# Presentation: 692827

## Improving Access to Medicaid Services for Homeless Families with Children 

**Patricia A. Post, MPA**
- National Health Care for the Homeless Council
- P.O. Box 60427, Nashville, TN 37206-0427
- 615-226-2292  council@nhchc.org
- www.nhchc.org

- Policy Academy 9
- November 2, 2005, Anaheim, CA

## Homeless families with children have more health problems but less access to health care than other families.  

**Homeless families with children have more health problems but less access to health care than other families.  **

## Homeless Parents

**More likely to have mental/behavioral health problems**
**Less likely to have a regular source of health care **
**     **
** **
**  **

**National Center on Family Homelessness, 1999**
**Institute for Children in Poverty, 1999**

** ****Homeless mothers have low-birth weight babies at**
**    ****twice the rate of other women (17% vs. 7.8%)**

**Notes:**
The experience of homelessness has been 
     found to impair the psychological
     functioning of homeless people, 
     regardless of age, gender, diagnosis, or 
     medical/psychological history.

	— Gonzalez EA et al. Neuropsychological evaluation of higher functioning homeless persons: A comparison of an abbreviated test battery to the mini-mental state exam. Journal of Nervous and Mental Disease; 189(3): 176–181, 2001.

## Homeless Parents

**>90% of homeless women **
**    ****have been victims of severe **
**    ****physical or sexual assault **
**    ****during their lifetime **
**>45% of homeless mothers **
**    ****have a major depressive **
**   ****disorder**
**     ****National Center on Family **
**     ****Homelessness, 1999**
**     **

## Homeless Children

**Physically abused at twice **
**    ****the rate of other children   **
**3 times as likely to have **
**    ****been sexually abused**
**>20% of homeless 3- to 6-year-olds have emotional problems serious enough to require professional care**

**National Center on Family Homelessness, 1999**

## Homeless Children

**3 to 6 times more likely to have ****asthma**** than the average American child        **
**Suffer from ****otitis media**** at rates 50% higher than the national average **
**1 in 4 homeless children ****requires referral to a specialist**** at the first primary care visit****   **
- 	Institute for Children & Poverty, 1999
- 	The Children’s Health Fund, 1999
- 	New York Children’s Health Project, 2002** **

## Why Does Medicaid Matter?

**  ****Helps pay for primary & preventive care that can**
**     ****reduce need for costly secondary & tertiary care **
**  ****Improves access to specialty & hospital care**
**  ****Provides coverage for prescription medications**
**  ****Helps people manage disabling conditions that **
**    ****precipitate and prolong homelessness**

## Reality Check

**Nearly all minor children who are homeless and all homeless parents who are pregnant or accompanied by children are eligible for Medicaid. **
**BUT 20% of children and 33% of parents in homeless families have ****no health insurance****.**
**Medicaid does not ensure access to needed health care — especially ****mental/behavioral health care****.**
**For most homeless adults unaccompanied by children, the only door to Medicaid is SSI.**

**Martha Burt. The Role of Medicaid in Improving Access to Care for Homeless Families, 2002**

## Homeless Service Users

**55% single adults****1**
**40% families with children****1**
**    ****23% minor children****2**
**5% unaccompanied youth****1**

**1**** US Conference of Mayors. Hunger & Homelessness Survey, 2004.**
**2**** Burt, Martha. 1996 National Survey of Homeless Assistance **
**  ****Providers & Clients.  Urban Institute, 1999.**
**3**** BPHC, 2004. (172 HCH grantees)**

**55% ****uninsured****2**
**  ****(71% HCH clients****3****)**
**	**
**30%**** Medicaid****2**
**   ****(****23% HCH clients****3****)**
**11% SSI****2**

## Eligible but Not Enrolled

-  **Nearly 1/3 of uninsured homeless clients may  **
**     ****be eligible for Medicaid but are not enrolled.**
-  **Aggressive outreach and advocacy can enable **
**	****10–30% of uninsured homeless clients to obtain Medicaid coverage.**

**Post, Patricia. Casualties of Complexity: Why Eligible Homeless **
**People Are Not Enrolled in Medicaid. Nat’l HCH Council, 2001:**
**www.nhchc.org/CasualtiesofComplexity.pdf**

## WHO Is Eligible but Not Enrolled?

**    ****Adolescents & Children**
** ****Don’t apply ****(immigrants, unaccompanied  minors)**
** ****Apply for SCHIP but not Medicaid**
** ****Lose coverage when a parent rolls off TANF**
**    ****Custodial parents & guardians**
** ****Lose or fail to apply for TANF-Medicaid**
** ****Fail to apply for Medicaid spend-down (Medically    Needy program)**
**Disabled persons**
** ****Have difficulty getting SSI-related Medicaid**
**    **

