A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 2.2. Enrollment Strategies


Establishing expanded eligibility for Medicaid is only the first step in expanding the population of Medicaid beneficiaries. Many of those newly eligible for Medicaid on the basis of income alone will not know about the opportunity to enroll and will not have experience with health insurance. Early-expansion states and providers working with individuals with very low incomes and those experiencing homelessness have evolved strategies for reaching, engaging, and enrolling the newly eligible population.

Enrolling people experiencing homelessness into Medicaid includes letting them know they are eligible, helping them with the enrollment process, and assuring that they remain enrolled. States that already expanded Medicaid eligibility through early implementation of the Affordable Care Act or provided Medicaid-financed coverage using 1115 waivers have developed or are developing strategies for accomplishing these tasks, which may interest many states that began to expand Medicaid eligibility in 2014.21

In these early implementer states, outreach and enrollment efforts generally started with people who were already receiving health care services from safety-net hospitals and clinics but were not Medicaid beneficiaries. Safety-net agencies have used state or local funding, grants, or other resources to pay for services for low-income people without insurance. This starting place can be effective in reaching people experiencing homelessness when they use hospital or clinic services.

Enrollment strategies employed by early implementation states include the following:
  • Starting with people already enrolled in state-only health insurance programs.
  • Focusing first on people using health services and engaging them at the time of treatment at clinics and hospitals.
  • Hiring and training specialized staff to handle the volume and the potential complexities of enrollment, and to help people obtain documents needed to complete the enrollment process.
  • Going to the streets, shelters, and other locations to engage and enroll people who are likely to be eligible but not already connected to care.
  • Using new technologies to enable completion of an application in one step.
  • Automatically enrolling people based on information and documentation previously submitted to the county or state to establish eligibility for other benefits.

Implementation of the Affordable Care Act significantly simplifies and streamlines the process of determining eligibility for Medicaid enrollment in the states that expanded eligibility based on income. In a letter to state health officials and Medicaid Directors in May 2013, CMS encouraged states to adopt strategies that will facilitate enrollment.22 These include: (1) enrolling any household that receives benefits through the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), because SNAP income eligibility falls slightly below income eligibility for Medicaid under the Affordable Care Act's eligibility expansion provisions (130 percent vs. 133 percent of the FPL); and (2) for parents of children already enrolled in the Children's Health Insurance Program (CHIP), enrolling the parents based on children's income eligibility. Further, states and the Federal Government are enhancing their ability to verify citizenship, residency, and income status through electronic searches of official records. When these electronic verification systems are fully operational, they should greatly facilitate access to required documentation. Unlike the health insurance marketplaces created under the Affordable Care Act that have specific open enrollment periods, enrollment into Medicaid is always open.

In states that do not expand eligibility for Medicaid, people who experience homelessness will only be eligible for Medicaid if they meet requirements for categorical eligibility through SSI, age, pregnancy, being a parent or a member of another defined eligibility group, in addition to having an income below the limits set by the state for each eligibility category.

2.2.1. Gathering Documents to Establish Eligibility

Under federal law, states must verify some of the information submitted by people who apply for Medicaid, including income, Social Security numbers, citizenship, and immigration status. For other aspects of eligibility, including state residency, age or date of birth, and household composition, states have more flexibility and may choose from the following options:

  • Rely on self-attestation without additional verification;
  • Rely on self-attestation to make the eligibility determination and verify post-enrollment; or
  • Verify data to determine eligibility.

States are establishing data linkages with federal and state data sources to facilitate electronic verification of information provided by Medicaid applicants. A federal data hub contains data from federal agencies such as the Internal Revenue Service, U.S. Social Security Administration, and U.S. Department of Homeland Security. State data sources can provide vital statistics and information about wages, unemployment compensation, and eligibility data for other public programs. If states verify nonfinancial eligibility criteria, they are expected to use electronic data sources to minimize requirements for applicants to submit paper documentation at the time they apply for or renew Medicaid eligibility.

Under federal law, a person must be a United States citizen or a legal resident for at least five years to qualify for enrollment in Medicaid (with some exceptions that provide limited coverage for emergency medical care or coverage funded by the state without federal funds).23 Approximately 30 states have taken up a new option, authorized in the Children's Health Insurance Program Reauthorization Act, to provide Medicaid and CHIP coverage to children and/or pregnant women who are lawfully residing in the United States, including those within their first five years of having certain legal status. The 2005 Deficit Reduction Act (DRA) imposed restrictions on eligibility for federal benefits and established requirements for Medicaid applicants to submit documentation of citizenship or immigration status. In the past it has been difficult for many people experiencing homelessness to meet these documentation requirements because they often do not have a birth certificate or appropriate identification cards. States and counties implementing coverage expansions in recent years have found that significant backlogs were created by the need for people to obtain and submit documentation to meet the DRA requirement.

Many people experiencing homelessness or living in PSH have behavioral health disorders or cognitive impairments that can make it difficult for them to understand and respond to written notices.24 In addition, people experiencing homelessness often find it difficult to get mail. This can impede program efforts to follow up and obtain additional documentation to complete a Medicaid application.

Targeted outreach and enrollment assistance efforts can help individuals experiencing homelessness to complete the enrollment process.

Targeted outreach and enrollment assistance efforts can help individuals experiencing homelessness to complete the enrollment process. If workers use mobile devices with wireless data access, they may be able to take pictures and submit copies of identification cards or other documents needed for verification of eligibility. Enrollment workers also try to complete the process at one time because it can be difficult to contact the individual again if additional information or documentation is required.

