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Updated Community Support Definitions – April 2025

Volume II – Community Supports to Members Experiencing or At Risk of Homelessness

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DHCS Updates

As of Spring 2025, 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: Service definitions for eight of 15 Community Supports that relate to health-related social needs

Include four refined definitions

Volume 2: Service definitions for seven of 15 Community Supports that relate to housing, inclusive of transitional rent
Effective July 1, 2025, DHCS is adding Transitional Rent as the 15th Community Supports service

This service will become mandatory for MCPs to offer on Jan. 1, 2026

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CalAIM | Community Supports

Indicates that MCP coverage is mandatory

Source: Community Supports Policy Guide

Housing Transition Navigation Services (HTNS)
Housing Deposits
Housing Tenancy and Sustaining Services (HTSS)
Day Habilitation Programs
Recuperative Care (Medical Respite)
Short-Term Post-Hospitalization Housing
Transitional Rent

Respite Services
Assisted Living Facility (ALF) Transitions
Community or Home Transition Services
Personal Care and Homemaker Services (PCHS)
Environmental Accessibility Adaptations (Home Modifications)
Medically-Tailored Meals (MTMs)/Medically-Supportive Food (MSF)
Sobering Centers
Asthma Remediation

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Orange highlights are optional for MCPs to coverage
CCHP offers 13 while all 4 SD MCPs offer the full suite

MCPs should contract with organizations that have experience delivering Community Supports services and an existing footprint in the communities they serve, working with the populations who are eligible to receive Community Supports. MCPs are encouraged to be creative in exploring new partnerships.

Community Supports are a set of 14 services provided by Medi-Cal managed care plans (MCPs) to address Medi-Cal members’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care.

Members may receive a Community Supports service if they meet the eligibility criteria, and if the MCP determines the Community Supports service is a medically appropriate and cost-effective alternative to services covered under the California Medicaid State Plan.

Link to updated definitions - https://www.dhcs.ca.gov/Documents/MCQMD/Community-Supports-February-2025-Service-Definition-Updates.pdf

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Additions to Policy Guide

Coordination between MCPs and County Behavioral Health agencies on housing initiatives

Increasing the role of county behavioral health agencies to address homelessness in the populations they serve
Effective July 1, 2026, county behavioral health agencies must spend 30% of BHSA funds on Housing Interventions for individuals with significant behavioral health needs who are experiencing or at risk of homelessness
Under California Welfare and Institutions Code section 5830(c)(2), BHSA funds "shall not be used for housing interventions covered by a Medi-Cal managed care plan"

Members cannot receive rental subsidies under BHSA so long as Transitional Rent is available
Counties may not fund services such as navigation, tenancy sustaining services, recuperative care, etc. to those who are eligible to receive those services as Community Supports through their MCP

Global cap on coverage for room and board services

Room and board services includes Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent

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Additions to Policy Guide

Global cap on coverage for Room and Board services

"Room and Board services" includes Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent
Coverage is limited to six months of Room and Board services per member within a rolling 12-month period

Rolling 12-month period begins from Member's first date of utilization of services, not from date of authorization
Transitional Rent – as a Roam and Board only intervention without additional clinical services – is capped at six months per household, per demonstration

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Additions to Policy Guide

Implementation principles for MCPs on Global Cap on coverage for Room and Board services

Room and Board Holds

A Member may leave a setting before the expiration of authorized Room and Board period. The MCP must count towards the global cap any Room and Board days the MCP is obligated to pay for under its agreement with the Community Supports provider

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 towards 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 for the days in which the Member is not residing in the setting

MCPs obligations if Member switches Plan elections

If a Member switches MCPs and the Member needs Room and Board services, the MCP must determine if the Member received Room and Board services from the previous MCP and for how long. Specifically:

