There is real capital and real operating revenue at the intersection of healthcare and senior housing — and there is a great deal of wishful thinking about it. This site separates the two, names the programs that exist today, and is honest about which ones have closed. If you are underwriting a senior housing deal against a healthcare revenue assumption, start here.
Almost every bad senior housing pro forma we see rests on one of these being misunderstood. They come straight from CMS and Medicare's own published guidance.
Each of these is real. None of them is a rent subsidy with the durability of a HAP contract, and knowing which are capital and which are operating revenue is the whole game.
Created by the Bipartisan Budget Act of 2018 and implemented through CMS guidance in 2019. This is the only place in the Medicare program where a dollar can reach a tenant's rent.
A Medicare Advantage plan may offer benefits to an enrollee who "has one or more comorbid and medically complex chronic conditions," is at high risk of hospitalization, and requires intensive care coordination. Permitted examples include structural modifications to the home, "general supports for living such as housing," and subsidies for rent or assisted living communities, along with utilities, food and non-medical transportation. The benefit must have a reasonable expectation of improving or maintaining the enrollee's health or function.
For the 2026 plan year, roughly 8% of individual Medicare Advantage plans and 72% of Special Needs Plans offer general supports for living. Those are the plans to talk to, and SNPs are where the concentration is.
New York's Health Equity Reform waiver amendment was approved 9 January 2024 and runs to 31 March 2027. Roughly $6.7 billion total, including up to $500 million for Social Care Networks and up to $3.17 billion for health-related social needs services.
Delivered through nine regional Social Care Networks. As of this year the program has screened over a million members, with 1,300-plus contracted providers across all 62 counties.
On 4 March 2025 CMS rescinded the 2023 and 2024 guidance under which these health-related social needs waivers were approved. Existing demonstrations continue to their scheduled expiration, but renewals of components that no longer align with current federal priorities are not expected. New York has requested a five-year extension to 2032. That is a request, not an approval. Do not underwrite past March 2027 on this.
A capitated program for people aged 55 and over who are certified as needing nursing-home level of care but can live safely in the community. Funded by pooled Medicare and Medicaid capitation. More than 90,000 participants across 33 states and the District of Columbia; average participant age is 76, and roughly 95% continue living at home.
The governing regulations at 42 CFR Part 460 require the PACE organization to furnish all Medicare-covered services, all state plan Medicaid services, and whatever else the interdisciplinary team deems necessary — primary care, nursing, social services, therapy, personal care, nutrition, recreation and meals. There is no room and board, housing or rent coverage anywhere in them.
A tenant and an anchor. PACE organizations need physical adult day center space, and co-locating one with affordable senior housing is a recognized and growing model. Your exposure is a commercial lease underwritten on the PACE organization's credit, plus the leasing and stabilization benefit of having a care provider in the building.
New York's Medicaid-funded assisted living model, for residents who are medically eligible for nursing facility placement but can be served in a less intensive setting. Medicaid pays the care component at roughly half the nursing home rate.
Medicaid buys the service package. The housing is paid separately — by the resident's own income plus the SSI congregate care supplement, with residents retaining only a small personal needs allowance. The ALP rate flows to the licensed operator, not to the housing owner.
Bed authority has loosened over the last decade: the requirement to decertify nursing home beds to create new ALP beds was eliminated, new beds are approved case by case on demonstrated need, and existing providers can apply for a limited number of additional beds through expedited review.
The most substantial operating subsidy available for supportive units in New York, and frequently misunderstood as capital. It is not — awardees must secure capital separately, generally within two years of award.
Round 10 (RFP MH253032) closed to applications on 9 September 2026, with conditional award notifications tentatively set for 3 November 2026. Rates are up to $34,000 per unit per year in the New York City metro area — the five boroughs plus Suffolk, Nassau, Westchester, Rockland and Putnam — and up to $31,000 in the rest of the state. Round 9, announced 9 December 2025, made 200 awards totalling $45.9 million and carried the cumulative program past 8,300 units.
Round 10 prohibits the scattered-site model outright. ESSHI funds may not support apartments leased from a private landlord in an existing complex. Housing must come from new construction, the adaptive reuse of non-residential space, or the repurposing of vacant residential units, in an integrated setting. A good deal of older guidance still describes scattered-site ESSHI — it no longer applies.
Eligible populations expressly include older adults who are disabled or frail. The award covers rental subsidy and occupancy costs together with staffing, health and behavioral health services, vocational support and crisis intervention.
Contracts run five years and are renewable subject to available state funding. Lenders and syndicators do underwrite ESSHI — but as a term-limited, appropriation-dependent contract, not as a hard rental subsidy. Size accordingly, and be careful with any published rate you find online: several widely-cited sources still show the older $25,000 figure.
