Department of Health and Human Servces

OFFICE OF

INSPECTOR GENERAL

MEDICAID AND HOMELESS INDIVIDUALS

V1C. 
Richard P. Kusserow 
cIaINSPECfOR GENERA 
JANARY 199  OFFCE OF INSPECfOR GENERA

The mission of the Offce of Inspector General (OIG), as mandated by Public Law 95-452 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs as well as the health and welfare of beneficiaries served by those programs. 
This statutory mission is carried out through a nationwide network of audits, investigations 
and inspections conducted by three OIG operating components: the Offce of Audit 
Servces, the Office of Investigations, and the Office of Evaluation and Inspections. The 
OIG also informs the Secretary of HHS of program and management problems and 
recommends courses to correct them. 
OFFICE OF AUDIT SERVICE 
The OIG's Offce of Audit Servces (OAS) provides all auditing servces for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS. programs and/or its grantees and contractors in 
carryng out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
INTIGATIONS 
OFFICE OF 
The OIG's Offce of Investigations (01) conducts criminal , and administrative 
, civil
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid 
program. 
AN 
OFFICE OF EVALUATION  INSPECfONS 
The OIG's Offce of Evaluation and Inspections (GEl) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department 
the Congress, and the public. The findings and recommendations contained in these 
inspetion report generate rapid, accurate, and up-to-date information on the effciency, 
vulnerabilty, and effectiveness of departmental programs. 
This report was prepared under the direction of William C. Moran, Regional Inspector 
General, Office of Evaluation and Inspections and Natalie Coen, Deputy Regional Inspector 
General, Offce of Evaluation and Inspections, Region V. Participating in this project were 
the following people: 
Chcago. IL  New York. NY  Headquars 
Barbara K. Butz (Project Leader)  Demetra Arapakos  Emile B. Baebel 
Pamela S. May  Susan E. Hardwick 
Jennifer Antico  W. Mark Krhat 
Kate McFadden  Department of Health and Human Servces 
OFFICE OF

INSPECTOR GENERAL

MEDICAID AND HOMELESS INDIVIDUALS

V1C' 
Richard P. Kusserow 
INSPECfOR GENERA 
'.(~cIa  OEI-05-91-03  EXECUTIVE 
SUMMAR 

PUROSE 
This inspection examined how Medicaid is used to serve homeless 
individuals with 
mental health, alcohol, or other drug problems. 
BACKGROUN 
Recent research suggests that approximately one-third of an estimated 600 000 
homeless population are severely mentally il, at least 40 percent have problems with 
alcohol, and an additional 10 percent abuse other drugs. In addition, it is estimated 
that at least one-half of the homeless mentally il population also have alcohol 
other drug problems.

