This chapter has examined the medical necessity criteria established by states that determine which Medicaid beneficiaries may receive specific services that have proven to be most efficacious in addressing the health and behavioral health needs of people experiencing chronic homelessness or living in PSH. It reviewed medical necessity criteria for behavioral health services covered under Medicaid's rehabilitative services option, HCBS under waivers or SPAs, and the opportunities now available through health homes. Exhibit 6.1 summarizes this discussion.
The chapter then described: (1) new ways to think about medical necessity--beyond diagnosis--and how these new ways of thinking may be used to serve the most vulnerable beneficiaries; (2) the value of targeting services to the most vulnerable, and ways that states' Medicaid programs could accomplish this goal; and (3) the desirability of smoothing transitions for people whose conditions change in such a way as to alter their eligibility for the specific level of care they have been receiving. States have the opportunity to shape their Medicaid state plan to increase the number of people who are or have been experiencing chronic homelessness for whom the answers to Exhibit 6.1's questions are "yes." Focusing on these themes could help states tailor the services in their Medicaid programs to maximally benefit people experiencing chronic homelessness or living in PSH, with the added benefit that others with complex interacting health and behavioral health conditions would also benefit.
|EXHIBIT 6.1. Eligibility for Different Medicaid Services|
|Step 1: Are you eligible for Medicaid?||NO||No Medicaid services|
|YES, categorically (SSI, children, pregnant women, certain family members)||YES, income-eligible in states that expand Medicaid eligibility|
|Eligible for full Medicaid state plan||Eligible for Alternative Benefit Plan (which may be the same as full Medicaid state plan)|
|Step 2: Do you meet medical necessity criteria for specific services that work for PSH tenants?[Medical necessity criteria for specific services vary by state.]||NO||Still eligible for other Medicaid services|
|YES, by having a SMI||YES, by having a disability/condition that meets medical necessity criteria specified in your state's Medicaid plan for 1 or more specific services (e.g., HCBS, health homes)|
|Eligible to receive rehabilitative and/or other behavioral health services under several Medicaid options, if included in your state's plan||Eligible to receive specific services (e.g., health home services)|
|Step 3: Do you receive this care from a qualified Medicaid provider?||NO||Medicaid will not cover the cost of this care|
|YES, Medicaid will cover the cost of covered services for which you meet medical necessity criteria|