Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 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
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.

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