The Department s response to homelessness is through both targeted and 
mainstream programs. The 1987 Stewart B. McKinney Act is the Federal 
Government s major targeted response to the homeless. Medicaid is one of the 
Department' s largest mainstream programs that could serve the homeless. It 
provides reimbursement for health servces, which can include mental health and 
substance abuse servces, for the poor, including the homeless. 
There is a lack of consistent, reliable data on Federal or State share Medicaid 
expenditures for either mental health or substance abuse servces for the homeless. 
However, the Medicaid Director estimates that overall, Medicaid spends $200 milion 
(Federal/State) annually in assistance for the homeless. 
SCPE AN MEllODOLOY 
Along with Medicaid, we looked at the Supplemental Security Income program (SSI) 
and the Al ohol, Drug Abuse, and Mental Health Servces (ADMS) block grant in 
this study. The issues examined were the availabilty, accessibilty and 
appropriateness of these programs for this population. We spoke 
with 298 
respondents in 10 States: California, Hawaii, Ilinois, Ohio, Oregon, Maryland 
Missouri, New Jersey, New York and Texas. They included: 224 ADMS grantees (95 
mental health, 129 substance abuse), 33 McKinney-funded providers, persons from 25 
Social Security district offces, and 16 State Medicaid staff. 
FIINGS 
Medaiwd isi i mport because it provi acces to prry car  and seres in genaL
It also  acces to mel helt or sustae abuse seres.  gr 
Nea two-thm of eth  ADMSg  r  are Medaid-reiurg Mred.aid is a greate
th  helt  in 
resOUe for  th th sustance abuse 
Prvi  diri  nuer 
peeie a  betwee th  of homele  who are 
an th nuer 
eligile for Medaid 
who actull receie 
li 
cloe ti betwee Medaid and SSI eligiil in mot State ma  acces to 
Th  partrl 
Medai for homele iinlns    drg adts an alcoholi. 
Prvi 
say tht homele  face nuus prble accesg Medaid tht 
thelves. 
th cant overome by 
me 
Ag mraj ori of ADMlSi g res help th homele apply gfor rM.e daid  helt
are more  to help th suste abuse 
McKi ignrelss s ugges many ways in whih proble in accesg Medaid for 
homele  can be overome. 
The is li eve of gover inties iwnhihl sha.e  ma Medaid more 
. availle accesle or apprprite for homele 
RECOMMNDATIONS 
We are asking Health Care Financing Administration (HCFA) to take several actions 
to support the following efforts to expand access to Medicaid for homeless 
individuals: (1) Departmental and inter-Departmental initiatives to increase servces 
for homeless individuals; (2) the development of similar initiatives by States; and (3) 
the development of special strategies by local providers. Specifically, we recommend 
that HCFA take these actions: 
So Sec 
wi th  Admtrtin  strte 
Work  (SSiAn) tol dsee.l op a join 
ineae acces to Medai for eligile homele 
in 
Cons wi th Puli Hea See  mols 
(PHS) and SSA to deelop  to help
home  Medaid Diemte the mols wily  prvi. 
apply for  to 
ase 
stte 
Prvi 
tehnal  to State, to promote th deelopm of State  and 
liges degn 
to us Medaid more efectiely to sere th poputin. 
Use th Intgen Coun on th Homele to provi technal asnce to oth
Fed agen an McKi provi  SP stte 
to enourge  inls.a n prmote
formlige 
to make Medaid more accesle to homele  COMM 
HCF A, SSA and the Assistant Secretary for Planning and Evaluation commented on 
this report; the full text of their comments is in Appendix C. They generally agreed
with our findings and recommendations. We also received comments from PHS 
staff. We made several changes in response to the 
suggestions we received. 
thank all those who commented on this report.  . ..  ..  ..  ..  ..  ..  .. . .. .  . ... .   . .... .    . .... .    . ..... .     . ..... ..     .  ..... .. .    ..  .... .  ..    . ..  .....   . .    ... . ....   . .    .. ... ...  .  .    .. .. ....  .  .    ... .. ...  . .  .   .. .... .. . .    . .  ......... 
..  ...   ...   ...   ....    .....     ......     . ..... .     . ..... .     . ..... .     . ..... .     . ..... .     . ..... .     .. .....  .     .. .....  .     .. .....  .     .. .....  .    . .. .... .  .    . .. .... .  .    . .. .... .  .    . .. .... .  .   .  .. ... ..  .   .  ... ... ..   .   .  ... ... ..   .   .  ... ... ..   .   .  ... ... ..   .   .  ... ... ..   .   .  ... ... ..   .   .  ... .. ...   .  .   ... .. ...   .  .   ... .. ...   .  .   ... .. ...   .  .   ... .. ...   .  .   ... .. ...   . .    ... . ....   . .    ...  ...   ..   ...  ..   ..  ...  ..   ..  ...  ..   ..  ...  .   .. ...     .....     ...   ...   ...   ...   ...   ...   ..  ..
TABLE  CONTENTS

PAGE 
EXECU SUMY

INODUCfON 

Purpose 
Scope 
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Methodology 
FImGS 
Providers say that Medicaid is important because it 
provides access to
primary care, and to servces in general. It also widens access to 
mental health or substance abuse servces

Nearly two-thirds of the ADMS grantees are Medicaid-reimbursed. 
Medicaid is a greater resource for the mental health grantees than 
the substance abuse grantees

Providers perceive a disparity between the number of 
homeless 
individuals who are eligible for Medicaid and the number who 
actually receive it . . . 
The close tie between Medicaid and SSI eligibilty in most States may 
limit access to Medicaid for homeless individuals
, particularly drug
addicts and alcoholics. . . . . . . . . . 
Providers say that homeless individuals face numerous problems 
accessing
Medicaid that they cannot overcome by themselves 
A majority of ADMS grantees help the 
homeless apply for Medicaid;
mental health grantees are more likely to help than 
substance abuse grantees 
McKinney grantees suggested many ways in which problems in 
accessing
Medicaid for homeless individuals can be overcome 
There is limited evidence of government initiatives which have made 
Medicaid more available, accessible, or appropriate for 
homeless individuals  ....................................... 
TABLE OF CONTENTS

