# Presentation: 521087

## Improving Access to Medicaid for Homeless Families with Children

- Pat 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

**Notes:**
I am Pat Post, representing the National Health Care for the Homeless Council, a membership organization comprised of Health Care for the Homeless providers across the United States. My presentation will summarize obstacles to Medicaid commonly experienced by homeless families and ways to reduce them recommended by service providers in 33 of these HCH projects. 
A more detailed analysis is available in Casualties of Complexity: Why Eligible Homeless People Are Not Enrolled in Medicaid, published by the National Health Care for the Homeless Council. This document is available on our Web site (www.nhchc.org/Publications) and is included in the resource binder provided to each State team.

## Why Does Medicaid Matter?

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

**Notes:**
Medicaid is an important safeguard of medical care for poor people.
Medicaid coverage helps to pay for primary and preventive care, which can reduce the need for costly secondary and tertiary care. 
Medicaid provides coverage for prescription medications, including psychotropic drugs, and improves access to specialty and hospital care needed to stabilize or resolve health problems that can precipitate or prolong homelessness. 
Primary care is necessary but insufficient to meet the health care needs of homeless people, whose complex health conditions partially explain why they are homeless.

## Why Homeless Children Need Health Care

- At high risk for uncontrolled, acute/chronic
-     medical conditions— asthma, otitis media, anemia, seizure disorders, dental problems
- One in 4 homeless children requires referral to a specialist at the first primary care visit
- Physically abused at twice the rate of other children;
-     3 times as likely to have been sexually abused
- > 20% of homeless 3-6 year olds have emotional problems serious enough to require professional care

**Notes:**
      Homeless children have more uncontrolled acute and chronic health problems than do poor children in stable housing, primarily due to their families’ higher psychosocial risks, residential instability, and limited access to appropriate health care. Gaps in health coverage, difficulty accessing care, and variable quality of care are common barriers experienced by homeless families. Health Care for the Homeless providers report that 1 in 4 children living in shelters require referral to a specialist at the first primary care visit, due to a chronic condition that was previously unidentified or inappropriately treated. Children living in shelters are twice as likely to have asthma as low-income housed children, and 3 to 6 times more likely than the average American child. Higher exposure to environmental allergens and lack of a regular source of care increase their risk for uncontrolled asthma. Sheltered homeless children suffer from middle ear infections (otitis media) at a rate 50% higher than the national average. These children are less likely than other children to have been breastfed, more likely to be exposed to second-hand smoke, and more likely to live in overcrowded conditions -- three main risk factors for otitis media. 
        Homeless children are physically abused at twice the rate of other children, and are 3 times as likely to have been sexually abused. Over 20% of homeless children 3-to-6 years old have emotional problems serious enough to require professional care. But not all behavioral problems experienced by homeless children are due to psychiatric disorders such as PTSD or ADHD. Many chronic medical conditions have negative developmental and behavioral consequences. For example, multiple ear infections, inappropriately treated, may result in hearing loss that can delay speech and language development, and eventually affect school performance. Sleep loss and exhaustion, common side effects of asthma can reduce a child’s capacity to learn and a mother’s ability to cope with the stress of being homeless. Untreated seizure disorders can result in brain damage. 

## Why Homeless Parents Need Health Care

- Homeless mothers have low birth weight babies at higher rates than other women
- More likely to have behavioral health problems (substance use disorders, major depression, PTSD); less likely to have a regular source of care
- > 90% homeless women have been victims of severe physical/sexual assault during their lifetime
- > 45% homeless mothers have a major depressive disorder

**Notes:**
Homeless women have low birth weight babies at higher rates than do other women. Risk factors include smoking while pregnant and periodontal infections.
Homeless women have significantly higher rates of behavioral health problems (substance use disorders, major depression, and PTSD) than low-income housed women, but are less likely to have a regular source of care. 
Over 90% of homeless women report severe physical and sexual assault during their lifetime.
More than 45% of homeless mothers have a major depressive disorder. The strongest predictor of behavioral health problems in homeless children is their mother’s level of emotional distress. 

