Federal Services Funding Streams | ACL Administration for Community Living

This table provides an overview of federal health, disability, and aging programs that could be leveraged to help fund service coordination. Programs like Supportive Services for Veteran Families (SSVF) can be helpful because the services can continue beyond the immediate crisis based on need and eligibility. When selecting funding sources to use, partners must consider the requirements and restrictions for each source. For example, states may coordinate and align Medicaid funding with other programs.

The funding streams listed use a variety of terms related to service coordination, such as care coordination, care management, case management, and person-centered counseling. To learn more about these terms, please see the Appendix.

Federal Funding Streams for Community and Health Services

Funding Stream	Basic Criteria	Funding Requirements	May Pay for Service Coordination	Supports and Services It May Cover
Certified Community Behavioral Health Clinics (CCBHCs)	Individuals across the lifespan with or at risk for mental health and/or substance use disorders (SUDs)	Individual-based	Yes	Directly or through formal partnerships: crisis services, outpatient mental health and substance use services, person and family-centered treatment planning, community-based mental healthcare for veterans, peer family support and counselor services, targeted care management, outpatient primary care screening and monitoring, psychiatric rehabilitation services, screening, diagnosis, and risk assessment Care coordination services, especially for those with complex needs
Community Mental Health Services Block Grant (MHBG)	Adults with serious mental illness; children with serious emotional disturbances	Individual-based	Yes	Treatment and recovery support services, including service coordination, case management, and counseling activities
Community Services Block Grant (CSBG)	CSBG awards funds to states, territories, and tribes and makes subawards to local historic agencies for community-based services. Children and adults with low incomes apply for help via entities in their community	State-based statutory formulas for grant allocations to local entities	Yes	Services and activities that aim to alleviate the causes and conditions of poverty via local organizations. Examples include job training; summer youth education; adult education; and emergency support, including utility assistance, housing, healthcare, transportation, and food aid. Specific service needs identified via area assessment through public input.
State Medicaid Programs	All populations that meet financial, and sometimes clinical, eligibility requirements	Individual-based	Yes	Transition coordinators Targeted case management Housing-related case management Enhanced case management or care coordination Outreach, education, application assistance, and benefits counseling (Services can vary by state, depending on CMS waiver authorities and approval.)
Medicaid Administrative Claiming (MAC)	All populations that meet financial, and sometimes clinical, eligibility requirements	Individual-based, billed by the single state Medicaid agency	Yes	Outreach and education Benefits counseling Application assistance Activities that support service coordination
[Medicaid] Money Follows the Person (MFP)	Individuals transitioning from institutional setting to the community who meet state nursing facility level of care and financial eligibility criteria	Individual-based	Yes	Transition supports, including but not limited to person-centered counseling, pre-tenancy supports, housing navigation, and tenancy sustaining service Rental deposits, pest control, furniture/personal belongings, employment, and community supports
Medicare	Age 65 and older or under age 65 deemed unable to work with a disability or end-stage renal disease	Individual-based	Yes	Medicare Physician Fee Schedule (traditional Medicare fee-for-service) codes for community health integration (CHI) and principal illness navigation services (PIN) under Medicare Part B for beneficiaries who screen positive for whole-person health needs or have a serious condition. Services include a person-centered assessment, care coordination, health education, self-advocacy training, health system navigation, and social and emotional support. (See also frequently asked questions about CHI and PIN.) Social and emotional support and other services to enable holistic, person-centered care. Organizations authorized to bill Medicare can arrange to have these services provided under contract by outside personnel employed by community-based organizations. Additional information on other Medicare coverage of services and supports delivered in home and community-based settings is available. Examples include advanced primary care management, chronic care management, transitional care management, and principal care management. Other Medicare flexibilities that can potentially support service coordination and other whole-person health needs, when available as part of a local Medicare health plan or Accountable Care Organization (ACO) and depending on eligibility criteria, include: Medicare Advantage supplemental benefits Medicare Advantage Special Supplemental Benefits for the Chronically Ill Medicare ACO model or other value-based payment model flexibilities around spending of earned shared savings bonuses or budget surpluses
Older Americans Act (OAA)	Individuals aged 60 and over	Population formula-based targeted to those with the greatest economic and social need	Yes	Person-centered counseling Information and assistance Home-delivered and congregate meals, caregiver supports, and chronic disease self-management programs, including falls prevention; may include home modifications
Projects for Assistance in Transition from Homelessness (PATH)	Adults with serious mental illness experiencing homelessness or at risk of becoming homeless	Individual-based	Yes	Outreach and engagement, case management, referrals for job training, educational services, housing services, and other supportive services Screening and diagnostic treatment, habilitation and rehabilitation services, community mental health services, and substance use disorders treatment Housing services per Section 522(b)(10) of the Public Health Services Act include minor renovations, moving assistance, security deposits, and one-time rental payments
Rehabilitation Act	Individuals of all ages with disabilities	Individual-based	Yes	Information and referral Transition services that facilitate transition from nursing homes and other institutions to the community and provide assistance to those at risk of entering institutions Services that facilitate youth transitions to postsecondary life Peer supports, home modifications, skills training, employment supports, and advocacy
Social Services Block Grant (SSBG)	Eligibility requirements vary by state.	Statutory formula	Yes	Services that aid economic self-sufficiency, prevention or remedy of neglect, abuse, or exploitation, adult independence support, and referral Social services designed for children, adults, older adults, and individuals with disabilities. Examples include child and adult protection services; case management; foster care; housing; transit assistance; congregate and delivered meals; services for persons with disabilities; and health supports such as substance use treatment and counseling, coordination, and referral.
State Opioid Response (SOR) Grants	Individuals who are at risk for or have an opioid use disorder, who are at risk of mortality from opioid overdose, or who are at risk for or have a stimulant use disorder	Individual-based	Yes	Prevention, treatment, and recovery support services, including service coordination, case management, and counseling activities
Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG)	Individuals in need of substance use prevention, treatment, and recovery support services	Individual-based	Yes	Support for sufficient case management and transportation — for pregnant women in substance use disorder (SUD) treatment and women with dependent children in SUD treatment — to ensure that these women and their children have access to primary medical care, referrals to prenatal care, childcare, primary pediatric care, SUD treatment, and other therapeutic interventions (for both women and their children) to address a variety of needs Prevention, treatment, and recovery support services
Supportive Services for Veteran Families (SSVF)	Veterans who meet income and other program requirements	Individual-based	Yes	Case management and other supportive services that prevent imminent loss of a home or housing; help with identifying more suitable housing; or immediate supports to quickly re-house homeless veterans and their families.
Veteran Directed Care (VDC)	Veterans of all ages and with all types of disabilities who are enrolled in the Veterans Affairs healthcare system or who do not require enrollment under 38 CFR 17.37 and who are in need of nursing home care	Individual-based	Yes	Person-centered counseling Home and community-based services managed by the veteran who uses their own monthly budget to directly hire workers and/or purchase goods and services to meet their needs in their home and community

Braiding: Financial Management Considerations

When considering a braiding strategy, start by reviewing available guidelines and statutory authorities for each potential funding source. Organizations will want to have systems that ensure ongoing compliance with financial management and outcome reporting standards defined by any given funder. Cost-allocation methods include:

Ensuring that there is no duplicate funding of service costs
Tracking revenues and expenditures by each funding source
Charging each funding source for its fair share
Maintaining the supporting documentation for distinct activities and their outcomes