Request information from prior MCP on Room and Board services and dates of coverage
Request information from Member on previous Room and Board service utilization in the prior 12-month period
Review prior utilization data if Member has previously been a Member of the new MCP
Ensure providers delivering Room and Board services provide information to MCPs about Room and Board service utilization, service providers, and dates of service

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Service	Limits Per Service	Limits Across the Services
Recuperative Care	Six-month limit per rolling 12-month period (per Member)	Six-month limit per rolling 12-month period (per Member) also applies across all three Room and Board services
Short-Term Post Hospitalization Housing	Six-month limit per rolling 12-month period (per Member)
Transitional Rent	Six-months of service per five-year demonstration (per household)

While 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 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 same 12-month rolling period.

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Additions to Policy Guide

Housing Support Plan

A Member's housing support plan sets forth a plan for achieving housing goals base on individual needs. A housing support plan will help ensure the time-limited Room and Board services will be provided in ways that best contribute to long-term housing stability.

DHCS requires MCPs to ensure a Member has a housing support plan in place as a condition for authorizing a Member for Transitional Rent. In many or most cases, the Member being referred to Transitional Rent/Housing Deposits has received or is receiving HTNS and has a housing support plan developed by the HTNS provider.

As of April 2025, DHCS is no longer requiring a Member to receive HTNS as a condition of receiving housing deposits

Content of housing support plan

Identify permanent housing strategy and solution, including payment sources and mechanisms, that will support Member once Room and Board services are exhausted
Identify full range of permanent housing supports that will support the Member in sustaining tenancy
Be informed by Member preferences and needs, and revised as needs change based on Member's circumstances
Be based on housing assessment that addresses identified barriers, measurable goals, approach to meeting goals, and identifies where other providers or services, both reimbursed and not reimbursed by Medi-Cal, may be required to meet goals
Be developed in a way that is culturally appropriate and trauma-informed

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Housing Transition Navigation Services (HTNS)

Definition

Housing Transition Navigation Services (HTNS) assist Members with finding, applying for, and obtaining housing. 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 HTNS activities.

Updates to:

Description/Overview
Activities
Eligibility
Licensing/Allowable Providers for Housing Deposits

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Housing Transition Navigation Services (HTNS)

Updated HTNS Activities include:

Conducting housing assessment that identifies Member's preferences and barriers related to successful tenancy
Developing a housing support plan based on housing assessment
Assisting in searching for housing and presenting options
Identifying and securing available resources to assist with attaining housing to assist with attaining housing and matching available resources to Members
Providing education to the Member about fair housing and anti-discrimination practices, including making requests for necessary reasonable accommodation if necessary

Updates to Licensing/Allowable Providers for HTNS include:

Public housing agencies are added as a type of providers MCPs may contract with

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Housing Transition Navigation Services (HTNS)

Updated HTNS Eligibility includes individuals who meet the following social AND clinical risk factor requirements:

Social Risk Factor Requirement- Experiencing or at risk of experiencing risk of homelessness
Clinical Risk Factor Requirement- Must have one or more of the following:

Meets the criteria for Medi-Cal Specialty Mental Health Services
Meets the access criteria for Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS)
One or more serious chronic physical health conditions
One or more physical, intellectual, or developmental disabilities
Individuals who are pregnant up to 12-months postpartum

OR

Individuals who are determined eligible for Transitional Rent

OR

Individuals who are prioritized for a permanent supportive housing unit or rental subsidy resource through the local homeless Coordinated Entry System

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Housing Deposits

Definition

Housing Deposits assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household. The services and goods 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 these services/goods.

