Homeless people have two compelling reasons to seek enrollment in Supplemental Security Income (SSI): (1) obtaining a reliable income source that will help them afford housing; and (2) increasing their access to appropriate health care through "categorical" eligibility for Medicaid for people who participate in SSI.1 Housing and health care providers also have a compelling reason to encourage their homeless and formerly homeless clients enrollment in SSI and Medicaid: the resources from those programs can help cover the costs that providers incur for the care they offer homeless and formerly homeless people.
Most homeless people have little or no income; many have health problems, but few have a regular source of medical care. There may be several reasons for this lack of regular medical care, but one is surely that they have no health insurance. Homelessness also complicates their ability to get medical care because their whereabouts and schedule are not predictable.
When chronically homeless people first meet health care providers, they usually have more than one serious health condition. Commonly they wait until a health condition is extremely serious and then seek care at emergency rooms, which can do little but respond to the immediate crisis. Often the person has:
No insurance or money, so no way for the provider to get reimbursed for health care.
No housing and no way to pay for housing--so no way to follow health regimens, get aftercare, or move toward recovery from the illness or to manage the condition.
No way to retain housing even if it is offered, unless the person gets other services.
If formerly homeless people are covered by insurance, they get better care. The public agencies that provide the health, behavioral health, and other supportive services that help keep formerly homeless people in housing also have a much easier time remaining fiscally solvent if their clients are covered by insurance that can reimburse them for much of the care that clients need.
Income from SSI helps formerly homeless people pay rent and have some money for living expenses, although those who receive SSI benefits have incomes well below the federal poverty level. Most permanent supportive housing (PSH) for formerly homeless people offer deep rent subsidies, but many rely on the tenant to pay some rent. SSI gives tenants the resources to pay their shares, with the rest of the rent usually covered by a subsidy such as a Housing Choice Voucher, project-based Section 8, or a Shelter Plus Care subsidy or by grant resources through the U.S. Department of Housing and Urban Developments Supportive Housing Program. Without income from SSI, many homeless people cannot afford to live in a community and be stably housed.
In 1996, the last time that national data were available, only 11 percent of all homeless people reported income from SSI, and only 8 percent from Social Security Disability Insurance (SSDI) benefits (Burt et al., 1999).2
In 2014, virtually all homeless and formerly homeless people will become eligible for Medicaid, but SSI will remain as important for chronically homeless people in the future as it is now. This is because the new Medicaid coverage for homeless and formerly homeless people will likely be for a relatively limited package known as benchmark or essential services. This service package is likely to contain more restrictions than full Medicaid and thus be less likely to cover the array of services that many formerly homeless people need. SSI eligibility, in contrast, renders beneficiaries categorically eligible for full Medicaid now and will still do so after 2014. In addition, many formerly homeless people will continue to need SSI income to help them pay for housing and other expenses.
Unfortunately it is not easy to establish eligibility for SSI. SSI eligibility is limited to those below certain income levels who are 65 or older, blind, or disabled. The Social Security Administration (SSA), which administers SSI, follows a five-step procedure to determine disability:3
Step 1: Is the person working? If the person is working and earns more than $1,010 a month in 2012, she or he wont be eligible.
Step 2: Is the persons condition severe? The condition for which the person is claiming disability must interfere with basic work-related activities.
Step 3: Is the condition found on the list of medical conditions? These are conditions that SSA considers so severe that they automatically mean that the person is disabled and thus eligible for SSI. If the conditions are not on the list, SSA must determine whether their severity is equal to that of conditions that are on the list. This is the situation many homeless people face. If the condition is judged to be as severe as a list condition, the person is eligible. If it is severe, but not as severe as a list condition, then the process goes to Steps 4 and 5.
Step 4: Can the person do the work he or she did previously?
Step 5: Can the person do any type of work? The answers to Steps 4 and 5 must be no for a finding of disability to be established.
Establishing eligibility on the basis of age or blindness is comparatively easy. Likewise, some medical conditions do not require any assessment of function, as long as testing and laboratory results adequately establish the condition. These conditions include pancreatic cancer and most other cancer listings, respiratory impairments, some cardiac impairments, and digestive system impairments. But a functional assessment is often required for medical conditions common among homeless people, including musculoskeletal, neurological, and mental impairments. For these conditions, proving a level of functional impairment sufficient to qualify as disabled in SSA terms often is not at all easy.
When talking to people in the field who have the responsibility to help homeless people qualify for SSI, one usually hears that the disability determination process takes many months and more often than not ends in failure, at least for the first application. The success rate on first application for all applicants, homeless or not, was 31 percent in 2010, and appeals are currently taking an average of about a year to complete.4 The rate is lower for homeless people, with only 10-15 percent succeeding on first application if they apply on their own without help from case workers or advocates (Dennis et al. 2011).
Challenges facing SSI applicants include completing the entire application, getting access to existing documents, inadequacy of existing documentation, and the fact that some diagnoses are harder to document than others. Documenting disability when substance abuse might be a contributing factor is especially difficult.
Nor do the challenges stop for homeless people once they become SSI beneficiaries. Troubled as they often are by mental illnesses and other disabling conditions, coupled with uncertain location and related unreliability of getting mail, homeless people often miss notices to present themselves for continuing disability review procedures and end up dropped from the rolls.
SSI is suspended when a person enters an institution such as a state hospital, jail, or prison for a full calendar month; if the stay lasts more than 12 consecutive months, SSI benefits are terminated and the individual must reapply. SSI recipients who are temporarily in institutions for medical care may continue to receive their benefits during the first three full months to maintain the home or living arrangement to which they would return. A physician must certify to SSA via letter that the recipient will be medically confined for 90 consecutive days or fewer. However, if an SSI recipient is in a hospital, skilled nursing facility, intermediate care facility, or nursing home and Medicaid is paying more than 50 percent of the cost of services provided to the individual, the maximum federal payment to the individual is reduced to $30 a month.
Excellent guides and technical assistance materials already exist to help professionals working with homeless people develop successful SSI applications. Two primary sources of this information are the National Health Care for the Homeless Council (NHCHC) (http://www.nhchc.org) and Substance Abuse and Mental Health Services Administrations (SAMHSAs) SSI/SSDI Outreach, Access, and Recovery (SOAR) Technical Assistance Center website (http://www.prainc.com/SOAR). Rather than duplicating such information, this brief introduces the issues related to establishing SSI eligibility for homeless people, summarizes relevant material from the NHCHC and SOAR websites, and describes findings from site visits completed for this project to the Boston, Chicago, and San Francisco Bay areas, and from ancillary contacts in Los Angeles and Maine.
We look at the challenges related to establishing eligibility one at a time, then review some of the approaches being used to help homeless people apply successfully. These approaches work for initial applications, appeals and reinstatement of benefits, so we do not discuss reinstatement separately.