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

07/23/2014

  1. Examples in this Primer are based on a three-year study conducted by Abt Associates Inc. for the Office of the Assistant Secretary of Planning and Evaluation, U.S. Department of Health and Human Services (HHS), which observed developments in six states and communities: California/Los Angeles, Connecticut, the District of Columbia, Illinois/Chicago, Louisiana/New Orleans, and Minnesota/Hennepin County. Details of the examples presented here may be found in: M.R. Burt, C. Wilkins, and D. Mauch, 2011, Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan. M.R. Burt, and C. Wilkins, 2012, Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. C. Wilkins, M.R. Burt, and D. Mauch, 2012, Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities. M.R. Burt and C. Wilkins, 2012, Establishing Eligibility for SSI for Chronically Homeless People. C. Wilkins and M.R. Burt, 2012, Public Housing Agencies and Permanent Supportive Housing for Chronically Homeless People. M.R. Burt, C. Wilkins, and G. Locke, 2014, Medicaid and Permanent Supportive Housing for Individuals Experiencing Chronic Homelessness: Emerging Practices from the Field. All are listed at the end of this report and available at http://aspe.hhs.gov/daltcp/reports.htm.

  2. For purposes of defining chronic homelessness, HUD's definition of a disabling condition is broader than the criteria used to determine eligibility for Supplemental Security Income (SSI), but SSI eligibility criteria apply for purposes of categorical eligibility for Medicaid. HUD's definition of a disabling condition includes people whose disabilities are attributable to substance use disorders, as well as people with other disabling physical or mental health conditions.

  3. The definition includes individuals who are exiting an institution (including a jail, substance abuse or mental health treatment facility, hospital, or other similar facility) where they resided for fewer than 90 days and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution. http://portal.hud.gov/hudportal/documents/huddoc?id=pih2013-15.pdf.

  4. Wilkins, Burt, and Mauch, 2012, Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities. C. Caton, C. Wilkins, and J. Anderson, 2007, "People who experience long-term homelessness: Characteristics and interventions". Chapter 4 in D. Dennis, G. Locke, and J. Khadduri (eds.), Toward Understanding Homelessness: The 2007 National Symposium on Homelessness Research. Washington, DC: HHS and HUD, http://aspe.hhs.gov/hsp/homelessness/symposium07/Caton.

  5. For example, in the 2012 Point In Time (PIT) count of people experiencing homelessness, communities reported that nearly 100,000 people were experiencing chronic homelessness, including 67,247 people who were unsheltered (sleeping on the streets, in encampments, or other places not meant for human habitation). Among people with severe mental illness experiencing homelessness (not all of whom were chronically homeless), 46,550 people were unsheltered. This means that more than 20,000 unsheltered people without a severe mental illness were unsheltered and experiencing chronic homelessness.

  6. Caton, Wilkins, and Anderson, 2007, "People who experience long-term homelessness: Characteristics and interventions." Burt, Wilkins, and Mauch, 2011, Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan. M.R. Burt, 2008, Evaluation of LA's HOPE: Ending Chronic Homelessness through Employment and Housing. Washington, DC: Urban Institute, http://www.urban.org/publications/411631.html.

  7. D.P. Culhane, S. Metraux, T. Byrne, M. Steno, J. Bainbridge, and National Center on Homelessness among Veterans, "The Age Structure of Contemporary Homelessness: Evidence and Implications for Public Policy," Analyses of Social Issues and Public Policy 13.1 (2013): 1-17, http://works.bepress.com/dennis_culhane/124.

  8. HUD, 2013, 2012, Annual Homeless Assessment Report (AHAR) Report to Congress, Exhibit 2-9, https://www.onecpd.info/resources/documents/2012AHAR_FinalReport.pdf.

  9. Los Angeles Homeless Services Authority, 2011, Greater Los Angeles Homeless Count Report, Los Angeles: Los Angeles Homeless Services Authority (page 3).

  10. Mandatory benefits include inpatient and outpatient hospital services; nursing facility, rural health clinic, FQHC, prenatal and freestanding birth center services; physician, nurse-midwife, and certified pediatric and family nurse-practitioner services; home health, family planning, tobacco cessation, laboratory, X-ray services; and early and periodic screening, diagnostic, and treatment services for children under age 21.

  11. Optional benefits include clinic services; prescription drugs; rehabilitative services; case management, HCBS as an alternative to institutionalization, physical, occupational, speech, hearing, and language therapy; diagnostic, screening, and a variety of other services that may be approved by CMS.

