Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 2. Medicaid Eligibility, Services, and Enrollment Strategies

Chapter 2 Highlights

For decades, people have qualified for Medicaid benefits based on categorical eligibility. The two most common eligibility categories have been as follows:

• The Covered Families and Children population--parents, children, and pregnant women whose household income is at or below the income eligibility levels established by states, which vary widely.

• The Aged, Blind, and Disabled population--elderly and disabled individuals who qualify if they meet the age and disability criteria for receiving Supplemental Security Income (SSI) or the disability criteria for Social Security Disability Insurance (SSDI) and whose incomes are low enough to qualify for Medicaid.

In anticipation of the Affordable Care Act of 2010's expansion of Medicaid eligibility in 2014 to households with incomes below 133 percent of the federal poverty level, some states expanded Medicaid eligibility early in the two ways explained below:

• Connecticut, Minnesota, and the District of Columbia used the Affordable Care Act's authority to implement early expansion of income-based Medicaid eligibility for some or all of the people who would become eligible in 2014 based on income.

• California and Illinois used Section 1115 demonstration authority to waive certain Medicaid requirements in order to expand coverage. States have long been able to use Section 1115 Research and Demonstration waiver programs to define specific groups of Medicaid beneficiaries, who then receive a package of services appropriate to their needs even if they do not meet categorical eligibility criteria. Under these waiver programs, states receive federal Medicaid funds to match their own outlays at the Federal Medical Assistance Percentage assigned to their state. California and Illinois took advantage of Section 1115 authority to create low-income health plans to serve all or most of the low-income population that would become eligible for Medicaid in 2014 and create a "bridge to reform" for public health and "safety net" hospital systems.

For people experiencing chronic homelessness or living in permanent supportive housing, the importance of Medicaid eligibility based on income cannot be overstated. Expansion offers health insurance coverage to thousands in this population who have not otherwise met categorical eligibility criteria.

Services available under Medicaid include the Medicaid state plan (the array of services that anyone qualifying for Medicaid on a categorical basis would be able to receive) and Alternative Benefit Plans (the basic array of covered services that states must provide to those newly eligible for Medicaid based on income alone). These plans may be different than the Medicaid state plan but must include the ten essential health benefits specified in the Affordable Care Act.

• 2.1. Introduction

  • Eligibility is one thing; getting newly eligible people enrolled in Medicaid and maintaining enrollment is another. In the course of eligibility expansion, states and localities have had to develop a range of outreach and engagement strategies for identifying eligible people, helping them enroll, and helping them maintain or re-establish their eligibility when it comes time for recertification. Assistance to establish eligibility for SSI has also been a priority.

    Using Medicaid-funded services to support people who live in permanent supportive housing requires that these PSH residents establish eligibility for and enroll in Medicaid or a program whose services are Medicaid-financed. This chapter reviews how eligibility has been established historically and what has changed since the Affordable Care Act became law in March 2010.

    Before the enactment of the Affordable Care Act, Medicaid eligibility was based on categorical requirements; the only way for a state to expand eligibility was through a Section 1115 demonstration program. With an 1115 Medicaid demonstration, states could use matching federal funds to provide Medicaid eligibility or some form of coverage to people who did not meet categorical eligibility criteria.

    This chapter first describes how people become Medicaid recipients under rules for categorical eligibility, which have been in place for decades and will continue to be applied into the foreseeable future. Second, we examine eligibility expansions that occurred in our six case study sites since the Affordable Care Act became law in 2010. The sites took different approaches to expanding coverage to people with histories of chronic homelessness and extensive service needs.

    Connecticut, Minnesota, and the District of Columbia used the Affordable Care Act's authority to implement early expansion of Medicaid eligibility for some or all of the people who would become eligible in 2014 based on income.

    California and Illinois are examples of states that used Section 1115 waivers to expand coverage. California's waiver allowed (but did not require) all counties to implement low-income health programs and most did, while the waiver for Illinois pertained only to Cook County. Waiver approval for Illinois came in late 2012, near the end of our study period. In California and Chicago, the waivers were intended to be a "bridge to reform," helping health care providers prepare for changes that were coming in 2014 with the implementation of the Affordable Care Act.

