This chapter has focused on ways that states can use various Medicaid authorities to include as covered Medicaid benefits the services needed by people with complex and interacting health and behavioral health needs, including those experiencing chronic homelessness or living in PSH. It described the legal auspices for the most commonly used approaches through which states can cover services needed by this population, as well as requirements for providers and settings. In addition to services provided by FQHCs, the authorities include the Medicaid state plan options of Rehabilitative and TCM services, and HCBS, either in the state plan or in a waiver program. States are slowly beginning to exercise the additional options available under the Affordable Care Act to establish one or more Health Homes to provide care coordination and integration to targeted populations with complex needs. The Health Home option seems especially promising as a way to provide the care coordination and service integration that proves so valuable for very vulnerable populations.
States may find it advantageous to re-examine their provisions for the settings in which particular types of care may be delivered and who is authorized to deliver them. Innovative models of care focus on serving people in the community or in their own homes rather than in clinic or treatment settings--a model of service delivery particularly suited to people experiencing chronic homelessness or living in PSH. Accommodating Medicaid state plans to this mode of service delivery for primary care, mental health care, and services to address substance use disorders would go a long way toward the goal of providing the integrated care that is most likely to achieve the best outcomes for this population. Movement is also occurring in the direction of reimbursing care delivered by properly certified and supervised peer support personnel. Peer support staff often have the greatest success in building trust and helping clients move toward full participation in treatment activities that lead to recovery.
When considering the options and authorities that may be used to cover services available to people who experience homelessness or live in PSH, it is important to keep in mind two basic requirements of the Medicaid program--freedom of choice and comparability. In general, Medicaid requires that beneficiaries have free choice of providers for benefits covered under the Medicaid program. This means that people living in PSH can opt to receive services from a qualified provider of their own choosing, whether that service provider is affiliated with the housing program or not. One possible exception is when states implement managed care arrangements, for which they often obtain Medicaid waivers that limit plan members' free choice of providers to those that are affiliated with the beneficiaries' managed care plan.
Also in general, Medicaid services covered in a state plan must be comparable for all beneficiaries, meaning that benefits available to one group of individuals may not be less in amount, duration, or scope than the benefits available to other individuals who meet similar medical necessity criteria.65 This means that Medicaid services cannot be limited to persons who are living in PSH, if these services are not also available to other Medicaid beneficiaries who need them, as determined by the medical necessity criteria established by the state for these services. There are some exceptions to Medicaid's comparability requirements, and some optional benefits (such as TCM or health home services) or waiver services may be targeted to specific groups of beneficiaries, with CMS approval. Chapter 6 provides more information about the criteria states may use to specify who is eligible to receive some Medicaid services.