The Winding Road to a Recovery Home

Without stable housing, recovery for substance use disorder is nearly impossible. "Recovery housing" (or more commonly referred to as a "sober home" or a "sober living residence") is a broad term that describes a safe, supportive, and substance-free living environment, particularly for individuals transitioning from a formal treatment program to independent living. Recovery homes may have rules, curfews, or encourage therapy, but they also allow residents substantial independence. Studies have confirmed that such communal housing has significant positive effects such as decreased substance use, reduced likelihood of return to use, lower rates of incarceration, increased employment, and improved family relationships.[1] However, insurance payers do not reimburse for a recovering behavioral health patient's stay in a recovery home because it is not considered medically necessary for treatment, essentially ignoring a vital component in the recovery process. While recovery housing remains a non-reimbursable service, increased attention is being given to the issue following recent legislation-the Consolidated Appropriations Act, 2023[2]-which requires that best practices for recovery housing be made publicly available and published on the Substance Abuse and Mental Health Services Administration's (SAMHSA's) website. The Act provides the industry with unified standards for recovery housing, and therefore, it is a significant step towards recovery housing becoming a reimbursable service by health care payers.

The need for recovery housing is not a new phenomenon; it has been recognized for more than a century. The first recovery homes appear to have originated in part through the Temperance Movement in the 1830s and were run by institutions such as the YMCA, YWCA, and the Salvation Army.[3] These homes were generally led by religious groups that believed in sobriety, and the residents were often required to participate in religious services.[4] Alcoholics Anonymous was started in the 1930s, and along with it, the creation of homes based on the "twelve-step program."[5] After World War II, housing prices increased and alcohol-related problems became more widespread. Later, in the second half of the 20th century, there were additional models of recovery homes, including Oxford Houses. These houses were financially independent and were premised on peer support and democratic leadership, i.e., not run by outside organizations.[6]

Regardless of the type of recovery home, they do not offer formal treatment services, and therefore, are unlicensed and operate with little oversight or regulation. However, three different organizations are promoting the concept of integrating recovery housing with medical treatment and issuing uniform standards for recovery housing: the National Alliance for Recovery Residences (NARR), SAMHSA, and the American Society of Addiction Medicine (ASAM).

NARR was founded in 2011; it is a nonprofit organization that seeks to improve access to quality recovery residences. After collaborating with major organizations and individuals involved in recovery housing, NARR established a national standard for recovery residences.[7] NARR has classified four levels of recovery residences that are differentiated by the intensiveness of the program and the level of care provided. Additionally, NARR provides a code of ethics and measurable quality standards for operating recovery housing because, fundamentally, the purpose of any recovery housing is to provide a substance-free environment that provides peer support for its residents. While NARR has great influence in the recovery housing community, it is a private, nonprofit organization and cannot require the implementation of its standards.

SAMHSA is an agency within the U.S. Department of Health and Human Services that is focused on behavioral health issues. Section 1232 of the Consolidated Appropriations Act, 2023, which is titled "Developing Guidelines for States to Promote the Availability of High-Quality Recovery Housing," required best practices be made publicly available and published on SAMHSA's website. Consequently, in September 2023, SAMHSA published guidance setting forth best practices for recovery housing. The best practices are intended to serve as guidance for states, governing bodies, providers, recovery house operators, and other stakeholders involved in the promotion of recovery from substance use disorders.[8] Interestingly, SAMHSA references NARR's four levels of supporting housing and duplicates the following table from NARR's website.[9]

In doing so, SAMHSA acknowledges the work of national organizations and essentially adopts NARR's levels of recovery housing. With this backdrop, SAMHSA provides 11 best practices as a guide when enacting policies and designing programs for recovery housing.[10]

The third organization advancing the notion that recovery housing should be a part of the recovery process is the ASAM, a professional medical society representing physicians, clinicians, and associated professionals in the field of addiction medicine.[11] The ASAM provides clinicians with a comprehensive set of standards for placement, continued service, and transfer of patients with addiction and co-occurring conditions.[12] The most recent addition of the ASAM, issued in December 2023, acknowledges the importance of recovery housing and provides best practices for sober living homes at every level of care. Similar to SAMHSA, ASAM relies upon NARR's standards for recommending housing, in addition to an outpatient level of care.[13] Notably, the Centers for Medicare & Medicaid Services (CMS) looks to the ASAM criteria guidance relating to reimbursement for addiction treatment services under Medicaid. Thus, ASAM's inclusion of recovery housing into its criteria may eventually lead Medicare and Medicaid to reimburse for recovery housing, and private payers generally follow thereafter.

