Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 4. Health Centers, Health CARE for the Homeless Programs and Federally Qualified Health Centers


Chapter 4 Highlights

Health Centers, including Health Care for the Homeless programs generally receive federal grants from HHS's Health Resources and Services Administration to provide comprehensive primary care and preventive services to low-income people in underserved communities. These Health Centers can also receive Medicaid reimbursements as Federally Qualified Health Centers. Among case study sites, FQHCs in Chicago, Los Angeles, and Washington are significant providers of health care and other services and supports to people with histories of chronic homelessness and to PSH tenants. They offer models of possible strategies that other communities could adopt.

Health Centers, including Health Care for the Homeless programs, face considerable changes as the Affordable Care Act moves into full implementation. Until 2014, over a third of their patients had no private or public insurance; many of the uninsured will now be Medicaid-eligible in states that expand Medicaid. The Affordable Care Act provided $11 billion in federal funding over five years to expand the Health Center program, with the goal of expanding access to health care services as more people in low-income communities obtain coverage. The volume of Health Center visits increased from 38 million in 2000 to 80 million in 2011, with more than one in six low-income people nationally receiving their care from these centers (Kaiser Commission 2013). Federal funding has expanded the number of Health Center medical staff, as well as staff who provide dental and mental health services.

Most patients of Health Care for the Homeless programs will become eligible for Medicaid coverage based on their low incomes if they live in states that expanded eligibility based on income in 2014. But barriers to Medicaid enrollment will likely persist for some people with histories of chronic homelessness because they lack reliable contact information or required identification documents, or find it difficult to navigate the application and eligibility determination process. In Los Angeles, PSH and homeless assistance providers have worked closely with Health Centers to help uninsured people access Health Center services and, if eligible, to enroll in Medicaid.

FQHCs are paid an "all-inclusive" rate for each visit a Medicaid patient makes with qualified staff. These pervisit rates often appear higher than Medicaid reimbursement fee-for-service rates paid to other types of providers who serve Medicaid beneficiaries, however, because the reimbursement is a bundled rate direct comparisons are not possible.

As many states increasingly rely on Medicaid managed care plans to provide health care for their beneficiaries, many Health Centers have joined these health plans' provider networks.

A growing number of Health Care for the Homeless programs and a few other Health Centers have developed programs to engage and provide ongoing health care and supportive services linked to permanent housing for people with histories of chronic homelessness. To do so they collaborate with numerous partners, including community-based mental health and housing support service providers and sometimes agencies providing rental assistance or PSH units.

Integration of primary and behavioral health care is an important goal, as is consideration of housing status and recognition of the importance of housing stability for health outcomes.

Best practices for serving people experiencing chronic homelessness or living in PSH often do not align with payment structures and requirements for FQHCs. Challenges include obtaining reimbursement for working "outside the four walls," offering "whatever it takes" wraparound services, using techniques such as motivational interviewing to address substance use issues, incorporating unlicensed staff such as peer support specialists into patient care teams, operating in a multidisciplinary team structure, and work aimed at assuring housing stability.

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