Updates to:

Description/Overview
Eligibility
Restrictions/Limitations
Licensing/Allowable Providers for Housing Deposits

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Housing Deposits

Updated Activities include:

Security deposits required to obtain a lease on apartment/home
Services necessary for individual's health and safety such as pest eradication, one-time cleaning prior to occupancy, along with necessary minor repairs to meet HUD Housing Choice Voucher program quality
Applications fees to cover the cost of the lease application

Additional changes:

First and last month's rent are required by landlord is removed from service description
DHCS is not establishing a standardized timeframe for utility arrears payments

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Housing Deposits

Updated Housing Deposits eligibility includes individuals who meet the following social AND clinical risk factor requirements:

Social Risk Factor Requirement: experiencing or at risk of experiencing risk of homelessness
Clinical Risk Factor Requirement: must have one or more of the following

Meets the criteria for Medi-Cal Specialty Mental Health Services
Meets the access criteria for Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS)
One or more serious chronic physical health conditions
One or more physical, intellectual, or developmental disabilities
Individuals who are pregnant up to 12-months postpartum

OR

Individuals who are determined eligible for Transitional Rent

OR

Individuals who are prioritized for a permanent supportive housing unit or rental subsidy resource through the local homeless Coordinated Entry System

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Housing Deposits

Restrictions and Limitations

Services do not include the provision of Room and Board or payment of rental assistance
Housing Deposits are available once per demonstration period

Housing deposits can only be approved one additional time with documentation as to what conditions have changed to demonstrate why providing Housing Deposits would be more successful on the second attempt

DHCS is no longer requiring a Member to receive Community Support HTNS as a condition of receiving Housing Deposits

All Members who receive Housing Deposits are required to have a housing support plan

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Housing Tenancy and Sustaining Services (HTSS)

Definition

Housing Tenancy and Sustaining Services (HTSS) help a Member maintain safe and stable tenancy once housing is secured. The services provided to a Member must be based on an individualized assessment of needs and documented in the Member's housing support plan.

Updates to:

Description/Overview
Eligibility
Restrictions/Limitations
Licensing/Allowable Providers for Housing Deposits

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Housing Tenancy and Sustaining Services (HTSS)

Updated HTSS Activities include:

Providing education for the Member about Fair Housing and anti-discrimination practices, including making requests for necessary reasonable accommodation if necessary
Coaching on developing and maintaining key relationships with landlords/property managers and/or neighbors with a goal of fostering successful tenancy
Coordinating with the landlord and care/case management provider, which can be the Member's ECM Provider or non-Medi-Cal housing supportive services providers such as a COC program case manager, to address identified issues that could impact housing stability

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Housing Tenancy and Sustaining Services (HTSS)

Updated HTNS Eligibility includes individuals who meet the following social AND clinical risk factor requirements:

Social Risk Factor Requirement- Experiencing or at risk of experiencing risk of homelessness
Clinical Risk Factor Requirement- Must have one or more of the following:

Meets the criteria for Medi-Cal Specialty Mental Health Services
Meets the access criteria for Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS)
One or more serious chronic physical health conditions
One or more physical, intellectual, or developmental disabilities
Individuals who are pregnant up to 12-months postpartum

OR

Individuals who are determined eligible for Transitional Rent

OR

Individuals who are prioritized for a permanent supportive housing unit or rental subsidy resource through the local homeless Coordinated Entry System

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Housing Tenancy and Sustaining Services (HTSS)

Restrictions and Limitations

Services do not include the provision of Room and Board or payment of rental assistance
These services must be identified as reasonable and necessary in the Member's housing support plan. Service duration can be as long as necessary. There is no limit on how many times an eligible Member may be authorized for HTSS.

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Day Habilitation Programs

Definition

Day Habilitation Programs are designed to assist a Member in acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary to reside successfully in the person's natural environment. The service is provided in a Member's home or an out-of-home, non-facility settings. The services are often considered peer mentoring when provided by an unlicensed caregiver with the necessary training and supervision

Updates to:

Description/Overview
Activities
Eligibility
Delivery with Other Community Supports and ECM
Licensing/Allowable Providers for Housing Deposits

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Day Habilitation Programs

Updated Activities include:

Providing a referral to non-Community Supports housing resources if the Member does not meet the eligibility criteria for HTNS, Housing Deposits, HTSS, or Transitional Rent

