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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

22-548m Refer Members to Housing Transition Navigation Services

Date: 07/22/22

Find out how to help Medi-Cal members who need permanent housing support and other services

Housing Navigators first work to understand the unique needs of individuals experiencing homelessness or housing instability, which may include housing, food, healthcare, or safety. Thereafter, the Housing Navigator works in partnership with the individual to develop a tailored housing plan.

If you identify an individual of any age or family who may need help, this guide gives information about a program for Housing Transition Navigation services available to eligible Medi-Cal members. It includes eligibility requirements, how to refer members to these services and the role of the Housing Navigator.

How long can members expect help

The services offered can last as long as needed. The initial authorization is for 12 months. After the initial 12 months, extensions are allowed in 6-month increments based on medical necessity.

Members must meet criteria to be eligible

Certain criteria are used to decide Medi-Cal member eligibility for Housing Transition Navigation services. Some of the eligibility requirements are listed below and include members:

  • Prioritized for permanent supportive housing unit or rental subsidy through the local homeless Coordinated Entry System or similar system1; or
  • Meet the Housing and Urban Development (HUD) definition of homeless and who are receiving enhanced care management, or at risk of higher utilization2; or
  • At risk of homelessness due to major barriers to housing stability and meet at least one of the following:
    • Have one or more serious chronic conditions; or
    • Have a serious mental illness; or
    • At risk of institutionalization or overdose; or
    • Require residential services because of a substance use disorder (SUD); or
    • Have a serious emotional disturbance (children and adolescents); or
    • Receiving Enhanced Care Management; or
    •    Transition-Age Youth with significant barriers to housing stability.

Note: A member is excluded from qualifying if they are in a state funded program with the same types of services. Also, the services do not include room and board or rental payments.

Where to refer members for housing and other services

There are two resources to connect Medi-Cal members to housing and other supportive services such as financial assistance, food pantries, medical care, and other no-cost or reduced-cost help. Members referred to a community supports (CS) provider who offers housing transition navigation services will connect the member to a Housing Navigator.

  • Findhelp – Search for the CS program and/or no-cost or low-cost direct services to support members with social determinants of health (SDOH) needs. The platform makes it easy to use to refer members to CS providers and close the loop on referrals. Follow the steps below to begin a search.
  1. Go to Findhelp.
  2. Enter a ZIP Code and click Search.
  3. Choose a topic from the top, then select a subtopic. Services vary based on the ZIP Code.
  4. Select the CS provider or service that matches what the member needs.
  • Provider directory – If you identify a member who qualifies for CS, use the provider directory.
  1. Go to the CalAIM resource page.
  2. Find a CS provider who matches the support services the member needs.
  3. Contact the CS provider based on the directory information and give the member's information.

Role of the Housing Navigator

The Housing Navigator confirms eligibility, identifies the support services needed and develops an individual housing support plan with the member. There is no lifetime maximum for this support.

The services given by the Housing Navigator include:

  • Tenant screening and housing assessment.
  • Develop an individual housing support plan.
  • Search for housing and giving options.
  • Help complete housing applications and documentation needed (e.g., Social Security card, birth certificate, rental history).
  • Help with benefits including applying for Supplemental Security Income.
  • Identify and secure resources to help with rent subsidy and match them to the member.
  • Identify and secure resources to cover expenses (e.g., deposits, moving costs and other one-time expenses).
  • Assist with reasonable accommodation, if needed.
  • Educate and engage with landlords.
  • Ensure the living space is safe and move-in ready.
  • Communicate and advocate for the member with landlords.
  • Assist with arranging the details of the move.
  • Have procedures and contacts in place to retain housing, including a support crisis plan.
  • Line up non-emergency, nonmedical transportation to help members’ mobility prior to transition and on move-in day.
  • Identify and coordinate installing environmental modifications for necessary accessibility accommodations.

Housing Navigator reaches out to many resources

The Housing Navigator works with many types of providers and agencies to coordinate a successful individual plan.
They may include:

  • Vocational service agencies
  • County agencies
  • Social services agencies
  • Public hospital systems
  • Affordable housing providers
  • Life skills training and education providers
  • Supportive housing providers
  • Mental health or SUD treatment providers, including county behavioral health agencies
  • Federally qualified health centers and rural health clinics

Examples of potential coordination entities: County Health, Public Health, Substance Use, Mental Health, and Social Services Departments, County and City Housing Authorities, Continuums of Care and Coordinated Entry System, Sheriff’s Department and Probation Officers, local legal service programs, community-based organizations, housing providers, local housing agencies, and housing development agencies.

Additional information

Providers are encouraged to access the California Health & Wellness Plan (CHWP) provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.

1 Local homeless Coordinated Entry System uses information to identify highly vulnerable individuals with disabilities, one or more serious chronic conditions, serious mental illness or institutionalization, requiring residential services because of a substance use disorder (SUD) and/or exiting incarceration.

2 Definition of homeless as defined in Section 91.5 of Title 24 of the Code of Federal Regulations; risk of higher utilization means members who have one or more serious chronic conditions and/or serious mental illness and/or is at risk of institutionalization or requiring residential services due to (SUD).