**[Slide 1]{.underline}**

[Improving Access to Medicaid for Homeless Families with
Children]{.underline}

[Pat Post, MPA]{.underline}

[National Health Care for the Homeless Council ]{.underline}

[P.O. Box 60427]{.underline}

[Nashville, TN 37206-0427]{.underline}

[615/ 226-2292]{.underline}

**[Slide 2]{.underline}**

[Why Does Medicaid Matter?]{.underline}

-   [Helps pay for primary/preventive care that can reduce need for
    costly secondary/tertiary care]{.underline}

-   [Improves access to specialty and hospital care ]{.underline}

-   [Provides coverage for prescription medications]{.underline}

-   [Helps people manage disabling conditions that precipitate and
    prolong homelessness]{.underline}

**[Slide 3]{.underline}**

[Why Homeless Children Need Health Care]{.underline}

-   [At high risk for uncontrolled, acute/chronic medical conditions---
    asthma, otitis media, anemia, seizure disorders, dental
    problems]{.underline}

-   [One in 4 homeless children requires referral to a specialist at the
    first primary care visit]{.underline}

-   [Physically abused at twice the rate of other children; 3 times as
    likely to have been sexually abused]{.underline}

-   [\> 20% of homeless 3-6 year olds have emotional problems serious
    enough to require professional care]{.underline}

**[Slide 4]{.underline}**

[Why Homeless Parents Need Health Care]{.underline}

-   [Homeless mothers have low birth weight babies at higher rates than
    other women]{.underline}

-   [More likely to have behavioral health problems (substance use
    disorders, major depression, PTSD); less likely to have a regular
    source of care ]{.underline}

-   [\> 90% homeless women have been victims of severe physical/sexual
    assault during their lifetime ]{.underline}

-   [\> 45% homeless mothers have a major depressive disorder
    ]{.underline}

**[Slide 5]{.underline}**

[Reality Check]{.underline}

-   [Nearly all minor children who are homeless qualify for Medicaid
    ]{.underline}

-   [Nearly all homeless parents who are pregnant or accompanied by
    children are eligible for Medicaid ]{.underline}

-   [Most homeless adults do ]{.underline}*[not]{.underline}*[ qualify
    for Medicaid under current policy]{.underline}

-   [Few State Medicaid programs cover non-disabled adults unaccompanied
    by children; those that do may not cover needed
    services]{.underline}

-   [The only door to Medicaid for many homeless adults is
    SSI]{.underline}

**[Slide 6]{.underline}**

[Homeless Service Users]{.underline}

-   [23% minor children]{.underline}^[1]{.underline}^

-   [11% custodial parents]{.underline}^[1]{.underline}^

-   [40% families+children]{.underline}^[3]{.underline}^

-   [54-66% single
    adults]{.underline}^[3]{.underline}^[,]{.underline}^[1]{.underline}^

-   [30% on Medicaid]{.underline}^[1]{.underline}^[ (22% HCH
    clients)]{.underline}^[2]{.underline}^

-   [11% SSI]{.underline}^[1]{.underline}^[ ]{.underline}

-   [55% uninsured]{.underline}^[1]{.underline}^[ (73% HCH
    clients)]{.underline}^[2]{.underline}^

[FOR MORE INFO\...]{.underline}

[1 Burt, Martha. 1996 National Survey of Homeless Assistance Providers &
Clients. Urban Institute, 1999.]{.underline}

[2 BPHC. 2002 UDS data.]{.underline}

[3 US Conference of Mayors. Hunger & Homelessness Survey,
2003.]{.underline}

**[Slide 7]{.underline}**

[Eligible but Not Enrolled]{.underline}

-   [Nearly 1/3 of uninsured homeless clients may be eligible for
    Medicaid but are not enrolled ]{.underline}

-   [Aggressive outreach and advocacy can enable 10-30% of uninsured
    homeless clients to obtain Medicaid coverage]{.underline}

[FOR MORE INFO\...]{.underline}

[Post, Patricia.]{.underline}*[ Casualties of Complexity: Why Eligible
Homeless People Are Not Enrolled in
Medicaid]{.underline}*[.]{.underline}*[ ]{.underline}*[Nat'l HCH
Council, 2001:]{.underline}

**[Slide 8]{.underline}**

[WHO Is Eligible but Not Enrolled?]{.underline}

[Adolescents & Children]{.underline}

-   [don't apply (immigrants, unaccompanied minors)]{.underline}

-   [apply for SCHIP but not Medicaid]{.underline}

-   [lose coverage when a parent rolls off TANF]{.underline}

[Custodial parents]{.underline}

-   [lose or fail to apply for TANF-Medicaid]{.underline}

-   [fail to apply for Medicaid spend-down]{.underline}

[Disabled persons]{.underline}

-   [have difficulty getting on SSI-related Medicaid]{.underline}

**[Slide 9]{.underline}**

[WHY Eligible but Not Enrolled? ]{.underline}

[Failed to apply]{.underline}

-   [Thought they weren't eligible]{.underline}

-   [Impaired capacity to apply]{.underline}

[Didn't complete enrollment]{.underline}

-   [Failed to receive mailed information]{.underline}

-   [Insufficient documentation]{.underline}

-   [Didn't show up for personal interview ]{.underline}

**[Slide 10]{.underline}**

[WHY Eligible but Not Enrolled? (continued)]{.underline}

[Eligibility denied]{.underline}

-   [Didn't have required documentation]{.underline}

[Inappropriately disenrolled]{.underline}

-   [Failed to receive/respond to recertification notice ]{.underline}

-   [Lack of required documentation to confirm continued
    eligibility]{.underline}