    After discussing eligibility, this chapter briefly outlines Medicaid services and how the basis of an individual's eligibility might affect the array of services that individual can receive. The chapter concludes with descriptions of practices that case study sites have used to engage people experiencing homelessness in health care, to help them establish Medicaid eligibility, and to ensure that they maintain that eligibility consistently over time. Later chapters provide extended discussions of mental health services, case management, and care coordination, which are particularly important for people experiencing chronic homelessness or living in PSH. Our discussions include how eligibility for these specific activities is determined.

• 2.2. Establishing Eligibility

  • 2.2.1. Categorical Eligibility for Medicaid

    For decades, people have qualified for Medicaid benefits based on categorical eligibility. The two most common eligibility categories have been as follows:

    • The Covered Families and Children population--parents, children, and pregnant women whose household income is at or below the income eligibility levels established by states, which vary widely.¹⁰

    • The Aged, Blind, and Disabled population--elderly and disabled individuals who qualify if they meet the age and disability criteria for receiving Supplemental Security Income (SSI) or the disability criteria for Social Security Disability Insurance (SSDI) and whose incomes are low enough to qualify for Medicaid.

    During the period covered by the case studies (2011-2013), most people experiencing chronic homelessness in the United States who became Medicaid beneficiaries did so on the basis of disability (usually mental illness) by first establishing their eligibility for SSI. Qualifying for either of these two categories is still an important way for people to establish Medicaid eligibility, and will be most important in the 25 states that are not going forward with eligibility expansion in 2014.

    2.2.2. Income-Based Eligibility for Medicaid

    The Affordable Care Act added an important new basis of eligibility to the two long-standing categories. The Act allows states to expand coverage to households with incomes up to 133 percent of the federal poverty level (FPL) without other "categorical" eligibility criteria. The intent is to provide all poor households with health insurance coverage by having them enroll directly into the state's Medicaid program. The Act's expanded eligibility provisions offer people experiencing homelessness or living in PSH an important opportunity to obtain coverage for health care that was difficult or impossible for them to obtain before 2014.¹¹

    When the Affordable Care Act became law, it allowed states to opt for "early implementation" of the income-based Medicaid expansion. Three jurisdictions selected for this study--Connecticut, the District of Columbia, and Minnesota--used the Affordable Care Act's authority to expand Medicaid eligibility based on income in 2010 or 2011 for some or all of those who would become eligible in 2014.¹²

    For example, Connecticut was one of the three case study sites that expanded Medicaid eligibility early. In April 2011, Connecticut expanded Medicaid eligibility to adults without children with incomes of up to 56 percent of the poverty level, a population previously served in the state's State Administered General Assistance (SAGA) program. The number of newly enrolled Medicaid members was much greater than expected--roughly twice the SAGA enrollment.

    Services for new enrollees were sometimes less than the full Medicaid state plan, as in the District of Columbia where the expansion population qualified for a basic level of Medicaid through health maintenance organizations (HMOs). Known as Childless Adult Medicaid, this plan came close to full Medicaid in that it included long-term care and mental health coverage, but it did not cover the full range of services that might be needed by someone with a disability.¹³

    The Affordable Care Act also specified January 1, 2014, as the date when all states would expand Medicaid eligibility to households with incomes up to 133 percent of poverty, with full federal funding for newly eligible people provided during the first few years. Following the Supreme Court decision of June 2012 that ruled against mandating the expansion, 25 states and the District of Columbia made the decision to expand and 25 states are not going forward at this time, though they may decide to do so at a later date. Exhibit 2.1 shows which of our six case study sites did early expansion and which have gone forward with full expansion as of January 1, 2014.

    EXHIBIT 2.1. Eligibility Expansion Approaches of the Six Case Study Sites

    State	Early Implementation, Enrolling   Income-Eligible People into State Medicaid Plan	Section 1115 Waiver to   Expand Coverage Through Plan   with Limited Services and Providers	Going Forward with   Full Expansion in 2014
    California		X	X
    Connecticut	X		X
    District of Columbia	X		X
    Illinois (Cook County only)		X	X
    Louisiana
    Minnesota	X		X

    2.2.3. Expanded Eligibility Through Section 1115 Demonstration Programs

    Another important way that states are able to extend Medicaid coverage to more households is through a Section 1115 demonstration program. These programs, which have been available for many years, allow states to use matching federal funds to provide some form of coverage to people who do not meet categorical eligibility criteria. Under these programs, states are allowed to waive certain federal requirements and may define specific populations and services to be covered. Some states have used these programs to expand coverage in ways that include people experiencing chronic homelessness or living in PSH.

