Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities. 1.5. State Steps Toward Implementing the Affordable Care Act


Some states are already moving to implement provisions of the ACA that allow them to expand coverage right now to include people living in poverty or near-poverty who do not have categorical eligibility for Medicaid. Other states are using Medicaid’s 1115 waivers as a “bridge to reform.” As research and demonstration projects, these waivers allow states to extend some form of coverage to people who do not qualify on the basis of current categorical eligibility criteria.

  • Under a Medicaid waiver, the Massachusetts Medicaid program provides benefits through MassHealth to designated groups of low and moderate-income people who would not otherwise meet categorical eligibility requirements. MassHealth offers health care benefits directly or by paying part or all of the health insurance premiums for qualified persons. Eligibility varies by coverage type, and qualifications and benefit packages are specified for each group of eligible persons. Chronically homeless people in Massachusetts are nearly all eligible for Medicaid, under the following types of coverage:

    • MassHealth Standard, which serves disabled SSI recipients.
    • MassHealth Basic, for those unemployed for a year or longer without other benefits.
    • MassHealth Essential, for those who are long-term unemployed but whose immigrant status bars them from MassHealth Basic.
    • CommonHealth--in the less likely scenario that they are over 65, disabled, and working 40 hours per month (e.g., some long-term shelter residents).
  • The level of coverage and types of services available for behavioral health care differ among these coverage packages. For example, MassHealth Standard and CommonHealth have more robust behavioral health benefits.

  • In California, a recently approved Medicaid waiver establishes expanded coverage under a new Low-Income Health Program (LIHP) that counties will design and implement, with counties providing the funds to match Federal Financial Participation (FFP). This strategy will likely produce significant variations among California counties as they determine who will be eligible and what services the LIHP will cover.

  • Maine has used a Medicaid waiver to establish coverage for limited health benefits for “non-categoricals” and has been able to enroll many chronically homeless people who have not gone through the SSI disability determination process. Because there is a cap on the number of people who can be enrolled under this provision of the waiver, the Maine Medicaid office also assesses “non-categoricals” to see if their disabilities are sufficient to qualify them for full scope Medicaid. The office has been able to qualify about two-thirds of “non-categoricals,” as disabled, which moves them from the “non-categorical” group into being “categorically eligible” and frees up “non-categorical” slots for new people. Individuals who have been re-classified in this way are strongly encouraged to apply for SSI, as the criteria to establish disability used by the Medicaid office are the same as those used by SSI, and qualifying for SSI would give people an income source in addition to their Medicaid coverage.

  • Connecticut was the first state to get federal approval to expand Medicaid income eligibility under ACA provisions. New Medicaid coverage replaces the state-administered General Assistance medical program and provides full Medicaid benefits for low-income adults who do not receive SSI or Medicare and are not otherwise eligible for Medicaid. Income eligibility for adults age 19-64 is 56 percent of FPL, except in southwestern Connecticut, where it is effectively 68 percent of FPL.

  • In May 2010, the District of Columbia (DC) filed a Medicaid SPA, expanding Medicaid eligibility under the authority provided by ACA to cover legal residents with incomes up to 133 percent of FPL who were not previously categorically eligible, and enrolled about 33,000 new beneficiaries. A few months later DC received approval of a waiver to increase the eligibility level to 200 percent of FPL, which added a few thousand more people to the Medicaid rolls. Nearly all of the homeless people who had previously been unable to meet Medicaid’s categorical eligibility requirements are now covered by Medicaid benefits. They are primarily single persons with substance use conditions.

  • Minnesota has also opted for early adoption of the ACA Medicaid expansion provisions. Newly eligible people will include an estimated 32,000 General Assistance Medical Care (GAMC) clients, 51,000 low-income adults from the MinnesotaCare program, and 12,000 uninsured persons. Before this expansion, homeless people served in the GAMC program could get care only in four safety net hospitals in the Twin Cities, which were too far away for many people to use. Now homeless people will have care delivered by Medicaid providers throughout the state.

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