  12. For more information see http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.html.

  13. This section is adapted from information contained in Substance Abuse and Mental Health Services Administration, Medicaid Handbook: Interface with Behavioral Health Services, HHS Publication No. SMA13-4773, Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), 2013.

  14. It is important to note that each state establishes an income criterion for Medicaid eligibility in addition to specifying services and other household characteristics. States electing to expand their income criterion for Medicaid eligibility under the Affordable Care Act began accepting households with incomes up to 133 percent of poverty or higher on January 1, 2014, but in the 25 states choosing not to expand income eligibility on January 1, 2014, single adults are still not eligible regardless of income, and families will continue to be eligible only if their household income is, on average, 48 percent of the federal poverty level (FPL) (Kaiser Family Foundation, 2014, Medicaid income limits as of January 2013 for parents and childless adults. http://kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014.

  15. HUD recently expanded the definition of chronic homelessness to include families, but the vast majority of people experiencing long or repeated episodes of homelessness are unaccompanied adults.

  16. See Wilkins, Burt, and Mauch, 2012, Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities.

  17. The law allows a standard adjustment that has the effect of increasing this limit to 138 percent of FPL. This is approximately $15,282 for an individual in 2013.

  18. In addition, the Affordable Care Act expanded Medicaid eligibility for former foster care children through age 25 if they were enrolled in foster care and Medicaid when they turned 18 or aged out of foster care. This provision expands Medicaid coverage for a group of transition-aged youth that is often at risk of homelessness and sometimes served in PSH.

  19. 2012 AHAR, 2011 data, p. 5, table 3.

  20. For more information see Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System, December 2013, http://csgjusticecenter.org/reentry/publications/medicaid-and-financing-health-care-for-individuals-involved-with-the-criminal-justice-system/.

  21. Burt, Wilkins, and Locke, 2014, Medicaid and Permanent Supportive Housing for Individuals Experiencing Chronic Homelessness: Emerging Practices from the Field.

  22. SeeCMS State Medicaid Directors Letter (SMDL), SHO #13-003, ACA #26, May 13, 2013, Facilitating Medicaid and CHIP Enrollment in 2014, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf. Other parts of the letter proposing options to maintain enrollment and prevent avoidable gaps in coverage are discussed below.

  23. For more information about these requirements see http://aspe.hhs.gov/hsp/immigration/restrictions-sum.shtml. For more information about uninsured people who do not qualify for Medicaid because of their unauthorized or recent immigration status see http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825.

  24. Described in detail in Chapter 3.

  25. For a list of Health Centers that have received federal grant funding for outreach and enrollment assistance see http://www.hrsa.gov/about/news/2013tables/outreachandenrollment/. For more information about the role of Health Centers in providing outreach and enrollment assistance see http://bphc.hrsa.gov/outreachandenrollment/.

  26. See CMS SMDL, SHO #13-003, ACA #26, May 13, 2013, Facilitating Medicaid and CHIP Enrollment in 2014, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf. Other parts of the letter proposing options to maintain enrollment and prevent avoidable gaps in coverage are discussed below.

  27. A full description of this program may be found at http://www.prainc.com/soar/.

  28. See Burt and Wilkins, 2012, Establishing Eligibility for SSI for Chronically Homeless People.

  29. See SAMHSA's Evidence-Based Practice kit for PSH at http://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-Based-Practices-EBP-KIT/SMA10-4510.

  30. C. Caton, C. Wilkins, and J. Anderson, 2007, "People who xperience long-term homelessness: Characteristics and interventions."

  31. The IMD payment exclusion is in Section 1905(a) of the Social Security Act (the Act) in paragraph (B) following the list of Medicaid services. The definition of an IMD is in Section 1905(i) of the Act and in 42 CFR 435.1010 of the Code of Federal Regulations. The exclusion for individuals aged 65 and older is in Section 1905(a)(14) of the Act, and 42 CFR 440.140. The exception for individuals under age 21 is in Section 1905(a)(16 of the Act and 42 CFR 440.160. Medicaid guidance can be found at Section 4390 of the State Medicaid Manual.

  32. Section 4.4 of this Primer provides more details about settings in which Medicaid HCBS may be delivered, including the qualities of a home and community-based setting.