    California and Illinois sought Section 1115 demonstration authority to extend Medicaid-financed services to some part of the low-income population, including many people who were experiencing chronic homelessness. Counties designed and provided the nonfederal funding to implement Low Income Health Programs that were authorized under these waivers. The health plans established by the counties included more limits on services and providers than would be the case starting in 2014, and participation in these plans did not constitute enrollment in the state's Medicaid program. Rather, these two jurisdictions used their Section 1115 demonstration programs as a "bridge to reform," helping health care providers prepare for changes happening with full implementation of the Affordable Care Act.

    In California, the Section 1115 program allowed counties to establish Low Income Health Plans that greatly extended eligibility for a package of basic health care services. Los Angeles County enrolled almost 200,000 newly covered persons in its plan by the end of 2012, and close to another 100,000 by the end of 2013.

    Illinois received approval for a similar Section 1115 program in late 2012 that is active only in Cook County. This waiver provided new opportunities for coverage for income-qualifying adults in the year before they became eligible for Medicaid in 2014. CountyCare offered health care services through Cook County Health and Hospital Services and its community partners. The Cook County Health and Hospital System was expecting that enrollment of newly covered persons would total over 100,000 by the end of 2013.

• 2.3. Medicaid Eligibility for People Who Are Chronically Homeless

  • Many adults who are disabled and homeless have a serious mental illness (SMI). Some homeless adults have other disabling health conditions, including physical disabilities, serious medical conditions, brain injuries, or cognitive impairments. They may also have co-occurring substance use disorders.

    As adults not living with children and therefore not part of the Covered Families and Children population, many people experiencing chronic homelessness have had a difficult time establishing categorical eligibility for Medicaid. Those who have been able to establish eligibility have done so through SSI based on disability. This will still be the primary route to Medicaid eligibility available to this population after January 2014 in states not expanding their Medicaid programs based on the income criterion available through the Affordable Care Act.

    In some states, people who are homeless but whose health conditions do not meet the level of functional impairment required by SSI, or those whose disabilities are attributable to substance use disorders and therefore not eligible for SSI, have been eligible to enroll in Medicaid under the terms of a Medicaid 1115 waiver that predates the Affordable Care Act.¹⁴ Likewise, since passage of the Act and before 2014, people living in the six states that opted for early expansion of Medicaid eligibility have been able to enroll if they met the criteria for their state's expansion.

• 2.4. Medicaid-Covered Health Services

  • As described in Chapter 1, Medicaid is implemented through partnerships between states and the Federal Government. Each state must develop a Medicaid state plan that describes the health care benefits its program will provide. The plan and plan amendments must be approved by the HHS Centers for Medicare and Medicaid Services (CMS).

    We include a discussion of covered services in this chapter on eligibility because it is easy to confuse eligibility for Medicaid per se with eligibility for the types of services most useful and important to people who are or have been chronically homeless. These include services and supports that can be delivered in a person's home or in other settings outside of an office, clinic, or treatment program, as well as case management and care coordination services. Not all Medicaid beneficiaries qualify to receive these types of services. Later chapters, which focus specifically on these types of services, describe the eligibility criteria for receiving them, which are established in terms of medical necessity.

    Federal law and CMS regulations prescribe a set of core benefits that each state must include in its Medicaid state plan.¹⁵ States may decide to cover additional optional services and may limit eligibility for additional services to specific groups of people.¹⁶ Medicaid state plan provisions specify many program details, including provider qualifications, definitions of covered services, target populations, criteria of medical necessity for each specific service, and payment mechanisms for covered benefits. States must obtain CMS approval for optional services and other program details through state plan amendments.

    While the expanded eligibility discussed above (Section 2.2.1) is a hugely important change affecting many poor people, including those experiencing homelessness, it is important to recognize that the types of care available through Medicaid may differ depending on certain characteristics of the beneficiaries. Both the basis for enrollment (categorical or income) and the health conditions of the beneficiary will affect eligibility for specific Medicaid-covered services.