## Reality Check

- Nearly all minor children who are homeless qualify for Medicaid
- Nearly all homeless parents who are pregnant or accompanied by children are eligible for Medicaid
- Most homeless adults do *not* qualify for Medicaid under current policy
- Few State Medicaid programs cover non-disabled adults unaccompanied by children; those that do may not cover needed services
- The only door to Medicaid for many homeless adults is SSI

**Notes:**
Although nearly all homeless children and their parents are eligible for Medicaid, the reality is that most homeless people do not qualify for Medicaid under current policy, regardless of their degree of impoverishment or medical need. 
Poor and homeless people who are not pregnant, not disabled, not elderly, or do not have dependent children – as many as two-thirds of all people known to be homeless – are ineligible for Medicaid in most States. For many homeless people, SSI (federal disability assistance) is the only door to Medicaid, although persons with a disability caused by alcohol or drug use are no longer eligible for SSI. 
Even homeless people who ARE eligible for Medicaid frequently have trouble completing the enrollment process and obtaining covered services. 

## Homeless Service Users

- 30% on Medicaid1
- 	(22% HCH clients)2
- 11% SSI1
- 55% uninsured1
- 	(73% HCH clients)2

- 1 Burt, Martha. 1996 National Survey of Homeless Assistance
-      Providers & Clients. Urban Institute, 1999.
- 2 BPHC. 2002 UDS data.
- 3 US Conference of Mayors. Hunger & Homelessness Survey, 2003.

**FOR MORE INFO...**

- 23% minor children1
- 11% custodial parents1
- 40% families+children3
- 54-66% single adults3,1

**Notes:**
Families with children represent the fastest growing portion of the homeless population, although they accounted for only one-third of all people reported to be homeless in 1996 and 40% of homeless residents in 25 cities surveyed by the U.S. Conference of Mayors in 2003. 
The obvious reason why most homeless people don’t qualify for Medicaid is that the vast majority are single-adults. Unless they have severe and chronic functional disabilities, adults unaccompanied by children do not meet eligibility criteria for Medicaid in most States. Over half of surveyed homeless people nationwide have no health insurance at all.

## 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_

**FOR MORE INFO...**

**Notes:**
Nearly one-third of uninsured homeless clients are thought to be eligible for Medicaid but not enrolled. That’s unacceptable.
We know we can bring these numbers down a little bit. Some HCH projects have demonstrated that with aggressive outreach and advocacy, 10-30% of their uninsured homeless clients can obtain Medicaid coverage. 

## 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**
- lose or fail to apply for TANF-Medicaid
- fail to apply for Medicaid spend-down
**Disabled persons**
- have difficulty getting on SSI-related Medicaid

**Notes:**
Three groups of uninsured homeless people are most likely to qualify for Medicaid: 
1. Adolescents and children who don’t apply for Medicaid — especially unaccompanied minors and immigrant children born in the United States — and those who lose Medicaid when parents no longer qualify for welfare or Transitional Medical Assistance and do not realize that their children still qualify for Medicaid.
2. Pregnant women or custodial parents qualifying for welfare who lose or never receive TANF-related Medicaid, or those meeting medically needy requirements who fail to apply for Medicaid spend-down. 
3. Disabled people automatically get Medicaid in most states when they qualify for SSI or other disability assistance. But getting SSI is extremely difficult for homeless claimants, who often lack sufficient documentation of functional impairments and fail to keep appointments for consultative examinations. Initiation and completion of the complex SSI eligibility determination process is especially difficult for those with severe mental illness, whose denial of illness and paranoia are often symptoms of their impairment.

## 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

**Notes:**
There are lots of important reasons why homeless people are eligible for Medicaid but fail to enroll. 

Many fail to apply because they thought they weren’t eligible or were unable to apply because of a functional impairment.