  33. Section 1905(a) of the Social Security Act (the Act).

  34. Services delivered by FQHCs are a mandatory state plan benefit at Section 1905(a)(2)(C), respectively, of the Act.

  35. Section 1905(a)(13) of the Act.

  36. Section 1905(a)(19) and 1915(g)(1) of the Act.

  37. Section 1945 of the Act as added by Section 2703 of the Affordable Care Act.

  38. Section 1915(i) of the Act.

  39. Section 1915(c) of the Act.

  40. For example, a waiver under Section 1115 of the Act.

  41. Under the Social Security Act, three types of organizations are eligible to enroll in Medicaid and Medicare as FQHC. They are: (1) Health Centers that receive grants under Section 330 of the Public Health Service Act; (2) Health Centers that meet all the requirements to receive a Section 330 grant but do not receive such funding; and (3) outpatient facilities associated with tribal organizations and Urban Indian Health Organizations. The first two categories are overseen by HRSA, and in this publication are jointly referred to as "Health Centers." HCH providers are a subset of Health Centers that receive Section 330 grants. This publication does not directly address Native American providers that are enrolled as FQHCs.

  42. The primary exceptions are people with incomes below the poverty level who live in states that have not expanded Medicaid eligibility. Other exceptions are immigrants with permanent residence but who are still within the five-year period during which they cannot receive public benefits, and people without documentation.

  43. HRSA 2012 National Homeless Data http://bphc.hrsa.gov/uds/datacenter.aspx?fd=ho&year=2012.

  44. Letter from James Macrae, Associate Administrator, HRSA Bureau of Primary Care to John Lozier, Executive Director, National Health Care for the Homeless Council, April 13, 2012.

  45. HRSA 2012 National Data for Homeless: Table 4--Selected Patient Characteristics http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2012&state=&fd=ho.

  46. For more detailed information about FQHC payment methodology see Chapter 7 of this Primer and http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SHO10004.pdf.

  47. See http://bphc.hrsa.gov/policiesregulations/legislation/index.html.

  48. For more information, refer to HRSA Policy Information Notice 2008-01, Defining Scope of Project & Policy for Requesting Changes, http://bphc.hrsa.gov/policiesregulations/policies/pin200801.html.

  49. Medicaid Handbook: Interface with Behavioral Health Services was published in August 2013. It is available at http://store.samhsa.gov/product/Medicaid-Handbook-Interface-with-Behavioral-Health-Services/SMA13-4773. Some of the information provided in the Medicaid Handbook has been incorporated into this report.

  50. This Informational Bulletin is available at http://content.govdelivery.com/attachments/USCMS/2012/12/03/file_attachments/178580/CIB-12-03-2012.pdf.

  51. Medicaid makes an important distinction between rehabilitative services and habilitative services. Services provided through the rehabilitative option must "involve the treatment or remediation of a condition that results in an individual's loss of functioning." Habilitative services are services generally designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings. Habilitative services can be covered by Medicaid through a HCBS waiver or optional HCBS State Plan services. Habilitation is one of the Essential Health Benefits that must be offered when a state adopts an "Alternative Benefit Plan" to provide coverage to people who are newly eligible for Medicaid beginning in 2014. States have some flexibility to determine how to design and implement these benefits and plans, consistent with rules established by the Federal Government. On July 15, 2013, HHS and CMS issued a Final Rule that includes several changes in the Medicaid program, including requirements to ensure that Medicaid benefit packages include Essential Health Benefits and meet certain other minimum standards. This Final Rule can be found at https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit#h-14.

  52. See http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7682.pdf.

  53. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/Clarifying-Guidance-Support-Policy.pdf.

  54. CMS has been approving peer support specialists in state plan rehabilitative services for a number of years. For more information, see http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD081507A.pdf.

  55. In addition, the Community First Choice 1915(k) Option was established by the Affordable Care Act. This allows states to provide home and community-based attendant services, under a person-centered service plan, to some Medicaid enrollees with disabilities who otherwise qualify for institutional care. Community First Choice provides an enhanced federal matching rate for expenditures related to this option.

  56. For more information on Medicaid HCBS see: http://aspe.hhs.gov/daltcp/reports/2010/primer10.htm and http://www.medicaid.gov/HCBS.

  57. A link to the Final Rule, as well as links to several fact sheets and summaries prepared by CMS, are available at http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html.

  58. See SMDL, 10-024, available at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.

  59. CMS guidance offers the following provider definitions:

    • A designated provider: May be physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, other.
    • A team of health professionals: May include physician, nurse care coordinator, nutritionist, social worker, behavioral health professional, and can be freestanding, virtual, hospital-based, community mental health centers, etc.
    • A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractors, licensed complementary and alternative medicine practitioners, and physicians' assistants.