-   [Lost benefits in violation of due process rights]{.underline}

**[Slide 11]{.underline}**

[Enrollment Barriers]{.underline}

[System inadequacies]{.underline}

-   [Lack of outreach and application assistance]{.underline}

-   [Ineffective communication of requirements]{.underline}

-   [Lengthy, confusing application forms/process]{.underline}

-   [Delayed eligibility determination]{.underline}

-   [Poorly trained eligibility workers with negative attitudes toward
    applicants]{.underline}

**[Slide 12]{.underline}**

[Enrollment Barriers (continued)]{.underline}

[Problems related to homelessness]{.underline}

-   [Transience, lack of transportation ]{.underline}

-   [Cognitive/ functional impairment]{.underline}

-   [Low educational/ literacy level, limited English
    proficiency]{.underline}

-   [Low priority for health care except in an emergency]{.underline}

**[Slide 13]{.underline}**

[Enrollment Barriers (continued)]{.underline}

[Other deterrents]{.underline}

-   [Inaccessible eligibility workers ]{.underline}

-   [Violation of enrollees' due process rights]{.underline}

-   [Inappropriate information sharing with INS]{.underline}

[SOURCE:]{.underline}

[Schlosberg, Claudia. National Health Law Program 1997,
1998]{.underline}

**[Slide 14]{.underline}**

[Improving Access to Medicaid]{.underline}

[Goals:]{.underline}

-   [Remove enrollment barriers for eligible homeless
    people]{.underline}

-   [Provide comprehensive benefits including mental/behavioral health
    services]{.underline}

-   [Ensure access to covered services and stable housing]{.underline}

-   [Expand eligibility for homeless adults]{.underline}

**[Slide 15]{.underline}**

[Improving Access to Medicaid (continued)]{.underline}

[Strategies:]{.underline}

-   [Be able to identify Medicaid applicants/enrollees as homeless
    ]{.underline}

-   [Be willing to adapt certain procedures to accommodate persons known
    to be homeless]{.underline}

-   [Use third-party representatives to facilitate enrollment and access
    to covered services ]{.underline}

**[Slide 16]{.underline}**

[Models that Work]{.underline}

-   [Data field in Medicaid MIS to identify/track homeless applicants
    and enrollees]{.underline}

-   [Presumptive eligibility/expedited enrollment for homeless children,
    pregnant/disabled adults]{.underline}

-   [Preventive health education and screenings in family shelters and
    school-based clinics]{.underline}

-   [Community work groups to monitor and address access
    barriers]{.underline}

-   [HCH providers as liaisons for homeless Medicaid
    beneficiaries]{.underline}

**[Slide 17]{.underline}**

[What States Can Do]{.underline}

[Simplify application/enrollment]{.underline}

-   [Reduce documentation requirements]{.underline}

-   [Eliminate face-to-face interview & asset test]{.underline}

-   [Standardize/expedite eligibility determination]{.underline}

-   [Outstation eligibility workers at FQHCs]{.underline}

-   [Verify eligibility only once annually]{.underline}

-   [Convene community work groups to identify and address
    enrollment/service access barriers]{.underline}

**[Slide 18]{.underline}**

[What States Can Do (continued)]{.underline}

[Ensure access to appropriate services]{.underline}

-   [Tailor services to meet the needs of people experiencing
    homelessness -- integrate medical and psychosocial
    services]{.underline}

-   [Specify expectations for the delivery of services to homeless
    enrollees in contracts with managed care organizations/
    providers]{.underline}

[FOR MORE INFO\...]{.underline}

[GWU Center for Health Services Policy & Research.]{.underline}*[
Purchasing Specifications: Medicaid Managed Care for Individuals Who Are
Homeless]{.underline}*[,]{.underline}*[ ]{.underline}*[June 2000:
]{.underline}

**[Slide 19]{.underline}**

[What States Can Do (continued)]{.underline}

[Expand coverage for homeless adults]{.underline}

-   [Use cost-savings from administrative simplification and
    coordination to expand Medicaid eligibility and covered services for
    adults unaccompanied by children]{.underline}

-   [Remember that many homeless youth and single adults were once
    homeless children]{.underline}

**[Slide 20]{.underline}**

[Most Cost-effective Strategy]{.underline}

[To prevent and end homelessness:]{.underline}

-   [Universal health coverage ]{.underline}

-   [Affordable housing]{.underline}

-   [A living wage for those able to work]{.underline}

-   [Adequate disability benefits for those who cannot]{.underline}