Within the framework of federal law, states establish policies regarding Medicaid eligibility.13 Federal law requires states to cover certain population groups and allows them to cover others. In general, Medicaid covers low-income mothers and children, elderly people, and people with disabilities, although specific income and other requirements vary by state. Parents, children, and pregnant women are commonly known as the Covered Families and Children population; elderly and disabled individuals are known as the Aged, Blind, and Disabled population. Disability status is often linked to the determination used by the U.S. Social Security Administration for SSI or Social Security Disability Insurance (SSDI).14
Before 2014, adults who were not elderly, disabled, pregnant, or parents of young children were not eligible for Medicaid in most states, regardless of their income. Some states used Medicaid 1115 waivers to expand coverage to some groups of children or adults who were otherwise not eligible for Medicaid, as part of research and demonstration projects that, in addition to whatever health benefits might accrue to participants, are required to show "budget neutrality" to the federal Medicaid program.
Among people experiencing chronic homelessness, nearly all are single adults living in households without children.15 Until recently, most were not eligible for Medicaid unless they first established eligibility for SSI.16 With implementation of the Affordable Care Act's provisions for expanded eligibility based on income on January 1, 2014, 25 states and the District of Columbia expanded eligibility for Medicaid in ways that significantly increase the number of people experiencing homelessness who are eligible for Medicaid benefits. Over time additional states are likely to do the same.
HUD's definition of chronic homelessness includes the criterion of one or more disabilities. Many people who are or have been chronically homeless have disabilities that would qualify them for SSI. The rest have a variety of health and behavioral health conditions, including substance use disorders that are not defined as disabilities for purposes of SSI or Medicaid eligibility.
The Affordable Care Act expands eligibility for Medicaid in several ways. First, the law as it was enacted required states to expand eligibility to people with incomes below 133 percent of the FPL starting in 2014.17 It provides federal funding for 100 percent of the costs of Medicaid benefits for this newly eligible population between 2014 and 2016, phasing down to 90 percent in 2020 and beyond.18 Before January 2014, the law allowed states to expand eligibility based on income, with the state and Federal Government sharing costs for Medicaid benefits at the regular matching rate until the end of 2013, without the "budget neutrality" required with an 1115 waiver. In June 2012, a U.S. Supreme Court decision had the effect of making the expansion of Medicaid eligibility to people with incomes below 133 percent of poverty optional for states.
On January 1, 2014, 25 states and the District of Columbia expanded Medicaid eligibility to adults with incomes below 133 percent of poverty. Six of these states had already done so earlier, for at least some of these adults, by implementing early-expansion of Medicaid eligibility. About 64 percent of homeless people reside in these states,19 where nearly all people experiencing chronic homelessness are expected to be eligible for Medicaid in 2014 if they are United States citizens or eligible permanent residents.
In the states that have not yet moved forward to expand Medicaid eligibility under the Affordable Care Act, people will still need to meet categorical eligibility requirements to enroll in Medicaid. For most people experiencing chronic homelessness, this means they must demonstrate that they have a disability that would also make them eligible for SSI, which is not always easy to do even for people who do have a qualifying disability.
For people with disabilities experiencing chronic homelessness, establishing eligibility for SSI benefits will continue to be important regardless of whether they live in a state that expands Medicaid eligibility. In some states, people who are eligible for Medicaid because they are SSI beneficiaries will have access to a broader range of Medicaid benefits, while those who are eligible under new income-based criteria may be enrolled in Alternative Benefit Plans that may cover a slightly different set of benefits. One advantage of Alternative Benefit Plans for people experiencing chronic homelessness, however, is that they include a requirement for behavioral health parity that could provide more behavioral health services for people under these plans than would be available through traditional Medicaid. Equally important, SSI provides a source of income that can be used to pay for some housing costs and for other basic living expenses.
A small but growing number of people experiencing chronic homelessness are eligible for Medicare in addition to Medicaid. The group of people who are "dual eligible" for both Medicare and Medicaid includes adults age 65 or older who receive Medicare because they are old enough and Medicaid because they have low incomes and few assets and qualify for SSI by reason of age. Many in this group also have one or more disabilities. Some other adults with end-stage renal disease or other disabilities could also be dual eligible, if they meet additional eligibility criteria.
2.1.1. Medicaid Eligibility for People Involved in the Criminal Justice System
Many people released each year from prison or jail do not have health insurance. In states that have expanded Medicaid eligibility under the Affordable Care Act, most of these recent inmates are likely to qualify to enroll in Medicaid because their incomes are very low.
Among people returning to the community from jails and prisons, many have health care needs related to mental illness, substance use disorders, and chronic health conditions. Some of these individuals were experiencing homelessness before they were incarcerated, and they are at very high risk of returning to homelessness when they return to the community. Continuity of care for medical and behavioral health conditions can help to improve health outcomes and reduce rates of reincarceration.20
States can adopt strategies to facilitate Medicaid enrollment and continued eligibility for Medicaid for people involved in the criminal justice system, including those who have experienced chronic homelessness. Under federal law Medicaid cannot pay for health care services provided in correctional settings, but federal law does not require states to terminate Medicaid enrollment during incarceration. Instead, states may suspend a beneficiary's Medicaid enrollment when a person is incarcerated. Suspension allows states to restore Medicaid coverage immediately when the person is released from jail or prison, without the gaps in coverage that occur when enrollment is terminated. At least 12 states have adopted laws or administrative policies to suspend rather than terminate Medicaid enrollment for incarcerated people.