofit We Are In, which is also paying for the contract between the KCRHA and Corporation for Supportive Housing.
Had Partnership for Zero achieved its original targets, every person living unsheltered in downtown Seattle would now be housed, and the KCRHA would be working to rapidly house each new person who arrived in the downtown area as part of the final, “hold steady” phase of the project. After this phase, KCRHA planned to expand the Partnership for Zero effort into other parts of Seattle and other regions of King County.
Since launching, the downtown effort has encountered many challenges, including a reluctance among private landlords to rent to people in the program. One issue that arose early on, according to a January 2023 memo from Dones to We Are In director Felicia Salcedo, is that landlords wanted assurances that formerly homeless tenants would be able to pay fair market rent after the first 12 months, when their Partnership for Zero rent subsidy runs out.
In February, We Are In announced another million dollars in funding for the program, but the future of the overall program remains unclear. We Are In declined to comment for this story.
Well much of the blame for this quagmire can easily be tagged on Dog Shit Horse Shit (DSHS…) which created a Byzantine methodology of accounting but not a means of getting it done, leaving each agency to fend for itself and create their own compliance structure. The Washington State Health Care Authority (HCA), Division of Behavioral Health (DBH,) another of the many tentacles of DSHS, and the division that is in charge of Foundational Community Supports acts just like any other DSHS division, building hard to manage systems and causing agencies to spend an ungodly amount of time and staffing trying to figure compliance shit out.
Some agencies, like Health Care-based agencies that provide a myriad of services and multiple programs that bill Medicaid for services already, have a database with the required fields for Medicaid billing already built in, take little training to master and accounting staff can pull reports all ready to submit to DSHS.
But a vast chunk of the agencies providing these homeless services don’t have any such database, I presume inclusive of KCRHA; theyt must try and navigate a way to building their own database to do this work. So whose fault is this? I place the blame on DSHS who have been pulling this same bullshit with other programs they create without providing the tools to make it efficient. They’ve known this is a systemic issue but they are fucking clueless; a thrashing Kraken with tentacles swinging everywhere and getting nothing done.
Dog Shit Horse Shit – remember that…
Medicaid is the lifeblood for funding public non-profit social services. However, meeting the federal administrative requirements is no small task. I have been watching since the inception of KCHRA if it was going to make the move to billing Medicaid for case management services directly or if they would subcontract with community health providers already approved to bill Medicaid.
Medicaid is means tested & there is also US citizenship/ resident alien requirement. The vast majority of the visibly homeless population would qualify. This is definitely a target population. Not only would accessing Medicaid open funding streams, and services it would also help create some order and structure for a client base who are subject to daily, hourly uncertainty and chaos.
I can picture a case management model, of one stop shopping for housing, medical, mental health, drug treatment, and support services…all billed to Medicaid.
The idea of a county regional housing authority was & still a great idea. Its function needs to be administrative, setting policy, building resources, meeting with stakeholders, contracting with direct service providers, being the resource direct service providers reach out to, but definitely not being a direct service provider.
Thank you,
Bill
You do know the “Upper Volta” comment in the article was trolling people who agree with that statement, yes? It was mocking, and you are owning yourself when you take it seriously.
Just letting you know.
If your comment is directed to me, no, I didn’t see the Upper Volta comment as trolling people who agreed with that statement. In fact, I thought it meant to call out the absurdity of all the PC mines we must now avoid. I’m in favor of diversity and inclusion and agree that too many have been sidelined for far too long for immutable characteristics that they shouldn’t change even if they wanted to. I thought it was a pretty funny counter to what I consider the overly prim seriousness with which many of our social justice warriors are so enamored. I don’t care if I’m right or wrong, really, but in case you were curious, that’s what amused me. And whatever you mean by “owning” myself, I could not care less-what you think of me is none of my business.
Same as always. “What’s your objective function?”
Is it to maximize funding and support to get the homeless of the streets, moving as many back to self-sufficiency that are capable of it and the rest to permanent shelter? Or other side issues?
For example, do we want the most efficient system, or one that transfers funds to let less efficient smaller operations keep up? Is the priority homeless ops or maximizing BIPOC/other smaller groups (who’s acted to ensure there are left handed trans immigrants from Upper Volta included in leadership roles!!!!???). Is the objective function to bring as many folks to self-sufficiency as possible, or is that discriminatory to the people who don’t see sobriety and normal life function to be in their definition of success? (that’s an actual activist quote seen on this very site)
Until we decide what the actual objective function is so we can maximize our efforts to match, we will continue to piss away half the funding on side issues and grifters.
So much YES to this comment! You said it so well. And you identified the overarching issue for all of our society while you were at it: How does success, finishing, arrival, whatever word stands for the project is done–how does that look? A detailed answer would serve to help people visualize a goal and that would help them figure out how to get there. For example, what does the world that Trump and his ilk strive for look like? Neo feudalism? No one seems to be asking or telling. Here at home, as you point out, is success contingent on “maximizing BIPOC/other smaller groups (who’s acted to ensure there are left handed trans immigrants from Upper Volta included in leadership roles…” Speak it! Well said. If such is a goal, let’s hear that. If not, let’s hear what is.
“Back in April, Dones said the KCRHA was about to start billing some services to Medicaid in a series of experimental “dry runs” that will “give us ample time to correct anything that is going wrong” before transitioning Partnership for Zero into a mostly Medicaid-funded program next year. Those dry runs haven’t happened, and the reasons for the delay remain somewhat opaque.”
Hmmm. The reasons for the delay remain somewhat opaque, do they? Why are these folks not accountable to anyone–whoever’s funding them–for explaining exactly and in detail the reasons for the delay? Could it be that they’re not accountable and all involved in any way want to hide that from the public? Smells like that to me.
And I love the part about “But establishing clients’ eligibility for the program and securing payment for ongoing services has been a daunting and sometimes money-losing challenge for service providers, who often have to hire specialized administrative staff and train case managers to meticulously document encounters with clients. In conversations with PubliCola earlier this year, providers explained how challenging it can be to translate notes by front-line case managers into billable Medicaid hours; a case worker who isn’t fully trained and dogged in their efforts to enroll clients and “constantly generate [billable] service contacts” can cost an agency significantly more than they bring in, one provider said.”
How challenging it is to “meticulously document encounters with clients.” Why aren’t they already doing that? Because no accountability is required of them so far. And talking about who is doing this work–the people from LEC have already proved they can’t manage their own lives, they can’t manage the responsibilities that were the excuse for just shoveling money to them.
Wouldn’t Medicaid provide trainers who could train local trainers? Wouldn’t Medicaid define what is supplemental and what is supplantive? It appears no one is even asking these questions, let alone pursuing solutions. More of the same sad blah, blah, blah, and meanwhile apparently there is funding going begging while we pay Dones $250K to pretend like he’s doing something now after he resigned, probably because his unfitness became impossible to further ignore or hide from us.
Yeesh!