U.S. Department of Health and Human Services …

1 Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term Care Policy A PRIMER ON USING MEDICAID FOR PEOPLE EXPERIENCING CHRONIC HOMELESSNESS AND TENANTS IN PERMANENT SUPPORTIVE HOUSING July 2014 Office of the Assistant Secretary for Planning and Evaluation The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the Department of Health and Human Services (HHS) on policy development issues, and is responsible for major activities in the areas of legislative and budget development, strategic planning, policy research and evaluation, and economic analysis. ASPE develops or reviews issues from the viewpoint of the Secretary, providing a perspective that is broader in scope than the specific focus of the various operating agencies.

2 ASPE also works closely with the HHS operating agencies. It assists these agencies in developing policies, and planning policy research, evaluation and data collection within broad HHS and administration initiatives. ASPE often serves a coordinating role for crosscutting policy and administrative activities. ASPE plans and conducts evaluations and research--both in-house and through support of projects by external researchers--of current and proposed programs and topics of particular interest to the Secretary, the Administration and the Congress. Office of Disability, Aging and Long-Term Care Policy The Office of Disability, Aging and Long-Term Care Policy (DALTCP), within ASPE, is responsible for the development, coordination, analysis, research and evaluation of HHS policies and programs which support the independence, Health and long-term care of persons with disabilities--children, working aging adults, and older persons.

3 DALTCP is also responsible for policy coordination and research to promote the economic and social well-being of the elderly. In particular, DALTCP addresses policies concerning: nursing home and community-based Services , informal caregiving, the integration of acute and long-term care, Medicare post-acute Services and home care, managed care for people with disabilities, long-term rehabilitation Services , children s disability, and linkages between employment and Health policies. These activities are carried out through policy planning, policy and program analysis, regulatory reviews, formulation of legislative proposals, policy research, evaluation and data planning. This report was prepared under contract #HHSP23320095624WC between HHS s ASPE/DALTCP and Abt Associates, Inc. For additional information about this subject, you can visit the DALTCP home page at or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, Humphrey Building, 200 Independence Avenue, , Washington, 20201.

4 Her e-mail address is: A PRIMER ON USING MEDICAID FOR PEOPLE EXPERIENCING CHRONIC HOMELESSNESS AND TENANTS IN PERMANENT SUPPORTIVE HOUSING Carol Wilkins Martha Burt Gretchen Locke Abt Associates July 23, 2014 Prepared for Office of Disability, Aging and Long-Term Care Policy Office of the Assistant Secretary for Planning and Evaluation Department of Health and Human Services Contract # HHSP23320095624WC The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services , the contractor or any other funding organization. i TABLE OF CONTENTS ACKNOWLEDGMENTS .. iv ACRONYMS .. v 1. INTRODUCTION .. 1 Innovative Strategies .. 1 Primary Audience for this 2 Characteristics of People Experiencing Chronic Homelessness .. 2 Why Focus on People Experiencing Chronic Homelessness.

5 4 Medicaid Not Expected to Pay for Housing .. 5 The Rest of This Primer .. 5 2. MEDICAID ELIGIBILITY AND ENROLLMENT .. 7 Eligibility for Medicaid .. 8 Enrollment Strategies .. 11 Helping Establish Supplemental Security Income .. 16 Summary .. 17 3. PERMANENT SUPPORTIVE HOUSING AND Services FOR PEOPLE EXPERIENCING CHRONIC HOMELESSNESS .. 18 Permanent Supportive Housing for People Experiencing Chronic Homelessness .. 18 Summary .. 24 4. MEDICAID AUTHORITIES AND OPTIONS, PROVIDERS AND SETTINGS .. 25 Overview of Authorities and Options .. 25 Federally Qualified Health Centers .. 26 Medicaid State Plan Optional Behavioral Health Benefits-- Rehabilitative Services and Targeted Case Management .. 31 Medicaid Home and Community-Based Services .. 36 Other Medicaid Waivers .. 39 Health Homes .. 40 Alternative Benefit Plans.

6 42 Summary .. 43 ii 5. DEFINING MEDICAID BENEFITS AND Services .. 45 Federally Qualified Health Center Services .. 45 Rehabilitative Services .. 46 Case Management .. 49 Collateral Contacts, Team Conferences, and Case Consultation .. 52 Services to Address Substance Use Disorders .. 53 Diversionary Services Covered Through Medicaid Managed Care Under an 1115 Waiver .. 54 Integrating Primary Care and Behavioral Health Services .. 55 Home and Community-Based Services .. 58 Summary .. 61 6. MEDICAL NECESSITY CRITERIA: WHO CAN RECEIVE SPECIFIC Services ? .. 63 Medical Necessity Criteria: Implications for People Living in Permanent Supportive Housing .. 63 Considerations for State Policymakers and Their Partners--New Ways to Think About Vulnerability and Medical Necessity .. 70 Summary .. 72 7. MEDICAID PAYMENT MECHANISMS AND INNOVATIVE SERVICE DELIVERY STRUCTURES.

