Many PSH tenants who are Medicaid recipients will have qualified because the SSA has determined them to be disabled enough to qualify for SSI, and being an SSI recipient makes them categorically eligible for Medicaid. In some states, chronically homeless people will have qualified for Medicaid and fall into Group 2 because their state offers Medicaid coverage under a waiver to people who are not categorically eligible, or because their state has chosen to implement the income requirements of the ACA before 2014 (when all states are required to do so).
Medicaid waivers offer states substantial flexibility in determining the people they will cover, within categories and for reasons acceptable to HHSs Center for Medicare and Medicaid Services. For example, both Massachusetts and Maine have Medicaid waivers under which they cover substantial numbers of currently and formerly chronically homeless people. The array of services available to some people who are enrolled waivers may be more limited than the full array of Medicaid services available to people enrolled under other eligibility criteria. Early implementers of the ACA such as DC, Connecticut, and Minnesota have also begun to extend coverage.
Many chronically homeless people have significant physical disabilities or disabling medical conditions. They do not, however, have a psychosis or major affective disorder and thus will usually not be eligible for specialized mental or behavioral health services. This means that public mental health systems will not be centrally involved in ending their homelessness. Many people in Group 2 do have cognitive impairments, serious and long-term substance use disorders, histories of trauma, and less severe mental health problems as well as physical health conditions. Medicaid costs can be very high for some homeless people in this group who receive care in hospitals, emergency rooms, detox facilities, and other settings for health crises that could be avoided if people received more appropriate and effective care and support.
When outreach and service-providers first encounter people who qualify for Group 2, they usually are not Medicaid recipients. However, with increasing contact and interactions, providers may determine that the people they are working with have chronic illnesses and disabling conditions that are enough to qualify them for SSI and, therefore, Medicaid. This happens most frequently with providers who are among the growing number that have worked closely with local SSA and state Disability Determination Services offices to improve their approach to applying for SSI (see Burt and Wilkins, 2011). In addition, some people in Group 2 have reached the age of 65 and thus qualify for Medicare and, if poor enough, also for Medicaid, regardless of their level of disability. Eligibility for Medicaid distinguishes people in Group 2 from those in Group 1.
Target populations for PSH within Group 2 include:
Very vulnerable homeless people living on the streets, particularly those who have serious medical conditions complicated by long-term substance abuse problems (County of Los Angeles, 2010; Moore, 2006; Strebnick, 2007).
Homeless patients being discharged from acute care hospitals (sometimes with stays in medical respite) and those who are being diverted or discharged from skilled nursing facilities (Burt, 2008b, Chapter 5, for Central City Concern Recuperative Care Program and Seattle/King Countys Medical Respite Program).
Frequent users of hospital emergency rooms, avoidable hospital inpatient care or readmissions, detoxification/sobering services, or other costly services (Corporation for Supportive Housing, 2010; Larimer et al., 2009; Linkins, Byra, and Chandler, 2006).
Homeless persons with HIV/AIDS or other specific health conditions (Aidala et al., 2007; Buchanan et al., 2009; Sadowski et al., 2009; Schwarcz et al., 2009; Wilkins and Bamburger, 2009; Wolitski et al., 2009).