Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 3.4. CountyCare: Cook County's Approach to Expanding Coverage


Cook County, Illinois, is another community that used a Medicaid waiver as a "bridge to reform." At the end of October 2012, Illinois received federal approval for an 1115 waiver to use Medicaid financing to expand coverage through CountyCare, a program operated by the State of Illinois and the Cook County Health and Hospital System (CCHHS). CCHHS moved quickly to launch implementation in 2013.

CountyCare offered coverage to uninsured adults between the ages of 19 and 64 who had incomes below 133 percent of the federal poverty level, were United States citizens or had been permanent legal residents for more than five years, and were not otherwise eligible for coverage through Medicaid or Medicare. CountyCare intended to enroll people in 2013 who would became newly eligible for Medicaid in 2014.

Similar to Healthy Way LA, two major goals of CountyCare were to: (1) obtain Medicaid financing to match Cook County spending for inpatient and outpatient services provided by the hospitals and clinics that are part of CCHHS; and (2) help CCHHS make changes that would allow it to remain a viable part of the health care delivery system when many of its patients enrolled in Medicaid or subsidized health insurance coverage with Affordable Care Act implementation in 2014.

The terms of the waiver required CCHHS to partner with Health Centers (Federally Qualified Health Centers or FQHCs) to serve as primary care providers for many CountyCare members. Soon after the state's Medicaid waiver was approved, CCHHS selected 13 Health Center partners, including Heartland Health Outreach (Chicago's Health Care for the Homeless program) and other Health Centers that have been involved in serving people experiencing homelessness and PSH tenants. Selection criteria included the following:

  • The number of uninsured patients currently served by the Health Center.

  • Geographic location, with the goal of filling gaps not already covered by CCHHS clinics.

  • Experience serving particularly needy populations, including people experiencing homelessness and people with HIV/AIDS.

  • Some capacity to provide behavioral health services.

  • Capacity to offer pharmacy, wellness and nutrition, and other services.

The package of benefits available to CountyCare members included inpatient and outpatient hospital services, physician and clinic services, lab and X-ray, adult dental, subacute substance use disorder services, mental health, and targeted case management services, as well as other services including up to 30 days of nursing facility care after a hospitalization.33

The implementation of CountyCare was expected to strengthen connections between CCHHS and partnering Health Centers and other providers of community-based services for low-income uninsured people, including many people who are experiencing homelessness. Partner Health Centers collaborated with CCHHS to enroll eligible people in CountyCare, helping their patients complete the application and gathering and scanning copies of the required documentation (including proof of identity, citizenship or permanent residency status, income, and residency in Cook County). CCHHS established a web portal for partner Health Centers to submit applications for enrollment. CountyCare members were expected to have enhanced access to specialists who work in CCHHS hospitals and specialty care clinics. Coordination was expected to improve among those specialists and the Health Centers that are part of the CountyCare provider network.

Some of the leaders at CCHHS perceived that the success of CountyCare would depend in part upon building stronger partnerships to co-manage care for shared patients, particularly those who are homeless and have both medical and behavioral health needs that require integrated and coordinated care and connections to housing. Linkages to community-based providers of behavioral health services were seen as critical, but important decisions about how these services would be implemented as part of CountyCare were still pending at the time of our final visit.

CCHHS also expected to establish partnerships with other local hospitals to make them part of the CountyCare provider network. At the time of our final visit, discussions and initial negotiations with other hospitals were just getting under way, starting with the hospitals already serving many of the patients who receive care from the Health Centers selected as part of the CountyCare provider network. For CountyCare members, coverage for nonemergency hospital care was to be available only at network hospitals.

CCHHS provides health care services at the county jail, and early in 2013 it began enrolling eligible people in CountyCare as they prepared for discharge from jail. The expectation was that connecting people to CountyCare would facilitate continuity of care as they returned to the community, particularly for people with HIV/AIDS or other complex health care needs.

CCHHS also offers patients some assistance with applying for Supplemental Security Income (SSI) benefits. It uses a vendor to review information about people who enroll in CountyCare to determine whether they are potentially eligible for SSI. Health and Disability Advocates provides a social worker and lawyer at Cook County's Stroger Hospital to assist with SSI applications and appeals.

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