PAGE 
RECOMMENDATIONS 
APPENDIX A: Methodology 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. A
APPENDIX B: Data Verification Sheet  . . . . . . . . . . . . . . . . . . . . . . . . . . .. B
APPENDIX C: Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. C INTRODUCTION

PUROSE 
This inspection examined how Medicaid is used to serve homeless individuals with 
mental health, alcohol, or other drug problems. 
SCPE 
The number of homeless in the United States is not known. The Urban Institute 
estimated in 1988 that between 567 000 and 600 000 are homeless in the U.S. on any 
given night. In March, the U.S. Census Bureau counted 178 828 persons in 
emergency shelters and 49 793 persons at pre-identified street locations; however 
they acknowledge that this is an undercount. 
Recent research suggests that approximately one-third of an estimated 600 000 
homeless population are severely mentally il, at least 40 percent have problems with 
alcohol, and an additional 10 percent abuse other drugs. In addition, it is estimated 
that at least one-half of the homeless mentally il population also have alcohol or 
other drug problems; we refer to such persons as the "dually diagnosed" in this 
report. This study focused on homeless individuals (as opposed to familes) with 
these problems; the terms "the homeless" or "homeless individuals" in the report 
refer strictly to this population. 
Federal efforts to assist the homeless are two-pronged: (1) specially targeted 
programs directed at the homeless population, and (2) mainstream programs that 
serve the homeless as a portion of their servce 
population. The major Federal 
targeted response is the 1987 Stewart B. McKinney Act, funded for fiscal year (FY) 
1991 at $682.3 millon. A 1990 study by the Office of Inspector General found that 
while McKinney programs have helped meet emergency needs, respondents did not 
view McKinney as the long-term solution to homelessness; rather, they advocated 
going, mainstream programs. 
greater Federal and State efforts through on-
This inspection looked at three major mainstream programs in the Department which 
could serve homeless individuals: Medicaid, the Alcohol, Drug Abuse, and Mental 
Health Servces (ADMS) block grant, and Supplemental Security Income (SSI). This 
report presents findings concerning Medicaid. Two separate reports present findings 
related to the ADMS block grant and SSI. 
We examined the availabilty, accessibilty and appropriateness of each of these 
mainstream programs for homeless individuals. "Availabilty" means whether a 
program or servce exists in an agency or community and homeless individuals are 
eligible for it. "Accessibilty" refers to the ease or difficulty homeless individuals have  in finding and utilzing available servces. "Appropriateness" refers to whether 
available, accessible servces match the homeless client s needs in a broad sense. 
BACKGROUN 
Medicaid is one of the Department's largest mainstream programs which could assist 
homeless individuals. The Health Care Financing Administration (HCF A) is 
responsible for Federal oversight of the program. A Federal-State jointly financed 
program which is administered by the States, Medicaid provides reimbursement for 
health servces, which can include mental health and substance abuse servces, for the 
poor, including the homeless. In 1989, 24 milion people were served at a combined 
5 bilion; the Federal portion of 
Federal/State outlay of $54. Medicaid expenses 
nationally was 56 percent. The Medicaid Director estimates that 
Medicaid spends 
$200 millon annually (Federal/State) in assistance for the homeless. 
Homeless individuals may apply for Medicaid directly with the appropriate State 
agency. For many, however, eligibilty is primarily through SSI, where they must 
qualify as aged, blind, or disabled. Section 1634 of the Social Security Act allows 
States to contract to have the Social Security Administration (SSA) make Medicaid 
eligibilty determinations; in such States, the SSI application also serves as the 
Medicaid application. Thirty-two States have adopted this process. In seven States 
those eligible for SSI are also eligible for Medicaid but they must apply separately. 
, both eligibilty criteria and the 
In 12 States application process are separate for each 
program. 
States may also cover homeless individuals as "medically needy." In addition, States 
may have State-only programs to provide medical assistance to specified poor people 
including the homeless, who do not qualify for Medicaid; matching Federal funds are 
not provided for such programs.