    In the post-2014 environment we can distinguish two general configurations of covered services, which are described below:

    • Medicaid State Plan: This is the array of services that anyone qualifying for Medicaid on a categorical basis would be able to receive. Federal law and CMS regulations stipulate the benefits a state must provide (mandatory benefits) and also allow states to cover a number of optional benefits (see footnote 16 and footnote 17).

    • Alternative Benefit Plans: This is the basic array of covered services that states must provide to the expansion population (those who qualify based on income alone). These plans may be different than the Medicaid state plan, with states defining benchmark coverage, but plans must include the essential health benefits specified by the Affordable Care Act.¹⁷ In 2014, many states have established Alternative Benefit Plans based on their Medicaid state plan, offering the same services that are offered in the state including long-term (nursing home) care.

    The Affordable Care Act stipulates that the "essential health benefits" offered by Alternative Benefit Plans must include treatment services for mental health and substance use disorders, as well as rehabilitation and "habilitative" services and devices.¹⁸ Behavioral health treatment cannot be more limited than treatment for physical conditions. Because of these "parity" requirements, an Alternative Benefit Plan might offer better coverage for treatment of substance use disorders than the state's Medicaid state plan but less coverage for some of the types of mental health services covered through other current mechanisms, such as optional rehabilitative services option or waiver programs.¹⁹

    While federal rules describe the minimum set of benefits that must be provided through Alternative Benefit Plans, states also have some flexibility to cover a more robust package of benefits tailored to the particular needs of population subgroups.²⁰ A package of tailored benefits could potentially be designed to meet the needs of people with histories of chronic conditions that may contribute to chronic homelessness. States will determine the design of benefit plans available to people who become eligible for Medicaid in 2014, and states will decide whether Medicaid will cover many of the services that are most often delivered in PSH models. States will also decide on the provider qualifications required for Medicaid reimbursement. As shown in Exhibit 2.2, the five case study sites that have gone forward with expansion have established Alternative Benefit Plans that are equal to the Medicaid state plan with no exclusions. Some states that are going forward with expansion are adopting more limited Alternative Benefit Plans.

    EXHIBIT 2.2. Alternative Benefit Plans of the Six Case Study Sites

    State	Alternative Benefit Plan
    California	Medicaid state plan
    Connecticut	Medicaid state plan
    District of Columbia	Medicaid state plan
    Illinois	Medicaid state plan
    Louisiana	Not going forward at this time
    Minnesota	Medicaid state plan

    2.4.1. Who Can Get What?

    Medicaid is fundamentally a benefit program that provides health care coverage in much the same way that private health insurance programs do. Some services may be available to everyone, such as physical exams, but most services will only be provided if the beneficiary's health condition justifies them. Thus, only people with advanced heart disease will get heart surgery and only pregnant women will get prenatal care.

    Most chronically homeless people and those living in PSH who reside in states that implemented expansion became newly eligible for Medicaid in 2014 on the basis of income. Once enrolled in Medicaid, they will qualify for their state's Alternative Benefit Plan. Most states have chosen to enroll the expansion population in Alternative Benefit Plans that are based on the state's approved Medicaid state plan.

    Several subsequent chapters describe in detail the services that are particularly important for people experiencing chronic homelessness or living in PSH. Chapter 5 discusses mental/behavioral health services, and Chapter 7 examines emerging models of care coordination. In addition to describing our findings with respect to the services themselves, each of these chapters also discusses the medical necessity criteria that an individual would have to meet to be eligible to receive the services.

• 2.5. Outreach and Enrollment Strategies: Challenges and Solutions

  • When any new public benefit becomes available, it takes time for people to understand what it offers and how its provisions apply to them. All potential beneficiaries of new or expanded programs have this problem, which they often share with case managers and others who have the responsibility of helping newly eligible people to access all of the benefits for which they qualify. Medicaid eligibility expansion is no exception.

    States that have expanded Medicaid eligibility through early implementation of the Affordable Care Act or provided Medicaid-financed coverage through waivers have developed many useful strategies to disseminate information about eligibility and stimulate interest among newly eligible people in the opportunities that have become available to them.

    Early outreach and enrollment efforts have generally started with people who are already receiving health care services from hospitals and clinics that have been using state or local funding, grants, or other resources to pay for services.