## WHY Eligible but Not Enrolled? 

**Failed to apply**
**Thought they weren’t eligible**
**Impaired capacity to apply**
**Didn’t complete enrollment**
**Failed to receive mailed information**
**Insufficient documentation**
**Didn’t show up for personal interview**

## WHY Eligible but Not Enrolled? 

** ****Eligibility denied**
**Didn’t have required documentation**
**   ****(e.g., proof of identity/residence/income)**
** ****Inappropriately disenrolled**
**Failed to receive/respond to recertification notice **
**Lack of required documentation to confirm continued eligibility**
**Lost benefits in violation of due process **
**   ****rights**

## Enrollment Barriers

**System inadequacies**
** ****Lack of outreach and application assistance**
** ****Ineffective communication of requirements**
** ****Lengthy, confusing application forms & process**
** ****Delayed eligibility determination**
** ****Poorly trained eligibility workers with**
**    ****negative attitudes toward applicants**

## Enrollment Barriers

** ****Problems related to homelessness**
** ****Transience, lack of transportation **
** ****Cognitive/functional impairment**
** ****Low educational/literacy level, **
**    ****limited English proficiency**
** ****Low priority for health care except in **
**    ****an emergency**

## Enrollment Barriers

**Other deterrents**
** ****Inaccessible eligibility workers **
** ****Violation of enrollees’ due process rights*******
** ****Inappropriate information sharing with**
**    ****Immigration & Naturalization Service**

- * **Right to timely notification of a change in eligibility,**
**   ****to a hearing, and to continued benefits pending**
**   ****determination of eligibility under any other category**
**   ****in the State’s Medicaid plan.**

## Improving Access to Medicaid

** ****Remove enrollment barriers for eligible **
**    ****homeless people. **
** ****Provide comprehensive benefits, including**
**    ****appropriate care for mental illness and**
**    ****substance use disorders. **
** ****Ensure access to Medicaid services and stable **
**    ****housing.**
** ****Expand eligibility for homeless adults.**

**Goals:**

## Improving Access to Medicaid

**     ****Strategies:**
** ****Be able to identify Medicaid applicants/enrollees**
**    ****as homeless. **
** ****Be willing to adapt certain procedures to**
**    ****accommodate persons known to be homeless.**
** ****Use outreach and case management to facilitate**
**    ****enrollment and access to covered services. **

## Models that Work

** ****Data field in Medicaid MIS to identify/track  **
**     ****homeless applicants and enrollees  **
** ****Presumptive eligibility/expedited enrollment **
**     ****for low-income children, pregnant/disabled adults****   **
**       ****CA, IL, MA, MO, NH, NJ, NM             29 States****   ****e.g., Baltimore, Chicago, Seattle****    **

**MA, NY, CT**

## Models that Work

** ****Preventive health education and screenings in **
**     ****family shelters and school-based clinics****  ****TN,**** ****CA **
** ****HCH providers as liaisons for homeless **
**     ****Medicaid applicants & enrollees****  ****Boston HCH Program**

## Models that Work

** ****Outreach to homeless & domestic violence shelters**
** ****Community workgroups to monitor and address **
**     ****access barriers**

**TennCare Shelter Enrollment Project, Tennessee**

## What States Can Do

**Simplify application & enrollment procedures**
-  **Reduce documentation requirements.**
** ****Eliminate face-to-face interview & asset test.**
**     **
** ****Standardize/expedite eligibility determination.**

## What States Can Do

**Simplify application & enrollment procedures**
**  ****Outstation eligibility workers at Federally**
**      ****Qualified Health Centers/family shelters.**
**  ****No waiting period before enrollment; **
**      ****verify eligibility only once annually.**
**  ****Convene community work groups to identify and**
**      ****address enrollment obstacles and access barriers.**

## What States Can Do

**Ensure access to appropriate services**
**Tailor services to meet the needs of homeless people — integration of medical and psychosocial services.**
**Specify expectations for services to homeless **
**    ****enrollees in contracts with managed care**
**    ****organizations and providers.**
**     ****Purchasing Specifications: Medicaid Managed Care for Individuals**
**     ****Who Are Homeless. GWU Center for Health Services Policy & **
**     ****Research, June 2000: www.gwhealthpolicy.org/newsps/Home/**

## What States Can Do

**Expand coverage for homeless adults**
**Use cost-savings from administrative simplification/ coordination to expand Medicaid eligibility and covered services for adults.**
*Remember:* **Many homeless youth and single **
**   ****adults were once homeless children.**

## Most Cost-effective Strategy

**To prevent and end homelessness:**
-  **Universal health coverage **
** ****Affordable housing**
** ****A living wage for those able to work**
** ****Adequate disability benefits for **
**    ****those who cannot**

## Health Care is a Human Right. 

**Homeless people are **
**the sum total of **
**our dreams**
** ****policies **
**intentions **
**errors **
**omissions **
**cruelties **
**and kindnesses **
**as a society.**
***Peter Marin, sociologist***