This is the one that genuinely put Medicaid dollars into a capital stack, and it is the single most important thing on this page to get right.
New York's Medicaid Redesign Team housing capital program provided roughly $100,000 to $200,000 per unit as subordinate debt, in exchange for a long-term service commitment and Medicaid data submission so the state could track savings. It capitalized the flagship healthcare-to-housing projects of the last decade.
The broader MRT supportive housing effort — roughly $880 million committed since 2011 across rental subsidies, services and capital — continues in other forms, and several MRT-adjacent programs remain: Access to Home for Medicaid, Health Homes supportive housing, Olmstead supportive housing, rapid transition housing, and agency-specific rental subsidies through OMH, OASAS and OPWDD. Those are worth working through project by project. The capital window that made the marquee deals work is not one of them.
Home and community-based services waivers under section 1915(c) are the workhorse of Medicaid's housing-adjacent spending — most states operate at least one covering housing transition services, home modifications and moving expenses.
New York's Nursing Home Transition and Diversion and Traumatic Brain Injury waivers go further and operate a housing subsidy that does pay monthly rent. Read the funding source carefully before building anything on it. The state's own program manual says it "is not a Medicaid or state-only medical assistance service, nor is it an entitlement program," and that availability of initial and continued funding "is contingent upon annual appropriations."
The participant contributes a third of monthly income, the subsidy is pegged to HUD fair market rent, and it is payer of last resort. There is no mechanism to pledge or underwrite it.
Metro East 99th Street in East Harlem is the best-documented example of Medicaid money capitalizing housing — and the clearest illustration of where each dollar actually came from.
Completed in 2014 by SKA Marin in collaboration with NYC Health + Hospitals, on a site across from Metropolitan Hospital. Residents were referred from long-term care facilities, and an on-site adult day program was operated by the Carter Burden Center for the Aging. Fordham's Graduate School of Social Service evaluated outcomes; participants in remote health monitoring were reported to have had a 35% reduction in hospitalizations.
The Medicaid contribution was a $7.3 million second mortgage from the MRT capital program — real capital, subordinate, in the stack. It was not rent. Rent was covered by Section 8. The adult day program was funded separately by the state health department and a private foundation. Three different sources doing three different jobs, and the healthcare money did exactly one of them.
Two different engagements. Most projects need the second before the first is worth starting.
The healthcare programs above fund services and, occasionally, a subordinate piece. The senior mortgage is a conventional affordable housing execution — and for senior and care settings, the program you choose is determined by the licensure of the building, not by the age of the residents.
The correct FHA program for assisted living, memory care, skilled nursing and board and care. New construction and substantial rehabilitation under 232, acquisition and refinancing under 232/223(f).
The right programs for independent senior housing — age-restricted apartments without a licensed care component. 221(d)(4) for new construction and substantial rehab, 223(f) for acquisition and moderate rehab.
Tax credit equity remains the largest single source in most affordable senior deals. The 4% credit with tax-exempt bonds where volume cap allows, or a competitive 9% allocation.
HOME, CDBG, National Housing Trust Fund, state housing finance agency soft loans, county and municipal trust funds, and FHLB Affordable Housing Program awards sponsored through a member bank.
The only thing on this page that reliably pays rent for the long term. Existing HAP contracts, project-basing of vouchers by the local housing authority, and RAD conversions where public housing is involved.
For an existing insured property, surplus cash notes and approved secondary financing can bring capital in behind the first mortgage without touching a rate you would not want to give up.
Most of the value here is diagnostic. The healthcare-and-housing field is full of revenue assumptions that do not survive contact with the actual program rules, and finding that out during underwriting is expensive.
A straight assessment of every healthcare dollar in your pro forma: what program it comes from, whether it is capital or operating, who the actual payee is, how long the authority runs, and what happens at renewal.
Identifying and structuring the counterparty — a PACE organization, a licensed ALP operator, a Social Care Network contractor, a health system, a Medicare Advantage or Special Needs Plan.
Building the sources and uses around a senior deal — sizing the first mortgage, layering tax credit equity and public soft debt, and identifying which subordinate sources are genuinely open today.
ESSHI and comparable operating awards, state agency applications, and the supporting narrative connecting the health case to the housing case in terms the reviewer is scoring against.
Preparing the healthcare component so it survives third-party underwriting — because a lender who cannot trace a revenue line to a durable contract will simply strike it from the sizing.
A short, direct review of a project someone else has already structured, focused on where the healthcare assumptions are load-bearing and whether they can hold the weight.
Send the basics and we will come back with an honest read on which healthcare sources can actually attach to it, and what the financing path looks like.
Most useful on a first pass: where the project is, whether the building will be licensed for care, who your healthcare partner is if you have one, and what stage you are at.