    The six communities studied intensively for this report were pursuing various enrollment strategies, described below. These include finding and engaging the newly eligible people and helping them through the Medicaid enrollment processes, helping people qualify for SSI, and helping people avoid being dropped from Medicaid.

    2.5.1. Strategies for Enrolling Newly Eligible Members

    Whether expanded eligibility occurred through early implementation or 1115 waivers, jurisdictions faced the challenge of enrolling thousands of people as quickly as possible. Some of the strategies used in this process include the following:

    • Starting with people already enrolled in state-only health insurance programs.

    • Starting with people using health services and engaging them at the time of treatment at clinics and hospitals.

    • Hiring and training specialized staff to handle the volume and the potential complexities of enrollment, and to help people obtain documents needed to complete the enrollment process.

    • Going to streets, shelters, and other locations to engage and enroll people who were likely to be eligible but not already connected to care.

    • Using new technologies to enable completion of an application in one encounter.

    • Automatically enrolling people based on information and documentation previously submitted to the county or state to establish eligibility for other benefits.

    Starting With Existing Enrollees and Those Using Health Services

    All five of the case study sites that pursued either early implementation of income-based eligibility or expansion through 1115 waivers began recruiting new enrollees from among people already enrolled in state-only health insurance programs or people already using safety net providers. Recognizing that enrollment would depend on the full understanding and cooperation of personnel in the agencies in contact with patients, these states clearly articulated the new eligibility criteria, pursued major informational and training strategies for people serving the target population, established enrollment procedures and forms, clarified the differences between old eligibility criteria (in jurisdictions with stateonly programs) and the new, and updated websites and other access points.

    These jurisdictions assumed from the start that one of the best ways to reach people was to tell them about the new program when they came in for treatment. New procedures were established at safety net provider clinics and hospitals, including Health Centers. In outpatient settings, patients were notified as they signed in for appointments or during walk-in times. In hospitals, they were contacted in the emergency department or, if admitted, once they were established in a bed.

    Hospital staff was encouraged to identify the people they saw most often and whose use of health care could become more rational and effective if they received proper case management. Special attention was focused on bringing these frequent users not only into Medicaid or the waiver plan, but also into case management and, if appropriate, housing. In Los Angeles, hospital staff reported almost immediate declines in hospital use after people in this group were connected with care and housing, which made them increasingly enthusiastic participants in strategies to engage this population.

    Hiring Additional Staff and Focusing Them Solely on Enrollment

    Health Centers in case study sites described the lengths they went to help their patients get enrolled into newly available coverage. Many hired staff for the sole purpose of processing applications and helping people get identification cards and other documents needed to establish eligibility. They then set up intake procedures at their appointment desk to refer all people coming in for care to the enrollment specialists first, before going to their medical appointment. The enrollment staff received specialized training in eligibility requirements and enrollment procedures. Many other safety net providers took similar steps to get people enrolled and connected to a primary care provider.

    Going to the Streets and Using New Technologies

    An important strategy for finding people who did not make frequent use of health care facilities was outreach to the streets. This strategy is important for addressing two barriers that often keep people experiencing chronic homelessness from enrolling in programs to which they are entitled--trust and difficulty navigating application processes. People experiencing chronic homelessness often have had negative interactions with public and safety net agencies, including health care providers, and have chosen largely to avoid them. Street outreach teams often include people who have had extensive contact with the people they want to enroll and have established a level of trust that makes it possible to start a conversation about enrollment.

    Mobile technology can help turn those conversations into completed applications. The most successful outreach teams use mobile devices that allow them to connect to application websites wirelessly. They visit meal sites, shelters, and street locations, "going where they are" to work with people to establish eligibility "on the spot," preferably within the same single encounter as finding people again can be a challenge. Team members can complete an application on-line while talking to the applicant, photograph and convey documents (e.g., Social Security card, birth certificate) and an image of the applicant, get needed signatures on their mobile devices, and so on. These strategies have proved to be successful in enrolling some of the hardest-to-find eligible people.