Providers of health, behavioral health, and homeless assistance services work to help people obtain missing birth certificates or other identification documents. In many cases the documents needed to establish eligibility for Medicaid are also needed to qualify for some housing assistance programs or for General Relief or other benefits provided by local or state government cash assistance programs. Providers of affordable and supportive housing and case managers working to assist homeless people with housing applications may already have collected some of the needed documents and can help their clients with the process of qualifying for Medicaid.

Some organizations that provide PSH or operate homeless assistance programs have become certified enrollment assistance entities or application counselors for Medicaid.

In some communities, organizations that provide PSH or operate homeless assistance programs have become certified enrollment assistance entities or application counselors for Medicaid, and designated staff members have become qualified as navigators or assistance personnel. These official statuses allow them to provide individualized help with the process of enrolling into Medicaid or subsidized insurance coverage through federal or state insurance marketplaces. In addition, many Health Centers have received federal grants to provide outreach and help their patients with enrollment.25 Health Centers that serve people experiencing homelessness, including those that deliver services in PSH, can be effective partners in facilitating Medicaid enrollment for people who need or already live in PSH. Private foundations have supplemented public investments in some communities, to support such targeted outreach and enrollment efforts. These activities ensure that people experiencing chronic homelessness get enrolled in Medicaid or in coverage that was made available (before 2014) through Medicaid 1115 waivers as a bridge to expanded Medicaid eligibility.

States can also engage officials in the corrections system to facilitate making Medicaid enrollment a key component of discharge planning for people who are leaving jails and prisons, many of whom are likely to be eligible to enroll in Medicaid or federally subsidized health coverage. Employees of state or county corrections departments and others who work with individuals who have been incarcerated may serve as authorized representatives for helping soon to be discharged inmates submit an application for Medicaid coverage.

In Connecticut, the state accepts a simplified Medicaid application from inmates who are soon to be released.

In Connecticut, the state accepts a simplified Medicaid application from inmates who are soon to be released. The applications are approved in an expedited manner and benefits are activated when the Medicaid agency receives notification that the person is being released. State corrections officials recognize that enrollment is only the first step in assuring access to health care and treatment services, and some inmates will need additional help to learn how to make and keep appointments and use available health care services appropriately.

2.2.2. Assuring Continuity of Care

States and communities that have enrolled newly eligible people into Medicaid managed care plans have had to assure continuity of care for people experiencing homelessness. States must notify new enrollees of their options for selecting a health plan and primary care provider or medical home. People experiencing homelessness may fall through the cracks of these notification processes, because they do not receive a notification sent by mail or because they do not understand the need to respond, the implications of the choices they are called upon to make, or that they will be assigned to a provider if they do not respond.

When a state Medicaid office assigns this population to a primary care provider because the people themselves have not made a choice, the assignment is often to a service provider that the beneficiaries have not previously used rather than to the care providers they are accustomed to seeing, if they have in fact had a relationship with a particular provider. Further, the assigned providers often have little capacity to meet complex needs, having no prior experience working with people experiencing homelessness. These experiences suggest that states that have or will be enrolling newly eligible people into Medicaid managed care plans will want to take steps to facilitate continuity of care as people transition from whatever care they were receiving before enrollment to the plans and providers they will use after enrollment.

With appropriate training and information, providers of services in PSH and other providers of health care and behavioral health services for homeless people may be able to work with Medicaid offices and health plans to help people who are newly eligible for Medicaid make choices about the most appropriate plans and providers based on existing relationships and needs. For example, if a clinic or provider offers primary care services that are available on-site in the person's supportive housing building or co-located with behavioral health services that the person is receiving, they can help a person select that provider. Helping people experiencing homelessness understand their options and make informed choices can help them avoid disruptions in care relationships that can occur if such people are auto-assigned to a health plan and health care providers that do not have the capacity to engage and serve this population.

2.2.3. Maintaining Enrollment

Enrolling people in Medicaid is important, but keeping them enrolled is equally critical. Before passage of the Affordable Care Act, Medicaid rules required beneficiaries to reestablish their eligibility, periodically submitting documentation to prove they continued to be eligible for Medicaid enrollment. Some states required redetermination as often as every six months. For people experiencing homelessness and for residents of PSH, the requirement to submit paperwork documenting continued eligibility poses the same issues as initial enrollment--without a reliable mailing address they often do not receive notices or fail to respond before the deadline and they experience difficulty assembling the required documentation. As a result, some providers of innovative coordinated or integrated care initiatives found their clients were being disenrolled from Medicaid in numbers almost equal to the rate of new enrollments.

In response, some agencies created systems designed to keep track of clients' recertification dates and worked with local Medicaid offices to ensure that paperwork was completed and submitted in time to prevent disenrollment.

The Affordable Care Act requires that states provide 12 months of continuous eligibility for Medicaid, rather than the shorter periods that many states had been using. As implementation of the Affordable Care Act proceeds in 2014, states are also expected to reduce or simplify requirements associated with the eligibility redetermination process and rely on electronic verification of income to establish continued eligibility. These changes should significantly reduce the churning in enrollment that was experienced in programs that expanded coverage before 2014. In its May 2013 letter to state Medicaid Directors, CMS included several options that states could adopt to reduce loss of eligibility.26

One action states can take to reduce churning in eligibility and prevent loss of benefits relates to people who enter jails or prisons. As described earlier, some states have adopted policies and procedures to suspend rather than terminate Medicaid eligibility upon incarceration, which facilitates resumption of benefits upon discharge without having to repeat the entire eligibility determination process. As many people experiencing homelessness now lose Medicaid benefits when they enter jail or prison, changing the practice from termination to suspension of benefits facilitates continued enrollment and access to care, and may reduce the risk of returning to homelessness.

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