7 74 Medicaid Fee-For-Service Payment Mechanisms .. 74 Medicaid Managed Care Payment Mechanisms .. 81 Payment Reform: Emerging Structures for Improving Health Outcomes and Reducing Costs .. 86 Summary .. 94 8. PUTTING THE PIECES TOGETHER .. 95 Making Changes, From Small Steps to Comprehensive Redesign .. 96 The Focus of State Change Efforts .. 98 The Need for Flexible Funding and the Role of Local Public and Private Funders .. 100 Changes at the Provider Level .. 100 Conclusion--Making It Happen .. 101 iii LIST OF EXHIBITS EXHIBIT Possible Service Definitions for Two New Housing Services Provided under 1915(c) Waiver .. 60 EXHIBIT Eligibility for Different Medicaid Services .. 73 EXHIBIT Impact of Behavioral Health Comorbidities on Per Capita Hospitalization among Medicaid-Only Beneficiaries with Disabilities .. 87 iv ACKNOWLEDGMENTS The Office of the Assistant Secretary for Planning and Evaluation, within the Department of Health and Human Services (HHS), acknowledges with gratitude the assistance of the HHS Centers for Medicare and Medicaid Services , the HHS Substance Abuse and Mental Health Services Administration, the HHS Health Resources and Services Administration, the Department of Housing and Urban Development, and the Interagency Council on Homelessness in completing this Primer.

8 At Abt Associates, Dr. Jill Khadduri and Dr. Meryl Finkel provided thoughtful review throughout the project. We also acknowledge the late Gary Smith, the principal author of the 2007 Centers for Medicare and Medicaid Services document, A Primer on How to Use Medicaid to Assist Persons Who are Homeless to Access Medical, Behavioral Health , and Support Services . v ACRONYMS The following acronyms are mentioned in this report. ACO Accountable Care Organization ACT Assertive Community Treatment AHAR Annual Homeless Assessment Report AIDS Acquired Immune Deficiency Syndrome CHCS Center for Health Care Strategies CHIP Children's Health Insurance Program CMCS CMS Center for Medicaid and CHIP Services CMS HHS Centers for Medicare and Medicaid Services COPD Chronic Obstructive Pulmonary Disease CSPECH Community Support Program for People Experiencing Chronic Homelessness DRA Deficit Reduction Act DSM-IV-TR Diagnostic and Statistical Manual, IV version.

9 Text revision FPL Federal Poverty Level FQHC Federally Qualified Health Center FY Fiscal Year GAF Global Assessment of Functioning HCBS Home and Community-Based Services HCH Health Care for the Homeless HHO Heartland Health Outreach HHS Department of Health and Human Services HIV Human Immunodeficiency Virus HRSA HHS Health Resources and Services Administration HUD Department of Housing and Urban Development IMD Institution for Mental Disease LOCUS Level of Care Utilization System LTSS Long-Term Services and Supports OB/GYN Obstetrics and Gynecology vi PIT Point in Time POC Plan of Care PPS Prospective Payment System PSH Permanent Supportive Housing SAMHSA HHS Substance Abuse and Mental Health Services Administration SMDL State Medicaid Directors Letter SMI Serious Mental Illness SNAP Supplemental Nutrition Assistance Program SOAR SSI/SSDI Outreach, Access, and Recovery SPA State Plan Amendment SSDI Social Security Disability Insurance SSI Supplemental Security Income TCM Targeted Case Management 1 1.

10 INTRODUCTION Ample evidence documents the potential for people with complex Health and behavioral Health conditions who have been homeless to achieve housing stability, pursue recovery, manage chronic Health conditions, and stay out of hospitals, if they receive appropriate Health care, other Services and supports, and care coordination. On January 1, 2014, in states that have chosen to expand Medicaid eligibility under the Affordable Care Act, nearly all chronically homeless people who lacked Health insurance became eligible for Medicaid. Even in states that have not expanded their Medicaid programs, Medicaid still offers eligible beneficiaries experiencing homelessness critical Health and supportive Services . This Primer offers state Medicaid officials and other interested parties strategies for using Medicaid to meet the needs of this very vulnerable population--some strategies that have succeeded in the past and some that are emerging under provisions of the Affordable Care Act.