States may not impose residency requirements on individuals without permanent 
addresses as a condition of eligibilty, and they must have a method for making 
Medicaid cards available for those without a permanent address. 
Any person who receives Medicaid is entitled to certain federally mandated core 
servces such as inpatient and outpatient hospital servces, and physician servces. 
States may also offer optional servces to enhance their response to the homeless: 
prescription drugs, out-patient clinic servces, targeted case management 
rehabiltation servces, and a home and community-based servces waiver, which may 
be targeted specifically to the chronically mentally 
il as an alternative to hospital 
care. They could also use a model application form now being developed by HCF A 
to specifically target the homeless, or develop a special "freedom of choice" waiver to 
target the homeless with alcohol or drug problems.  The variation across States in terms of the 
tyes of mental health and substance 
abuse servces covered, and the extent of coverage, is considerable. However, there 
is one important provision that applies across the board: Medicaid does not cover 
in-patient servces for people between the  64 at institutions for mental 
ages of 22-
disease (IMDs): facilities of 16 or more beds with over 50 percent of the residents 
classified as mentally il. Since both mental ilness and substance abuse are 
categorized as mental diseases, this IMD exclusion pertains to drug addicts and 
alcoholics who get Medicaid, as well as to the mentally il. 
There is a lack of consistent, reliable data on 
expenditures (State or Federal share) 
for either mental health or substance abuse servces for the homeless. However, it 
appears that Medicaid is a meaningful 
source of funding in the mental health arena. 
In FY 1987, according to the National Association of State Mental Health Program 
Directors, $749 milion in Federal Medicaid dollars accounted for 8 percent of all 
revenues directly controlled by State mental health agencies. They also estimate that 
of all funds received by mental health organizations in the U.  , 25 percent are from 
Federal sources, including Medicaid. 
Little is known about the extent of Medicaid coverage of substance abuse servces in 
general. Neither law nor regulations specif substance abuse treatment as a

reimbursable Medicaid servce, although reimbursement is allowed if treatment is 
provided under an approved servce category. 
The Omnibus Budget Reconcilation Act of 1990 included a provision that " 
(Medicaid) servce (including counseling) shall be excluded from the definition of 
medical assistance' solely because it is provided as a 
treatment servce for alcoholism 
or drug dependency." In August 1990, HCFA wrote all State Medicaid directors to 
generally clarify its position on substance abuse treatment. 
MEODOLOY 
During pre-inspection we conducted an extensive review of literature, including 
program de criptions, Federal legislation and regulations, and articles, reports and 
research papers of all kinds. We also talked with persons at the Public Health 
Servce (PHS), SSA, HCFA, the National Association of State Alcohol and Drug 
Abuse Directors, the National Association of State Mental Health Program Directors 
and other related associations; foundations; and experts. We spent two days with a 
special mobile assessment unit in Chicago. 
To collect data for the study, we reviewed portions of (1) the 1989 reports and 1990 
plans for the ADMS block grant, and (2) the Medicaid plans, and summaries of the 
plans, for the 10 States in our sample: California, Hawaii, Ilinois, Ohio, Oregon 
Maryland, Missouri, New Jersey, New York, Texas.  We also spoke by telephone or in person to  There 
298 respondents in these States. 
were four tyes of respondents: 
The executive directors or program directors of 224 ADMS mental health and 
substance abuse grantees. We discussed the inspection issues related to 
ADMS, Medicaid and SSI with them. 
Staff of 33 McKinney-funded Health Care for the Homeless (HCH) grantees 
and research demonstration grantees (mental health and substance abuse). 
We spoke to them about Medicaid and SSI. With their experience in servng 
this population, they should be particularly knowledgeable about these issues. 
For example, HCH grantees have a mandate to refer clients to mainstream 
programs for benefits such as SSI and Medicaid, or for servces, such as those 
provided by ADMS grantees. 
Sixeen State Medicaid staff in the 10 States in the sample. We discussed 
questions raised through our review of State plans regarding State eligibilty 
criteria, servces, and activities related specifically to homeless individuals. 
Social Security staff in 25 district offices located in the same areas as the 
McKinney respondents. We spoke with them for their perceptions about SSI 
and homeless individuals, to complement the perspectives of ADMS and 
McKinney respondents. 
A detailed description of the methodology for this study is in Appendix A.  " "
FINDINGS

