Chapter 2 covers Medicaid eligibility issues for anyone applying for Medicaid, including the changes in the Affordable Care Act. It also describes strategies for reaching, engaging, and enrolling very low-income and homeless people that have evolved in states that opted for early-expansion after 2010 and developed by providers working with people experiencing chronic homelessness. Chapter 3 describes PSH, the approach that shows the strongest evidence for effectively ending homelessness for those who have been homeless the longest. It describes the housing and its tenants, and gives a general overview of the services that help tenants remain stably housed and healthy.
Chapter 4 describes the Medicaid authorities available to states to accommodate the needs of people experiencing chronic homelessness. These include benefits covered through longstanding strategies, options, and waivers, including Medicaid-financed care provided by Federally Qualified Health Centers (FQHCs)/Health Care for the Homeless (HCH) programs, under options for providing behavioral health care (rehabilitative services and targeted case management [TCM]), through state plan amendments (SPAs) for home and community-based services (HCBS), and other options. It also describes new possibilities under the Affordable Care Act such as Alternative Benefit Plans and new optional Medicaid health home benefits.
Chapter 5 describes the ways that service delivery for Medicaid-covered services can be organized and how providers can be reimbursed for care delivered to people experiencing chronic homelessness and those living in PSH, including new approaches being developed in communities that were part of the study underlying this Primer. It covers services through FQHCs, Medicaid rehabilitative services and other services available under optional Medicaid state plan benefits and waivers, and services needed to coordinate and integrate care across medical, behavioral health, and housing needs. It also considers integration strategies and related issues as a matter of concern for promoting the efficiency and effectiveness of a state's Medicaid program for people with complex health needs.
Chapter 6 describes the criteria of medical necessity that apply to the array of services that might potentially benefit people experiencing chronic homelessness or living in PSH. Chapter 7 reviews payment mechanisms and structures for payment reform. Chapter 8 concludes with a summary of the changes at the state and provider levels that can contribute to supporting people with histories of chronic homelessness.
In addition to describing the innovations themselves, this Primer identifies lessons learned and some of the challenges being encountered as states strive to offer appropriate care to those who have experienced chronic homelessness. Examples, which come from the six states involved in the study underlying this Primer, are works in progress. Strategies continue to evolve as states develop strategies to accommodate a major system such as Medicaid to the needs of a new and highly vulnerable population.
Many state Medicaid offices have been very focused on major tasks related to the Affordable Care Act, preparing for eligibility expansion and enrolling large numbers of people into new forms of coverage beginning in 2014. These administrative demands may have limited their capacity to also focus on small numbers of high-cost and extremely vulnerable beneficiaries, including those who are homeless. This Primer describes significant opportunities for structuring Medicaid elements to increase Medicaid's applicability to people who have been chronically homeless, which states may choose to address in coming years.