    Auto-Enrollment

    Los Angeles County pursued an auto-enrollment strategy for newly eligible people to be covered through Healthy Way LA, basing eligibility on information and documentation that had been submitted when applying for other benefits. This information, which included documentation of residency, citizenship, age, and income, could be used to verify eligibility for coverage through the waiver program. The County also auto-enrolled people who were on the General Relief rolls into Healthy Way LA. Through autoenrollment, many people who were experiencing homelessness obtained coverage. However, enrollment alone did not connect people to health care, because many people did not know they had been enrolled into Healthy Way LA and did not know they had been assigned to a primary care provider or clinic. Their care-seeking behavior did not change until they connected in person with an outreach worker or with someone at a clinic or hospital. Funding from local foundations allowed the County Department of Health Services and several Health Centers to add outreach workers and case managers who actively worked to enroll people experiencing homelessness into coverage through Healthy Way LA and Medicaid, and to get those who were enrolled connected to a primary care provider or clinic that would best meet their needs.

    After January 1, 2014, both case study sites that used 1115 authority to expand coverage automatically transitioned eligible beneficiaries from their waiver programs (Healthy Way LA and CountyCare) into enrollment in the state's traditional Medicaid program with full access to the entire Medicaid state plan. In the transition, most participants were assigned to a primary care provider and Medicaid managed care plan based on information about each person's primary care assignment and service use through the waiver program.

    In 2014, California also implemented "Express Lane" enrollment into Medicaid for people receiving benefits through the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps). This process uses the information provided by applicants for SNAP benefits to determine eligibility for Medicaid enrollment, without the need to complete a new application or submit additional documents.²¹

    2.5.2. SSI Eligibility

    Even in states that implement the expansion of Medicaid eligibility permitted under the Affordable Care Act, enrolling people who are chronically homeless in Supplemental Security Income will continue to be important. The categorical eligibility for Medicaid that comes with enrollment in SSI may provide access to a broader array of services available in a Medicaid state plan than in the benefit package available under an Alternative Benefit Plan. Access to full Medicaid state plan benefits can help cover more of the costs that PSH providers incur for the care they offer clients who are currently or formerly homeless. In addition, SSI provides these clients with a reliable income source to help pay for rent and other essential items.

    There are, however, many barriers to qualifying for SSI, so it is very important for people experiencing chronic homelessness or those already living in PSH who are not yet enrolled in SSI to work with knowledgeable people who can guide them through the process. Applicants must document that their disability meets requirements of the Social Security Administration's (SSA's) requirements for diagnosis type, duration, and severity or functional impairment. As the process can be long and complicated, very few applicants experiencing chronic homelessness are approved on their first application attempt unless they have support from well-trained case managers, legal assistance, or help from other advocates.²²

    The case study sites examined in this study used a number of strategies to support SSI outreach and enrollment in SSI.

    In Louisiana, persons displaced by Hurricanes Katrina and Rita in 2005 and other more recent hurricanes could gain access to federally funded PSH services. The source of these funds was timelimited disaster-related Community Development Block Grant funding. Beginning in 2008, the state's Permanent Supportive Housing Program (PSHP) used its homeless outreach teams to facilitate SSI enrollment for its clients. In PSHP, clients are assigned to the community support teams, so the issue of finding clients has not been as acute as in some other communities. PSHP caseworkers did have to work on engaging those clients, helping them understand the importance of obtaining SSI, and assisting them in obtaining documentation, completing the application, and continuing to pursue enrollment when an initial application was denied, which happened frequently. In cases where clients once had been SSI beneficiaries but enrollment had lapsed, sometimes for many years, PSHP staff helped with reinstatement. By 2011, at least 80 percent of current PSHP clients were SSI recipients and thus qualified for Medicaid, up from no more than 25 percent at the time the program was initiated.

    In Los Angeles, the county-funded B.E.S.T. program, housed at JWCH's Center for Community Health (a Health Center), has achieved excellent results in helping people establish eligibility for SSI. On average, B.E.S.T. clients are approved for SSI within four months of enrollment in B.E.S.T., and more than 90 percent are approved with their first application. B.E.S.T. attributes its success to experienced staff who have support from upper management, do whatever it takes for clients, have excellent relationships with local SSA offices, and have highly developed and efficient records retrieval and standardized forms and procedures. In addition, the program focuses on clients who are likely to be approved; the program takes fewer than 20 percent of the people it screens, but is able to help almost all of its participants obtain SSI. Such screening is fairly common among agencies that work with clients to establish SSI eligibility since this is the most efficient way to deploy their specialized knowledge.