Others fail to complete the application and enrollment process because 
 They didn’t receive mailed information (no contact with stable address   listed on application); or 
 They couldn’t obtain or lost documentation required to confirm their eligibility (proof of  residency, age, income or assets); or 
 They couldn’t make it to the personal interview (no transportation, or competing priorities for obtaining food and shelter interfered).

## WHY Eligible but Not Enrolled?

**  ****Eligibility denied**
- Didn’t have required documentation
**  ****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

**Notes:**
Even persons who complete the application process may have their eligibility denied when some of the documentation they submitted is determined to be insufficient.
 Finally, homeless people are inappropriately disenrolled from Medicaid because they fail to receive or respond to a recertification notice, because they can’t present required documentation to verify continued eligibility, or when their due process rights are violated. 
This isn’t surprising, given the variation of Medicaid eligibility requirements and enrollment procedures from State to State, compounded by the mobility of people living in crisis. Homeless persons who qualify for Medicaid in one State but move to another are among those most likely to be eligible but not enrolled.  Obtaining required documentation to verify eligibility (birth certificates, proof of income and residency) is especially difficult for victims of physical and emotional abuse. 

## 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

**Notes:**
Three kinds of enrollment barriers prevent eligible homeless persons from obtaining Medicaid coverage, according to surveyed homeless service providers and the published literature: 
1. system inadequacies, 
2. problems related to homelessness, and 
3. actions deterring enrollment that are contrary to law or public policy.
Lengthy and complex enrollment procedures, excessive documentation requirements, poorly trained and overburdened eligibility workers, and lack of accommodation for non-English speakers and persons with educational and functional limitations — these are some of the system inadequacies that discourage homeless people from completing Medicaid application and enrollment procedures. 

## 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

**Notes:**
Proof of identity, residence and income is difficult to come by for people without a home or a car or continuous employment, especially for those who are fleeing domestic violence. Obtaining required documentation is often costly, time-consuming and intimidating, and homeless people may have no safe place to keep it, once it is obtained. Personal papers are often stolen or lost in moving from place to place. Lack of required documentation to verify eligibility is the most frequently cited Medicaid enrollment obstacle for homeless people.
Mental illness and substance abuse, lack of transportation, transience, and educational and functional limitations also present barriers to enrollment. Mistrust of government programs and fear of public officials from past experience also explain their reluctance to apply for entitlements. 
Finally, persons experiencing homelessness may be intimidated by paperwork (especially if they don’t read or speak English), they may not understand the benefits of Medicaid coverage, or they may fail to complete the enrollment process because they are unaware that their application has been approved.

##  Enrollment Barriers

**  ****Other deterrents**
- Inaccessible eligibility workers
- Violation of enrollees’ due process rights
- Inappropriate information sharing with INS

- Schlosberg, Claudia. National Health Law Program 1997, 1998.

**SOURCE:**

**Notes:**
Other deterrents to enrollment include actions that are contrary to law or public policy:
Failure to outstation eligibility workers. Unless a state demonstrates that it has an equally or more effective alternative plan for outstationing, the state must have an outstationed eligibility worker at every disproportionate share hospital or Federally Qualified Health Center participating in the state’s Medicaid program (HRSA, 2001). As of April 2000, only 6 states had satisfactorily met federal outstationing requirements.
Violation of due process rights. These include the right to timely notification of a change in eligibility, and the right to a hearing and continued benefits pending determination of their eligibility under any other category in the state’s Medicaid plan.
Inappropriate information sharing with the INS  Medicaid eligibility workers are not required by federal law to share information about the immigration status of applicants with the Immigration and Naturalization Service. Doing so often deters undocumented homeless parents from applying for Medicaid for children born in the US, who are eligible.

