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.