A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 6. Medical Necessity Criteria: WHO Can Receive Specific Services?


Chapter 4 described the various statutory authorities under which states could incorporate services important for people experiencing chronic homelessness or living in PSH into their Medicaid programs. It also discussed the provider qualifications and settings in which services may qualify for Medicaid reimbursement. Chapter 5 then examined some specific services and service models included in at least some state Medicaid programs that are being used to serve this population. This chapter examines which Medicaid beneficiaries are eligible to receive the specific services that may be covered by Medicaid, with a focus on the services of most use to people experiencing chronic homelessness or living in PSH. It does so by looking at the medical necessity criteria that a Medicaid beneficiary would have to meet to be eligible for some of the most effective specific services.

In addition to the federal and state policies that determine who is eligible to enroll in Medicaid, states set additional eligibility criteria to determine who, among all of the people who are enrolled in Medicaid, is eligible to receive specific services such as HCBS, health home services, or rehabilitative services. States may consider diagnoses and other health and functional criteria to define medical necessity for these services, and they may use a number of different terms to refer to medical necessity. These terms include level of care criteria or service criteria. Medical necessity criteria are designed to ensure that people with legitimate needs have access to services that are likely to be effective, economical, and appropriate to the illness, injury or type of disability for which the service is being performed.

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