## Improving Access to Medicaid

**Goals:**
- Remove enrollment barriers for eligible homeless people
- Provide comprehensive benefits including mental/behavioral health services
- Ensure access to covered services and stable housing
- Expand eligibility for homeless adults

**Notes:**
Research has demonstrated that having Medicaid improves homeless families’ access to health care — particularly medical care. To increase their access to Medicaid, State and local policy makers are advised to work toward the following goals:
1. First, expedite the enrollment of homeless people who are likely to be eligible for Medicaid, including children, custodial parents, and persons with chronic, disabling conditions.
2. Second, resist the temptation to adopt bare-bones benefit packages that fail to meet the comprehensive health care needs of people with chronic illnesses; offer comprehensive benefits, including mental health care and appropriate substance abuse treatment services.
3. Third, make sure that Medicaid enrollees can obtain the services to which they are entitled, optimally within the context of stable housing.
4. Finally, expand Medicaid coverage to include more single adults, who comprise the vast majority of homeless people.

## 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 third-party representatives to facilitate enrollment and access to covered services

**Notes:**
We know how to increase access to Medicaid for eligible homeless people. The only question is whether we have the willingness to do so. Three strategies are known to work. They are simple and make common sense, even within severe fiscal constraints:
1. Be able to identify applicants and enrollees as homeless. Because public costs associated with delayed or inappropriate health care for homeless families are especially high, every effort should be made to facilitate early access to the most cost-effective care to meet their medical and psychosocial needs.  
2. Be willing to adapt certain procedures to accommodate persons known to be homeless.
3. Use third-party representatives, such as experienced homeless assistance providers, 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 homeless children, pregnant/disabled adults
-  Preventive health education and screenings in
-     family shelters and school-based clinics
-  Community work groups to monitor and
-     address access barriers
-  HCH providers as liaisons for homeless
-     Medicaid beneficiaries

**Notes:**
MA, NY, and CT all have a place on their Medicaid application and a data field in their Medicaid management information system that enable the Medicaid agency to identify applicants and enrollees who are homeless and to track the cost, utilization, and quality of services provided to them.
29 States offer presumptive Medicaid eligibility for pregnant women, and presumptive eligibility is available to low-income children in 8 States (CA, CT, MA, MO, NE, NH, NJ, and NM). Presumptive eligibility for Social Security Income (which is linked to Medicaid in most States) is also an option that can States and localities can use to expedite health care access for persons with severe functional impairments. Baltimore and Chicago have implemented presumptive SSI eligibility for homeless persons with severe mental illness.
In TN, the TennCare Shelter Enrollment Project initiated expedited enrollment in the State’s Medicaid managed care program for sheltered homeless children in 20 counties during 2002. Last year, a few local health departments began to conduct health screenings at selected family shelters. Stakeholder groups including shelter providers meet regularly in communities across the State to monitor and reduce access barriers to TennCare enrollment and covered services. As a result, over 80% of homeless children residing in TN emergency shelters are enrolled in TennCare, more than 30% of enrolled children see a primary care provider during their shelter stay, and only 5% of homeless children lack health insurance by the time they leave homeless or domestic violence shelters.
In MA, health care providers can serve as representatives of homeless Medicaid enrollees; a copy of all communications from the Medicaid agency is sent to the enrollee’s authorized representative, who confirm their homeless status and helps to locate them. We invite you to tell what communities in your State are doing during the discussion period following these remarks.