    See http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/Health-Homes-FAQ-5-3-12_2.pdf.

  60. For more information see http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10024.pdf.

  61. More information about these approved SPAs is available at http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html.

  62. A full discussion of Alternative Benefit Plans is beyond the scope of this Primer. For additional guidance about Alternative Benefit Plans, please refer to the CMS SMDL which was issued on November 20, 2012, SMDL #12-003 available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-003.pdf and additional information about Alternative Benefit Plans is available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Alternative-Benefit-Plans.html.

  63. The July 15, 2013 Final Rule regarding Essential Health Benefits and other minimum standards for Medicaid benefit packages can be found at https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit#h-14.

  64. More information about the application of parity requirements to Medicaid Alternative Benefit Plans is contained in a January 2013 CMS SMDL http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf.

  65. This requirement is contained in 42 U.S.C. § 1396a(a)(10)(B).

  66. More generally Medicaid cannot pay for room and board, services to inmates in public institutions, or services furnished to individuals residing in IMDs. These limitations apply to a wide range of Medicaid services; they are not specific to rehabilitative services.

  67. For more information about ACT as an evidence-based practice for people experiencing homelessness, see http://usich.gov/usich_resources/solutions/explore/assertive_community_treatment.

  68. CMS staff can provide additional information and guidance to states regarding requirements that are applicable to TCM services. These case management services must allow individuals free choice of any qualified Medicaid provider, and may not be used to restrict access to other Medicaid services. States may define the target group(s) for TCM services and include a separate SPA when subgroups differ in terms of services, provider qualifications, or payment methodology. Medicaid pays for TCM services only if there are no other liable third parties to pay for such services, except for case management that is included in an individualized education program or individualized family service plan.

  69. See Section 5.6 for a more extended discussion of integrated care.

  70. More information about these practices can be found in the U.S. Interagency Council on Homelessness Solutions Database at http://usich.gov/usich_resources/solutions/explore/motivational_interviewing and http://usich.gov/usich_resources/solutions/explore/integrated_treatment_....

  71. See Burt, Wilkins, and Mauch, 2012, Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan, p.6-10.

  72. See http://www.integration.samhsa.gov.

  73. These worksheets are available at http://www.integration.samhsa.gov/financing/billing-tools#Billing. It is important to understand that these worksheets provide a PIT and information may change as states change their Medicaid programs.

  74. For additional information about HCBS, see Understanding Medicaid Home and Community Services: A Primer, http://aspe.hhs.gov/daltcp/reports/2010/primer10.htm.

  75. For purposes of HCBS, the term respite refers to a service that provides a caregiver, who is often a family member, with temporary, intermittent, and substitute support services for a person with a disability who qualifies for HCBS. This is very different from the use of the term respite to refer to medical respite programs that provide services for people experiencing homelessness.

  76. A link to the Final Rule as well as links to several fact sheets and summaries prepared by CMS are available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html.

  77. Federal law prohibits Medicaid payment for room and board, but payment of a security deposit to a landlord is not considered rent.

  78. These psychosocial rehabilitation services are provided as part of a comprehensive specialized psychiatric program available to all Medicaid-eligible adults with significant functional impairments meeting the need levels in the 1915(i) resulting from an identified mental health or substance use disorder diagnosis.

  79. W. Sowers, C. George, and K. Thompson, 1999, "Level of care utilization system for psychiatric and addiction services (LOCUS): A preliminary assessment of reliability and validity." Community Mental Health Journal, 35(6):545-63.

  80. See Burt, Wilkins, and Mauch, 2011, Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan.

  81. See Burt, Wilkins, and Mauch, 2011, Medicaid and Permanent Supportive Housing for Chronicallyu Homeless Individuals: Literature Synthesis and Environmental Scan. A. Basu, R. Kee, D. Buchanan, and L. Sadowski, 2011, "Comparative cost analysis of housing and case management program for chronically ill homeless adults compared to usual care." Health Services Research.

  82. See Center for Medicaid and CHIP Services (CMCS) Informational Bulletin, July 24, 2013, Targeting Medicaid Super-Utilizers to Decrease Costs and Improve Quality, http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf.

