In comparison to group membership in the overall population of chronically homeless people, group membership of tenants in PSH appears to be somewhat skewed toward those in Group 3, although the skew may not be very large in some jurisdictions.
A 2008 survey of all PSH programs in the District of Columbia (DC) found that 79 percent of tenants had SMI (Burt and Hall, 2009), while similar surveys of three states and three counties in 2007 found that 60 percent of PSH residents had SMI (Burt, 2008a).5 A separate survey of Ohio PSH indicated that more than 90 percent of PSH tenants had a mental illness, and most also had a co-occurring substance abuse problem. Data from PSH programs reporting through Homeless Management Information Systems to the 2010 Annual Homeless Assessment Report to Congress, however, show a substantially lower prevalence of mental illness among PSH residents --43 percent (HUD, 2011). Variations reflect, among other factors, the policies of different jurisdictions in the commitment of their public mental health systems to helping people eligible for their services to move into PSH.
|EXHIBIT 1. Differentiating Access to Medicaid-Reimbursed Health Care Among Three Groups of People*|
|Criteria||Met?||Implications for Group Membership and Scope of Health and Behavioral Health Services Likely Covered by Medicaid|
|Q 1. Income low enough to meet requirements?||No||Not eligible for Medicaid. In some cases people may become eligible for Medicaid services if they meet other eligibility criteria and spend down some of their income by paying a share of costs for Medicaid-covered services.|
|Yes ask Q2||In 2011, the median income cutoff for Medicaid across the 50 states and DC was 64% of the federal poverty level (Heberlein, Brooks, and Guyer, 2011). In 2014, the ACA will make all people with incomes at or below 133% of poverty eligible on the basis of income. This will include virtually all homeless people. Medicaid coverage for these newly eligible people may be offered through benchmark benefit packages that offer at least essential benefits. Services covered by benchmark benefit packages are usually more limited than regular Medicaid as to type and intensity/frequency. Some services needed by chronically homeless people, particularly services delivered outside of doctors offices, clinics, or hospitals, may not be covered.|
|Q2. Meet requirements for Medicaid eligibility on basis of disability or other categorical eligibility criteria?||No||GROUP 1 Not Eligible for Medicaid in most states, where Medicaid is available to single adults only if they are in a group with categorical eligibility (e.g., disabled or elderly, or pregnant). Exceptions include Medicaid eligibility now in states that decided to implement ACA eligibility provisions more quickly or have waivers to serve people who are not categorically eligible.|
|Yes ask Q3||Medicaid-eligible. Usually people meet this requirement by establishing eligibility for SSI, which also provides an income source. Otherwise they must meet the same disability criteria as for SSI, but assessment is by a Medicaid eligibility office, not the SSA; it usually takes less time and is not as difficult, but does not include any cash benefit.|
|Q3. Meet requirements for specialized mental health services, as established by the medical necessity criteria specified in a states Medicaid Plan for these services.||No||GROUP 2 Qualify for Medicaid, but not for specialized mental health services. Medicaid service coverage for people in this group, who have categorical eligibility, is more comprehensive than the benchmark benefits or essential benefits that will become available to Group 1 in 2014 and are available to some people in some states now. However, Group 2 people are unlikely to be eligible for extensive behavioral health services or care coordination for people with multiple health needs.|
|Yes||GROUP 3 Qualify for Medicaid, and for specialized mental health services. Medicaid-eligible, and also qualify for specialized mental health services plus the same full Medicaid benefits available to those in Group 2. Many state Medicaid programs have authorized rehabilitation services for eligible clients, whether homeless or not, that come closest to meeting the needs of chronically homeless people and formerly homeless people residing in PSH. State and county mental health agencies often target as their clients the population eligible for these specialized mental health services. The services can and often do cover intensive and extensive treatment and supportive services to stabilize symptoms and help clients recover/move toward stable community residence. Persons in this group will most likely have SSI or Social Security Disability Insurance already, but if not, providers will be able to help them get it.|
|* These categories apply to any adults seeking Medicaid eligibility, including the chronically homeless people on whom this study focuses.|