Currently, for a person in recovery from a substance use disorder and without financial means, a recovery home may not be possible. However, the interplay between NARR, SAMHSA, and ASAM and the resulting alignment that recovery housing, with uniform standards, is integral to long-term recovery, leads to greater hope that recovery housing may one day be covered by insurers. Indeed, recovery homes create supportive environments that improve long-term outcomes, thereby making sense not only from a medical perspective but also a financial one.

This article is brought to you by AHLA's Behavioral Health Practice Group. AHLA's Behavioral Health Group thanks Jeffrey Lynne (Beighley Myrick Udell Lynne + Zeichman) for editing this article. Copyright 2024, American Health Law Association, Washington D.C., Reprint Permission Granted.

Reddy's Rule #5:
Note that recovery housing is often used interchangeably with the terms such as sober housing, transitional housing, or supportive housing. Each of these terms are nuanced, and each regulator will have a precise definition for the term it is using. If you are an individual or entity that provides recovery housing, it is important to consider the various terms for recovery housing and their distinctions, and to check federal, state and local rules regarding guidelines for operation and reimbursement.

Be well.

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[1] Substance Abuse and Mental Health Servs. Admin. (SAMHSA), Best Practices for Recovery Housing, https://store.samhsa.gov/sites/default/files/pep23-10-00-002.pdf (citing Jason, L. A., & Ferrari, J. R. (2010). Oxford House recovery homes: Characteristics and effectiveness. Psychological Services, 7(2), 92-102. https://doi.org/10.1037/a0017932; Jason, L. A., Olson, B. D., Ferrari, J. R., & Lo Sasso, A. T. (2006). Communal housing settings enhance substance abuse recovery. American Journal of Public Health, 96(10), 1727-1729), https://doi.org/10.2105/AJPH.2005.070839 (Jason et al., 2006; Jason & Ferrari, 2010; Polcin et al., 2010); Polcin, D. L., Korcha, R., Bond, J., & Galloway, G. (2010). What did we learn from our study on sober living houses and where do we go from here? Journal of Psychoactive Drugs, 42(4), 425-433, https://doi.org/10.1080/02791072.2010.10400705).
[2] Pub. L. No. 117-328.
[3] Stairway to Freedom, A Brief History of Sober Living Houses & Why They're Still Important (Feb. 2017), https://stairwaysoberliving.com/blog/history-of-sober-living-houses#:~:text=Polcin%20and%20Henderson%20explain%20that,to%20participate%20in%20religious%20services (hereinafter A Brief History of Sober Living Houses); see Douglas Polcin and Diane Henderson, A Clean and Sober Place to Live: Philosophy, Structure, and Purported Therapeutic Factors in Sober Living Houses, J. Psychoactive Drugs, 40(2): 153-159 (Jun. 2008), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556949/.
[4] Id.
[5] Polcin and Henderson, supra note 3 (citing Wittman FD, Biderman F, Hughes L. California Department of Alcohol and Drug Programs. ADP 92-00248. 1983. Sober living guidebook for alcohol and drug free housing), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556949/#R24.
[6] A Brief History of Sober Living Houses, supra note 3, https://stairwaysoberliving.com/blog/history-of-sober-living-houses#:~:text=Polcin%20and%20Henderson%20explain%20that,to%20participate%20in%20religious%20services; see Polcin and Henderson, supra note 3 (citing Kaskutas LA. The Social Model Approach to Substance Abuse Recovery: A Program of Research and Evaluation. Rockville, MD: Center for Substance Abuse Treatment; 199.).
[7] NARR, Standards and Certification Program, https://narronline.org/affiliate-services/standards-and-certification-program/; NARR Standard 3.0, https://narronline.org/wp-content/uploads/2018/11/NARR_Standard_V.3.0_release_11-2018.pdf.
[8] Best Practices for Recovery Housing, supra note 1.
[9] Id.
[10] Id.
[11] ASAM, Crucial changes to substance use, co-occurring disorder care standards published (Oct. 5, 2023), https://www.asam.org/news/detail/2023/10/05/crucial-changes-to-substance-use--co-occurring-disorder-care-standards-published.
[12] ASAM CRITERIAr (4th Edition), https://www.asam.org/asam-criteria.
[13] ASAM, supra note 11.