    In the District of Columbia, the Medicaid enrollment process (both before and after expansion) includes a screen for homelessness and disability. Enrollment staff are expected to refer someone who is experiencing homelessness or is highly likely to be found disabled to Interim Disability Assistance (IDA), a special section within the department that assesses them for likely SSI eligibility. If SSI eligibility is likely, the person is enrolled in IDA while applying independently for SSI. IDA staff help the applicant to assemble the documentation needed for IDA eligibility. IDA pays a monthly stipend as well as qualifying the applicant for full fee-for-service Medicaid. IDA stops as soon as SSI receipt is approved. With SSI, full fee-for-service Medicaid continues.

    If a person experiencing homelessness already has a caseworker from any of several agencies, that caseworker will assist with this process. The contracts for case management in its PSHP (see below) include the requirement that caseworkers assist with IDA/SSI applications. All of these caseworkers are trained in the HHS Substance Abuse and mental health Services Administration's (SAMHSA's) SSI/SSDI Outreach, Access and Recovery (SOAR) techniques, which staff say has helped facilitate access to IDA/SSI.²³ In previous years, the Los Angeles County Department of Health Services (DHS) recovered between $2.3 and $2.4 million in health care costs from Medicaid; since the SOAR training, that amount increased to $3.5 million in 2011 and was expected to go up even further for 2012.

    For more information on these and other examples of strategies for improving access to SSI for homeless and formerly homeless people, see Burt and Wilkins 2012b.

    2.5.3. Maintaining Medicaid Enrollment Over Time

    Organizations intending to provide comprehensive and coordinated care for populations with complex health conditions usually make financial calculations based on a set of assumptions. One essential assumption is that once someone is enrolled in Medicaid, that individual will remain enrolled and the provider can count on receiving a given amount of money from Medicaid every month to cover the cost of care.

    Provider experiences during the first year or two of operating in the new mode has shown that this assumption is not borne out by reality. An important but not initially fully appreciated reason is the attitudes and care-seeking habits of the newly eligible population. Many newly enrolled beneficiaries have never had health insurance, and have difficulty understanding the need to maintain coverage when they do not need care. They are accustomed to going to the doctor, emergency room, or hospital when they are sick, usually very sick as they wait too long to seek care, and do not see why they should worry about maintaining insurance coverage when they can always get re-enrolled on the spot when they need care again.

    Thus enrolling people in Medicaid is only the first challenge; keeping them enrolled can be equally challenging. Some providers reported that almost as many patients drop off their rolls every month, due to loss of Medicaid eligibility attributable to difficulties with recertification, as they are able to enroll. Before full implementation of the Affordable Care Act, states often required their beneficiaries to re-establish eligibility every six months, and sometimes more often.²⁴ Beneficiaries had to submit paperwork to document their continued eligibility. In recent years, state policymakers in several of the case study sites enacted requirements for frequent eligibility redetermination as a strategy for achieving budget savings. If beneficiaries did not submit the paperwork on time they were dropped from Medicaid and had to go through a full reapplication process to get reinstated. These requirements are quite difficult for people experiencing homelessness to comply with, putting them at great risk of losing eligibility not only because they have more difficulty assembling the documentation required, but also because their unstable housing situations mean they may not receive reminders of pending deadlines.

    For example, people experiencing homelessness often face gaps in eligibility for California's Medicaid program because they do not receive notifications or are unable to complete the paperwork required to maintain their enrollment. Service providers find it difficult to communicate with the county and the state to verify that the people they serve are currently enrolled in Medicaid, and county and state records have been known to differ.

    Because Medicaid providers may experience disallowances if they bill for services delivered while a client is off the rolls, they invest considerable staff time in verifying enrollment and documenting eligibility.

    Hennepin County, Minnesota, is one case study site finding that its assumptions about stable enrollment have not been borne out. Hennepin County is developing an Accountable Care Organization called Hennepin Health, which began enrolling people who were newly eligible for Medicaid shortly after Minnesota implemented its early expansion of income-based Medicaid eligibility in March 2011.

