# Presentation: 138443

## Improving Access to Medicaidfor Homeless People

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

**Notes:**
This presentation briefly summarizes some important ways in which state and local officials can help to prevent and end chronic homelessness by improving access to Medicaid services.

## Why Does Medicaid Matter?

- Helps pay for primary and preventive care services, which reduce costly specialty and hospital care
- Improves access to secondary and tertiary care (*Primary care isn’t enough to meet health care needs of chronically homeless people*)
- 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 helps pay for primary and preventive care, which can reduce the need for costly specialty and hospital care. Medicaid provides coverage for prescription medications and improves access to secondary and tertiary care that is needed to stabilize or resolve health problems that can precipitate or prolong homelessness. (Primary care isn’t enough to meet the health care needs of chronically homeless people.)

## Reality Check

- Most homeless people do not qualify for Medicaid under current policy
- Few State Medicaid programs cover nondisabled adults, and those that do may not cover needed services
- For many homeless people, SSI (disability assistance) is the only door to Medicaid

**Notes:**
But the reality is that most poor and homeless people do not qualify for Medicaid under current policy. Few state Medicaid programs cover nondisabled adults. For many homeless people, SSI is the only door to Medicaid. 

## Homeless Service Users

- 55% uninsured
- 	(64% HCH clients)
- 30% on Medicaid
- 	(20% HCH clients)
- 11% SSI

- Burt, Martha. 1996 National Survey of Homeless Assistance
-      Providers & Clients. Urban Institute, 1999.
- BPHC. 2002 UDS data.

**FOR MORE INFO...**

- 66% single adults
- 23% minor children
- 11% custodial parents

**Notes:**
The obvious reason why most homeless people don’t qualify for Medicaid is that two-thirds of them 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 and two-thirds of homeless adults unaccompanied by children have no health insurance at all.
According to the 1996 National Survey of Homeless Assistance Providers and Clients, 66% of homeless service users are adults unaccompanied by children, 23% are minor children and 11% are custodial parents; 30% are on Medicaid, only 11% have SSI, and 55% are uninsured. Fewer HCH clients are on Medicaid (19%) and more are uninsured (73%), mainly because most homeless people who are eligible for Medicaid tend to go elsewhere for medical care. 
Lack of health insurance is a serious problem for displaced individuals and families, because it prevents them from obtaining the health care they need to stabilize or resolve health problems that can precipitate or prolong homelessness. 

## Eligible but Not Enrolled

- Nearly 1/3 of uninsured homeless clients may be eligible for Medicaid but are not enrolled
- Aggressive outreach & 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 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. 
  Nevertheless, the reality is that most homeless people do not qualify for Medicaid under current policy. 

## WHO Is Eligible but Not Enrolled?

**   ****Disabled persons**
- have difficulty getting on SSI-related Medicaid
**   ****Women**
- fail to apply for Medicaid spend-down
- lose or fail to apply for TANF-Medicaid
**   ****Children**
- don’t apply (immigrants, unaccompanied minors)
- apply for SCHIP but not Medicaid
- lose coverage when a parent rolls off TANF

**Notes:**
Three groups of uninsured homeless people are most likely to qualify for Medicaid: 
 Disabled people automatically get Medicaid in most states when they qualify for Social Security Income or other disability assistance. But getting SSI is extremely difficult for this population, particularly for persons with severe mental illness. 
Women meeting medically needy requirements who fail to apply for Medicaid spend-down, or those qualifying for welfare who inappropriately lose or fail to apply for TANF-related Medicaid.
Children and adolescents who don’t apply for Medicaid—especially immigrant children born in the US and unaccompanied minors; children who apply for the State Children’s Health Insurance Program but not for Medicaid; and children who lose Medicaid when their parents no longer qualify for welfare or Transitional Medical Assistance and do not realize that their children still qualify for 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

**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 those who complete the application process may have their eligibility denied when some of the documentation they submitted (proof of residency, age, income or assets) 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 of continued eligibility at recertification, or when their due process rights are violated. 

## 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:**
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. 
For example, the Federal Medicaid statute specifies only one documentation requirement to verify eligibility (proof of citizenship), while New York State’s Medicaid agency regulations prescribe 20. New York is not alone in requiring excessive documentation to confirm eligibility.

## Enrollment Barriers

** ****Problems related to homelessness**
- Transience, lack of transportation
- Cognitive/ functional impairment
- Low educational/ literacy level, LEP
- 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. 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 on foot. 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, particularly for chronically homeless people.
Mistrust of government programs from past experience, and fear of public officials who may be associated with law enforcement efforts to drive homeless people from the area also explain their reluctance to apply for entitlements. Finally, persons experiencing homelessness may be intimidated by paperwork (especially if they are illiterate or don’t speak English), then may not understand the benefits of Medicaid coverage, or 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:**
Actions deterring enrollment include:
Failure to outstation eligibility workers. Federal policy requires State Medicaid agencies to provide outstationed Medicaid eligibility workers at all FQHCs serving families and children—but most of they aren’t doing it. 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 sharing of applicant information with 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.