Updated Eligibility includes:

Experiencing homelessness or exited homelessness and entered housing in the last 24 months or at risk of homelessness or institutionalization whose housing stability could be improved through participation in a Day Habilitation Program

Updates to Delivery with Other Community Supports and ECM:

While receiving Day Habilitation Program services, Members needing assistance with housing-related services and supports should be referred for the Housing Trio and may also be referred for Transitional Rent

Updates to Licensing/Allowable Providers for Day Habilitation include:

Community-based providers, including federally qualified health centers are added as a type of providers MCPs may contract with

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Recuperative Care (Medical Respite)

Definition

Recuperative Care, also referred to as medical respite care, is for individuals who are experiencing or at risk of homelessness and need a short-term residential setting in which to recover from an injury or illness (including a behavioral health condition). A stay in a Recuperative Care setting allows an individual to recover form an injury or illness while also obtaining access to primary care, behavioral health services, case management, and other supportive social services.

Updates to the overview include:

Limited or short-term assistance with Instrumental Activities of Daily Living (IADLs) and/or Activities of Daily Living (ADLs) are permitted to the extent of licensure

Updates to:

Description/Overview
Eligibility
Restrictions/Limitations
Delivery with Other Community Supports and ECM
Licensing/Allowable Providers for Recuperative Care

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Recuperative Care (Medical Respite)

Updated Activities include:

Providing a referral to non-Community Supports housing resources if the Member does not meet the eligibility criteria for HTNS, Housing Deposits, HTSS, or Transitional Rent

Updated Eligibility includes:

Members must meet both criteria of requiring recovery in order to heal form an injury or illness AND experiencing or at risk of homelessness

Updates to Restrictions and Limitations:

Recuperative Care cannot exceed a duration of 6 months per rolling 12-month period and is subject to 6-month global cap on Room and Board services
Facility operators and their employed staff providing Recuperative Care that are not licensed as Community Care Facilities may not directly assist Members with ADLs or IADL

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Recuperative Care (Medical Respite)

Updates to Delivery with Other Community Supports and ECM:

During a stay in a Recuperative Care setting, Members should be offered HTNS and may be referred for Transitional Rent. MCPs must ensure that members who meet the eligibility requirements for Recuperative Care are offered ECM.

Updates to Licensing/Allowable Providers for Day Habilitation include:

Peer respite settings are added as a type of providers MCPs may contract with

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Short-Term Post-Hospitalization Housing

Definition

Short-Term Post-Hospitalization Housing provides Members who are exiting an institution and experiencing or at risk of homelessness with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting the institution. This would include recuperative care facilities, inpatient hospitals, residential substance use disorder or mental health treatment facility, correctional facilities, or nursing facilities. Short-Term Post-Hospitalization Housing setting must provide Members with ongoing supports necessary for recuperation and recovery, receiving necessary medical/physical/psychiatric/substance use disorder care, receiving case management, and beginning to access other housing supports such as HTNS.

Updates to:

Eligibility
Restrictions/Limitations
Delivery with Other Community Supports and ECM
Licensing/Allowable Providers for Short-Term Post-Hospitalization Housing

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Short-Term Post-Hospitalization Housing

Updated Eligibility includes individuals who meet ALL the following criteria:

Exiting an institution, which includes recuperative care facilities, inpatient hospitals, residential substance use disorder or mental health treatment facility, correctional facility, or nursing facility

AND

Experiencing or at risk of experiencing risk of homelessness

AND

Meet one of the following criteria:

Are receiving ECM; have one or more serious chronic conditions; have serious mental illness; are at risk of institutionalization or requiring residential services as a result of a substance use disorder

AND

Have ongoing physical or behavioral health needs as determined by a qualified health professional that would otherwise require continued institutional care if not for receipt of Short-Term Post-Hospitalization Housing

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Short-Term Post-Hospitalization Housing

Updates to Restrictions and Limitations:

Short-Term Post-Hospitalization Housing cannot exceed a duration of six months per rolling 12-month period and is subject to six-month global cap on Room and Board services

Updates to Delivery with Other Community Supports and ECM:

During a stay in a Short-Term Post-Hospitalization Housing, Members should be offered HTNS and may be referred for Transitional Rent. MCPs must ensure that members who meet the eligibility requirements for Short-Term Post-Hospitalization Housing are offered ECM.

