Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field. 6. Medicaid Managed CARE


Chapter 6 Highlights

Medicaid managed care began in many states with a focus on enrolling children and families. However, a growing number of states now allow people with disabilities to enroll in managed care plans, and some states require that most seniors and people with disabilities do so. Among case study sites, California, Illinois, and Minnesota have this requirement for all or many beneficiaries who are seniors and persons with disabilities.

Many states are using managed care plans to provide coverage to people who became newly eligible for Medicaid in 2014 under the terms of the Affordable Care Act, which includes many people experiencing homelessness or living in PSH.

As the shift to managed care happens, it will be essential for many of the organizations that provide Medicaidcovered health services to indigent and homeless people to become part of the health plans' provider networks.

Managed care plans must either deliver care coordination services to their members or contract with other organizations to do so. It is typical for the plans to do nearly all such services by telephone--a practice with severe limitations when working with clients experiencing homelessness and even people living in PSH. As they accommodate to serving members with more complex health and behavioral health conditions, managed care plans are being encouraged to revamp their approach to care coordination for these higherneed members.

Coordination between managed care plans and public mental health departments with regard to shared patients is often quite minimal. One exception among case study sites is Minnesota, where managed care plans under the state's Special Needs Basic Care demonstration are responsible for a range of Medicaid-covered services that includes both medical care and community behavioral health services. Some of these managed care health plans have structured agreements with community-based providers of mental health services, including services linked to PSH, to integrate health-related care management services with the targeted case management services they deliver. These providers receive additional reimbursement for the more-intensive coordination activities involved.

Managed care plans have an incentive to control costs by helping to reduce avoidable hospitalizations or emergency room visits for their members. When the managed care plans receive funding on the basis of capitation, a fixed payment per-member per-month, they may have the flexibility to do some things that could potentially be of great help to members with complex and co-occurring health and behavioral health needs, depending on the specific provisions of a state's Medicaid program and of the contracts between the state and health plans. These include using part of their per-member per-month funding, or their profits, to pay for more-intensive care coordination services if those services are likely to produce better outcomes while reducing the use of other types of services such as inpatient hospital care.

A major issue for managed care plans is rate-setting, specifically being able to negotiate risk-adjusted rates based on the complexity of a member's health status and therefore the intensity of the care coordination needed. Generally states are not using risk-adjustment methodologies that account for the complexity of health needs and the history of service utilization and costs for people experiencing chronic homelessness and others with the most complex health and social support needs.

An example of care coordination in a behavioral health carve-out is Louisiana's Behavioral Health Partnership. Louisiana has undertaken a multiyear, comprehensive redesign of its public behavioral health system for children and adults, requiring numerous waivers and state plan amendments. One of this program's components, authorized under a Section 1915(i) state plan amendment, was designed explicitly to cover the array of behavioral health services needed to help people experiencing homelessness get and keep housing. It is an excellent example of a Medicaid state plan modification that has won CMS approval to have Medicaid cover the care coordination services most needed by people experiencing homelessness and living in PSH.

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