## What States Can Do

-  **Simplify application/enrollment**
-  Reduce documentation requirements
-  Eliminate face-to-face interview & asset test
-  Standardize/expedite eligibility determination
-  Outstation eligibility workers at FQHCs
-  Verify eligibility only once annually
-  Convene community work groups to identify
-     and address enrollment/service access barriers

**Notes:**
Some States have already demonstrated a number of ways that are known to improve the likelihood that eligible homeless people will enroll in Medicaid. Simplification of application and enrollment procedures is something that all States can do. Here’s how:
 Reduce documentation requirements: Allow self- declaration of residency and income, which can be verified by audits or data matching with State records. Under federal law, the only document that individuals must provide in establishing eligibility for Medicaid is proof of immigration status, if the applicant is a non-citizen.  Many States require as many as 20 different documents. Research indicates that non-means-tested health insurance affords better access to health care than Medicaid does. The complexity of Medicaid eligibility requirements and enrollment procedures partially explain that discrepancy.
 Eliminate the face-to-face interview and asset test. Most states have dropped the face-to-face interview as a requirement for Medicaid enrollment and renewal, but parents still have a harder time obtaining and renewing health coverage than do children. 46 States have eliminated the asset test for children, and 21 States, including Arizona and Oklahoma, have eliminated the asset test for parents of Medicaid-eligible children, resulting in significant administrative cost savings and no increase in the Medicaid eligibility error rate. 
 Standardize and expedite eligibility determination. This can can help to prevent delays in needed health care and more costly care when untreated health problems deteriorate. 
 Outstation eligibility workers at Federally Qualified Health Centers (FQHCs) and other places where homeless families with children obtain services, including emergency shelters. By April 2000, 38 states had outstationed eligibility workers in at least one of their FQHCs. Maine and Oklahoma have implemented outstationing in most or all of their FQHC grantees.
 Verify eligibility only once annually. 38 States (including Arizona, Iowa, Maine, Michigan, and New Hampshire) allow children on Medicaid and their parents to renew coverage every 12 months. 
 Use community-based, interagency collaboration as a vehicle for identifying and addressing Medicaid enrollment barriers experienced by homeless families.

## What States Can Do

**Ensure access to appropriate services**
- Tailor services to meet the needs of people experiencing homelessness – integrate medical and psychosocial services
- Specify expectations for the delivery of services to homeless enrollees in contracts with managed care organizations/ providers

- 	GWU Center for Health Services Policy & Research.* Purchasing Specifications: Medicaid Managed Care for Individuals Who Are Homeless*,* *June 2000: www.gwhealthpolicy.org/newsps/Home_/_

**FOR MORE INFO...**

**Notes:**
To ensure access to health services that are likely to help stabilize homeless people or prevent homelessness altogether, States should
Tailor Medicaid services to meet the needs of people experiencing homelessness. Resist the temptation to adopt “bare-bones” benefit packages that fail to meet the comprehensive health care needs of people with chronic illnesses; offer comprehensive benefits including mental health care, appropriate substance abuse treatment, and access to transitional housing. 
Make sure that Medicaid enrollees can obtain the services to which they are entitled. Remember that stable housing improves access to both health insurance coverage and health care. 
Specify expectations for the delivery of services to homeless enrollees in contracts with managed care organizations and providers. Use the model managed care contract language developed for HRSA by George Washington University (available online) to assure that homeless Medicaid recipients in managed care plans receive appropriate services from experienced providers. 

## What States Can Do

**Expand coverage for homeless adults**
- Use cost-savings from administrative simplification and coordination to expand Medicaid eligibility and covered services for adults unaccompanied by children
- Remember that many homeless youth and single adults were once homeless children

**Notes:**
Finally, States are urged to implement federal options to cover more uninsured adults in their Medicaid programs, recognizing that adults unaccompanied by children comprise the vast majority of uninsured homeless people, and that many homeless youth and single adults were once homeless children. 
Cost savings — from administrative simplification and coordination, from less uncompensated care, reduced utilization of unnecessary emergency and hospital care, and adherence to evidence-based medicine — can make Medicaid expansions both affordable and cost-effective, even within severe fiscal restraints.

## 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

**Notes:**
Remember that the most cost-effective strategy to prevent and end homelessness for homeless families and individuals is to assure 
universal health coverage, 
affordable housing, 
a living wage for those who are able to work, and 
adequate disability benefits for those who cannot.