Updates to Licensing/Allowable Providers for Day Habilitation include:

Peer respite settings are added as a type of providers MCPs may contract with

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Transitional Rent

Transitional Rent provides up to six months of rental assistance in interim and permanent setting to Members who are experiencing homelessness or at risk of homelessness, have certain clinical risk factors, and have either recently undergone a critical life transition, or who meet other eligibility criteria.

The policies governing Transitional Rent are driven by three key objectives:

Ensure a connection to long-term housing supports, such as rental subsidies, for Members receiving Transitional rent to provide a pathway to housing stability and prevent a return to homelessness
Use the temporary housing stability afforded by Transitional Rent as an opportunity to help Members connect to needed health care services
Minimize administrative barriers so that Members experiencing or at risk of homelessness can readily access Transitional Rent

Under BH-CONNECT waiver, CMS refers to this service as Short-Term Rental Assistance. DHCS will continue to use the service name Transitional Rent.

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Transitional Rent

Members are eligible for Transitional Rent if they meet ALL the following criteria:

Clinical Risk Factor Requirement- Must have one or more of the following:

Meets the criteria for Medi-Cal Specialty Mental Health Services
Meets the access criteria for Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS)
One or more serious chronic physical health conditions
One or more physical, intellectual, or developmental disabilities
Individuals who are pregnant up to 12-months postpartum

Social Risk Factor Requirement- Experiencing or at risk of homelessness
One of the following requirements:

Transitioning Population: Transitioning out of an institutional or congregate residential setting, carceral setting, interim housing, recuperative care or short-term post-hospitalization housing, or foster care
Experiencing unsheltered homelessness
Eligible for Full-Service Partnership (FSP)

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Go-Live Date	Details
July 1, 2025	MCPs have the option to launch coverage of Transitional Rent MCPs electing to launch at this time may select one or more Transitional Rent-eligible POFs to cover, with DHCS approval MCPs electing to launch at this time will be required to continue to cover all POFs they elect to cover for the duration of the demonstration (through December 31, 2029)
Jan. 1, 2026	All MCPs are required to cover Transitional Rent for Members meeting the Behavioral Health POF within the overall population eligible for Transitional Rent In addition, MCPs may elect to cover one or more additional Transitional Rent-eligible POFs, with DHCS approval

DHCS has selected the Behavioral Health POF for initial mandatory go-live on Jan. 1, 2026 to align with the launch of the BHSA Housing Interventions on July 1, 2026.

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DHCS has selected the Behavioral Health POF for initial mandatory go-live on Jan. 1, 2026 to align with the launch of the BHSA Housing Interventions on July 1, 2026

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Transitional Rent

Transitional Rent may be used to cover the following expenses:

Rental assistance in allowable settings (permanent or interim settings)

Transitional Rent may not be used to cover eviction prevention at this time

Storage fees, amenity fees, and landlord-paid utilities that are charged as part of rent payment
Housing Deposits Community Support may be used for coverage of additional expenses not provided under Transitional Rent

A Transitional Rent Provider is distinct from an HTNS Provider based on the focus of their activities:

Transitional Rent Providers focus on engaging and paying landlords
HTNS Providers focus on helping the Member find and obtain housing

When the MCP authorizes a Member for Transitional Rent, the MCP must also authorize the Member for ECM, assign an ECM provider, and share all necessary information with the ECM provider to enable the ECM provider to begin conducting in-person outreach to the Member.

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