    Hennepin Health has faced challenges maintaining and increasing the number of people enrolled in the plan because many people lose coverage when they fail to submit their eligibility paperwork every six months. In December 2012, enrollment stood at 6,000 people. Although the plan enrolls about 1,000 members every month, it also loses 800 members whose coverage is dropped because they have not submitted the required documentation.

    The State of Minnesota recently approved a process for sharing eligibility redetermination dates with Hennepin County, but in December 2012, Hennepin Health was still working with paper lists. Staff hope to integrate the information about eligibility redetermination dates into state data systems so that clinic workers can monitor upcoming deadlines and encourage clients to submit required documentation on time. This could include providing reminders when patients visit the clinic or contacting members whose eligibility ends.

    Hennepin Health contracted with a vendor to track and facilitate eligibility redeterminations, but this did not have a significant impact on reducing the rate at which members lost coverage. Hennepin Health has found that many of the very low-income adults enrolled in the plan had not established strong connections to primary care providers in the past, instead relying on emergency rooms for care when needed. It is taking time and ongoing efforts to help previously uninsured adults build relationships with care providers and recognize the value of having year-round coverage with ongoing access to a primary care provider.

    Minnesota's broader experience with enrollment churning in the Medicaid expansion population has been similar to the experience with plan enrollment at Hennepin Health. However, state agency staff expect that changes in 2014 will reduce churning. Factors such as simplifying eligibility and income verification and a change from 6 months to 12 months for redetermination should significantly reduce the number of people who lose eligibility or experience gaps in enrollment.

    2.5.4. Shifts to Managed Care Enrollment

    In some of the case study sites, the state Medicaid program is requiring that recipients be enrolled in a Medicaid managed care plan. This reflects a nationwide trend. In 2012, the Kaiser Family Foundation reported that more than half of all Medicaid beneficiaries were already enrolled in managed care plans.²⁵ Until recently, seniors and people with disabilities were less likely to be enrolled in managed care arrangements than children and their parents, but an increasing number of states are expanding mandatory managed care enrollment to include people in this group. States are likely to use Medicaid managed care plans to provide coverage to people who are newly eligible for Medicaid. When the District of Columbia established income-based eligibility in April 2010, for example, it assigned all new Medicaid beneficiaries to a managed care plan. Those who had been enrolled in its self-financed health insurance program (Alliance Health Care) were assigned to one health plan (United), and all other enrollees were assigned to either United or another health plan (Chartered).

    Enrolling people with histories of homelessness and complex needs has posed challenges for managed care plans. For example, the enrollment process often requires that Medicaid beneficiaries select a managed care plan from among two or more choices and designate a primary care provider, or get assigned by default if they do not make a choice. The selection of (or assignment to) a plan and provider usually limits where people can receive Medicaid-reimbursed health care services, or which providers can get reimbursed if they deliver care. These issues are discussed in more detail in Chapter 6.

• 2.6. Summary

  • Many of the challenges that people experiencing homelessness, living in PSH, and other people with extremely low incomes had with enrolling in Medicaid were lessened after full implementation of the Affordable Care Act in 2014. On January 1, 2014, individuals with incomes lower than 133 percent of the federal poverty level, including those who are or were experiencing homelessness, became eligible for Medicaid for the first time on the basis of income in 25 states and the District of Columbia. About 64 percent of people experiencing homelessness reside in the states currently going forward with expanded eligibility (HUD 2012, p.5), increasing the likelihood that people experiencing homelessness or living in PSH will be able to access the services they need. A high percentage of people experiencing chronic homelessness have a serious mental illness, usually coupled with co-occurring behavioral and physical health conditions. Alternative Benefit Plans, in which they are likely to be enrolled, include behavioral health services as part of the essential benefits required by the Affordable Care Act, which will make these services available for the first time to many of the new beneficiaries. Further, streamlining of eligibility determination and recertification should make enrollment easier and greatly simplify maintaining eligibility, which should reduce the problem of enrollment churning. Reaching and engaging people experiencing homelessness or living in PSH and keeping them enrolled will always be challenging, but new options for covering the costs of care coordination under the Affordable Care Act, plus increased provider experience over time, should begin to address these issues. Given the importance of Medicaid coverage for people with complex health and behavioral health conditions, the changes evolving under the Affordable Care Act show the promise of bringing more people into care, providing more appropriate and coordinated care, and helping them remain in care.

     

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