Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities. 8. Health Homes

The ACA established a new state Medicaid option to provide “health home” services for enrollees with chronic conditions. A “health home” is intended to provide enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long-term services and supports for people with chronic illness across their lifespan. States may offer health home services to “eligible individuals with chronic conditions” who select a designated health home provider.⁴³ The health home option become available to states on January 1, 2011, and CMS preliminary guidance was issued in November 2010.⁴⁴ The usefulness of this new state option for people with chronic patterns of homelessness and residents of PSH is not yet clear.

• 8.1. Who is Eligible for Health Home Services?

  • States have some flexibility in defining the population who will be eligible to receive health home services. The law describes chronic conditions that include a mental health condition, a substance use disorder, asthma, diabetes, heart disease, and obesity, and also gives the Secretary of HHS authority to expand this list of chronic conditions. To qualify to receive health home services, a person must have at least two chronic conditions or one chronic condition and be at risk for another, or one SPMI.

    A state may decide to offer this benefit to all people who meet the criteria established in the ACA; alternatively, it may choose to target health home services to people with particular chronic conditions, or a higher number of conditions, or more severe conditions. The law stipulated that states mustserve dual-eligible beneficiaries (who are covered by both Medicaid and Medicare) if they otherwise qualify for health home services.

    The types of chronic conditions described in the law include those that are prevalent among chronically homeless people, as well as many other people who are enrolled in Medicaid. It is not clear, however, whether a state can establish target criteria for health home enrollment that might take into consideration additional factors such as chronic homelessness or frequent or avoidable use of hospital inpatient or emergency room care.

• 8.2. Potential for Using the Health Home Option for Residents of Permanent Supportive Housing

  • In several states, supportive housing service-providers and other advocates are talking with Medicaid program officials about potential opportunities to provide health home services to target populations that will include PSH residents. Some supportive housing service-providers, especially FQHCs, are assessing their ability to become a health home, and some are working to build the capacity to meet current or anticipated health home provider standards. Other supportive housing service-providers are seeking to develop collaborative partnerships with health care providers who are more likely to become health homes.

    Several state officials who participated in site visits for this study expressed some hesitation about their fiscal capacity to pursue the new health home option, even though federal matching funding would cover 90 percent of costs for the first two years of implementation. They have some interest in pursuing the option if the state could craft target criteria in a way that would achieve overall savings, by providing health home services to people with complex health problems who are high-users of hospital inpatient care.

    In Illinois, HHO and a few other provider organizations that now serve chronically homeless people are consulting with state Medicaid officials about the possibility of a pilot “health home” project, with the target population strictly limited to chronically homeless, multiply disabled, frequent users of crisis public services. Careful assessment and targeting would be needed to achieve cost neutrality or potential savings in state costs by the time federal matching contributions are reduced to the standard rate after two years.

    The pilot project would use Medicaid managed care financing to deliver comprehensive health and behavioral health services. Services could be coupled with housing supported by HUD housing subsidies provided through a partnership with the Chicago Housing Authority and a grant recently awarded to the AIDS Foundation of Chicago through HUD’s SHP for new PSH units for chronically homeless persons.

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