  83. C. Mann, 2011, Medicaid and CHIP: On the Road to Reform. Presentation to the Alliance for Health Reform/ Kaiser Family Foundation (based on FY 2008 MSIS claims data). See R. Kronick M. Bella, T. Gilmer, and S. Somers, 2007, The Faces of Medicaid II: Recognizing the Care Needs of People with Multiple Chronic Conditions. Center for Health Care Strategies (CHCS), Inc., http://www.chcs.org/usr_doc/Full_Report_Faces_II.PDF.

  84. For more information, refer to the CMCS Informational Bulletin CIB-07-24-2013; see footnote 31.

  85. See text at Section 4.3.1 and associated footnote 50, for details on the difference between habilitative and rehabilitative services.

  86. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Fee-for-Service.html.

  87. Even as states increasingly move to Medicaid managed care payment and delivery systems and may provide payment to the managed care plans on a capitated (per-member per-month) basis, the managed care plans often pay some service providers on a fee-for-service basis.

  88. For details on these service and payment arrangements, see Burt, Wilkins, and Locke, 2014, Medicaid and Permanent Supportive Housing for Individuals Experiencing Chronic Homelessness: Emerging Practices from the Field.

  89. HRSA 2012 Health Center data is available at http://bphc.hrsa.gov/uds/datacenter.aspx and homeless program grantee data is available at http://bphc.hrsa.gov/uds/datacenter.aspx?fd=ho&year=2012.

  90. For a discussion on how the PPS is developed, see http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/smd011901d.pdf.

  91. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Deli... and http://kff.org/medicaid/issue-brief/medicaid-and-managed-care-key-data-trends/ for basic information on Medicaid managed care options and enrollment statistics.

  92. In most cases, the monthly fee paid to primary care providers participating in primary care case management programs is only a few dollars a month. For these programs the expected level of case management or care coordination services is significantly less-intensive than the face-to-face case management and care coordination activities that are part of efforts to facilitate access to housing and appropriate health care services chronically homeless people with complex health needs.

  93. According to CMS, in 2011 more than 74 percent of all Medicaid beneficiaries in the United States were enrolled in some form of managed care. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf.

  94. States may implement mandatory enrollment in Medicaid managed care under the authority provided by a 1915(b) waiver or 1115 demonstration waiver, or as a state plan option under Section 1932 of the Social Security Act.

  95. See http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf, page 9.

  96. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimate based on 2004 MSIS data. Cited in CHCS publication, Clarifying Multi-Morbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations, http://www.chcs.org/usr_doc/clarifying_multimorbidity_patterns.pdf.

  97. Kronick, Bella, and Gilmer, 2009, The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions.

  98. See http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf.

  99. Source: http://www.chcs.org/usr_doc/HighUtilizerReport_102413_Final3.pdf.

  100. See http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-07-24-2013.pdf.

  101. See http://www.chcs.org/publications3960/publications_show.htm?doc_id=1261570.

  102. See SMDL #12-001 available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-001.pdf and SMDL #12-002 available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-002.pdf.

  103. 220 mostly Medicare ACOs were operating as of March 2013, with 3.2 million assigned beneficiaries in 47 states plus the District of Columbia and Puerto Rico. Many are in one or another stage of development but not yet operational. See http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf. See the extensive materials, including briefs and webinars, accessible through http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/.

  104. For more information see The Balancing Act: Integrating Medicaid Accountable Care Organizations into a Managed Care Environment, http://www.chcs.org/usr_doc/ACO111313_Final.pdf.

  105. T. McGinnis, 2012, Medicaid ACOs: Collaborating toward an improved Health System, http://www.chcs.org/usr_doc/acnews0912McGinnis2.pdf.

  106. For more information see SMDL #12-002, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-002.pdf.

  107. Planning for Accountability: Emerging Medicaid ACO Models and Key Issues for States, http://www.chcs.org/publications3960/publications_show.htm?doc_id=1261575#.UnJv9vmsh8E and Accountable Care Organizations in Medicaid: Emerging Practices to Guide Program Design, http://www.chcs.org/usr_doc/Creating_ACOs_in_Medicaid.pdf.

  108. B. Heath, Jr, Kathy Reynolds, and Pam Wise Romero, 2013, A Standard Framework for Levels of Integrated Healthcare, SAMHSA-HRSA Center for Integrated Health Solutions, http://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare.

  109. Henry J. Kaiser Family Foundation, Integrating Physical and Behavioral Health Care: Promising Medicaid Models, http://kff.org/medicaid/issue-brief/integrating-physical-and-behavioral-health-care-promising-medicaid-models.


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