Service providers working with PSH tenants and people experiencing chronic homelessness reported that a relatively small but growing number of the people they serve are eligible for both Medicare and Medicaid. These "dual eligible" individuals are among the costliest patients enrolled in both Medicare and Medicaid, and they often receive very fragmented care despite having multiple and disabling physical and behavioral health conditions and insurance coverage from both programs. Integrating Medicaid and Medicare benefits is extremely complicated, but given the extraordinary costs associated with health care for this group of beneficiaries, integration is increasingly a priority for the Federal Government and for many states.106
So far, most providers of services in PSH have not been very involved in emerging efforts to integrate care for dual-eligibles, but a few are beginning to recognize the need to do so. The number of people who experience chronic homelessness and are eligible for both Medicare and Medicaid is likely to rise as the average age among people experiencing chronic homelessness increases.
The Illinois Care Coordination Innovations project and Together4Health, described in Chapter 7, will include a focus on enrolling and coordinating care for dual eligible adults. Implementation began in late 2013.
During the study period, California was preparing to launch a demonstration program to integrate care for dual eligible adults using the state's Medicaid managed care plans and requiring greater coordination between those plans and county mental health and substance use disorder services as well as long-term services and supports. In March 2014, CMS approved an amendment to California's 1115 waiver to authorize the state to begin providing coverage under the Coordinated Care Initiative.107 Implementation will begin no sooner than April 2014 in eight counties (Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara). This may create new opportunities for coordination between the managed care plans and the programs that have been funded and managed through the county mental health system. These include PSH and other services funded through the Mental Health Services Act for people with serious mental illness who are experiencing homelessness.