##  Medicaid Access,  Homelessness

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

**Notes:**
How can state and local officials increase the access of homeless people to Medicaid services? The checklist is short and makes common sense:
1. First, expedite the enrollment of homeless people who are likely to be eligible for Medicaid, particularly those with chronic disabling conditions.
2. Second, expand coverage to include more single adults, who comprise the vast majority of chronically homeless people.
3. Third, 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.
4. Finally, be sure that enrollees can obtain the services to which they are entitled, optimally within the context of stable housing.

## What States Can Do

**     ****Three primary strategies:**
- Be able to identify 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.

## Models that Work

- Data field in Medicaid MIS to identify/track homeless beneficiaries - Boston, NYC, CT
- Outreach/presumptive eligibility for persons
-    with disabilities  - Maryland, Chicago
- Homeless Unit in SSA field office to identify/address reasons for delayed/denied disability claims - Boston
- HCH providers as liaisons for homeless applicants and enrollees - Massachusetts

**Notes:**
Boston, New York, and Connecticut all have a place on their Medicaid application and a data field in their Medicaid management information system (MIS) that allow the Medicaid agency to identify applicants and enrollees who are homeless and (potentially) to track the cost/utilization of services provided to them.
The SSA field office in Chicago sends outreach workers to the psychiatric unit at a local university hospital to initiate SSI/SSDI applications for all mentally ill inpatients likely to qualify for benefits.  They get physicians to fill out medical reports before the patients are discharged, to assure that diagnoses are appropriately documented, and work to expedite approval for disability benefits and Medicaid enrollment.
Boston’s SSA field office has established a Homeless Unit  with special expertise in processing disability claims filed by homeless individuals. Advocates have worked closely with DDS staff to identify the reasons why homeless claimants have a higher rate of denials than other claimants (e.g., insufficient medical evidence of disability, failure to show up at consultative evaluation), and to address them.
In Massachusetts, health care providers can serve as representatives and liaisons with homeless Medicaid enrollees; a copy of all communications from the Medicaid agency is sent to the enrollee’s authorized representative, who confirms homeless status and helps to locate the enrollee.

## Simplify Application/Enrollment

- Reduce documentation requirements: allow self-declaration of residency & income (verified by audits or data matching with State records)
- Eliminate face-to-face interview & asset test
- Standardize/expedite eligibility determination
- Outstation eligibility workers at FQHCs
- Verify eligibility once annually

**Notes:**

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. 7 states including Nebraska have dropped the face-to-face interview requirement a renewal for parents, as well as children. 21 states, including Connecticut, Delaware, Oklahoma, and DC, [states that sent teams to PA5] have eliminated the asset test for parents and children on Medicaid or SCHIP, resulting in significant administrative cost savings and no increase in the Medicaid eligibility error rate. (cf. Cohen Ross and Cox, Preserving recent progress on health coverage for children and families: New tensions emerge, Center on Budget and Policy Priorities, July 2003 (www.kff.org/content/2003/4125/4125.pdf); and Smith, Vernon K. Eliminating the Medicaid Assets Test for Families. Kaiser Commission on Medicaid and the Uninsured, April 2001 (www.kff.org/content/2001/2239/2239.pdf).
Expediting eligibility determination helps to prevent delays in needed health care, and can avoid costly emergent care. Unless a State demonstrates to CMS that it has an equally or more effective alternative plan for outstationing, the State must have an outstationing worker at each DSH hospital or FQHC (including look-likes) participating in the State’s Medicaid program (SMDL #01-008, January 18, 2001).
Verify eligibility once annually or when circumstances affecting eligibility change.
Outstation eligibility workers at Federally Qualified Health Centers.

## Ensure Service Access

- Tailor services to meet the needs of people experiencing homelessness – integrated 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:**
[Encouraged state/local officials to use this model managed care contract language to assure that homeless Medicaid recipients in managed care plans receive appropriate services from experienced providers. Also distributed handout summarizing more detailed ways in which States can protect homeless Medicaid beneficiaries under managed care.]

## Expand Coverage

- Use cost savings from administrative simplification and coordination to expand Medicaid eligibility and covered services
- Most cost-effective strategy to prevent and end chronic homelessness: universal health coverage, affordable housing, living wage for those able to work, adequate disability benefits for those who cannot