Findig #1: Provders say that Medcad is importt beus it provdes accss to 
al  acc 
priar cae, and to servces in genera. It  widens  to menta heath or 
substace abus servce. 
According to a quarter of the ADMS grantees and 6 of the 33 McKinney grantees 
Medicaid is important because it contributes to stabilizing a person by helping meet 
primary health care needs. Many respondents stressed that homeless individuals 
greatly need such care, including dental care. A fifth of the ADMS mental health 
grantees, and 36 percent of the substance abuse grantees, said that their homeless 
clients differ from other clients in having "multiple  chronic " or "serious" physical 
problems. They called Medicaid a "cornerstone" or "step towards" rehabilitation in 
this sense.

Slightly over two-thirds of ADMS and McKinney respondents said that Medicaid is 
important in a solution to homelessness because it increases access to servces, or to 
the servce system in general. A tyical comment was: "It gives them access to 
servces they would not get otherwse. The more servces you access, the more 
people you come into contact with who know about your problem and can help you 
get back into the mainstream.

A majority also said that Medicaid helps increase access to mental health or 
substance abuse servces for homeless individuals, although there was no consensus 
about which tye of servce is made more accessible. There was notable agreement 
that Medicaid (1) makes more servces, more diverse servces, or more private 
providers available to the homeless, and (2) enables providers to accept more 
patients. Every McKinney respondent mentioned one or both 
of these points. 
Despite this view, it is interesting that respondents were much more 
liely to think 
Medicaid is important for providing access to the servce system, or for financing
priary 
health care, than for widening access to treatment. One reason could be 
that they consider health care the most urgent need. Another could be 
that they see 
problems in accssing treatment, even for those on Medicaid. Some of the problems 
they mentioned are: (1) waiting lists or lack of beds, (2) too few treatment servces 
(mental health and substance abuse, whether Medicaid-reimbursed or not), (3) too 
few providers who accept Medicaid reimbursement, and (4) inadequate coverage of 
servces they see as particularly important for this population: community-based or 
residential treatment, outreach, or case management. In this vein, almost half of the  ADMS mental health grantees and a quarter of the substance abuse grantees 
recommended expanded coverage of some sort to better serve this population. 
Only a quarter or less of respondents said that Medicaid is not as important as other 
resources in reaching a long-term solution. McKinney grantees were the most likely 
to see it as a "band-aid " or much less important than housing, employment
, or SSI. 
A typical comment was: "You need so much else. 
Findig #2: Nearly two-thds of the ADMS grantees are Medicad-reimbured.
Medicad is a greater resource for the menta health grtees than the substace 
abuse grantees. 
Six-three percent of the 168 ADMS grantees we spoke with were receiving 
Medicaid reimbursement last year. More of the mental health grantees (80 percent) 
than the substance grantees (49 percent) were Medicaid-reimbursed. From 
information they provided on their annual budgets and Medicaid reimbursement, we 
estimate that nationally, for ADMS-funded grantees that serve the homeless 
Medicaid constitutes 9. 1 percent of the total budget for mental health grantees and 
6 percent for substance abuse grantees. (Appendix A explains how this projection 
was derived. 
Finding #3: Providers perceive a disparty between the numbear ocf hto meless 
individual who are eligible for Medicad and the number who  receive it. 
Many providers, both ADMS and McKinney grantees, could not say how many of the 
homeless individuals they serve are either eligible for or receive Medicaid (actually 
have a "green card"). They do not collect this information. We found this 
particularly surprising of Health Care for the Homeless grantees; one of their 
mandates is to help the homeless in obtaining entitlements such as Medicaid. 
Only 16 percent of the ADMS respondents actually knew how many, or what 
proportion, of the homeless individuals they serve are on Medicaid. Almost all 
ADMS and McKinney respondents gave us an estimate, guess, or narrative response 
such as "a lot" or "a few . Furthermore, their estimates were widely divergent, with 
no apparent patterns by tye of grantee or any other criterion. 
Hence, we do not know from respondents how many homeless individuals are eligible 
for or actually receive Medicaid. However, we can say that a majority perceive a 
disparity. Of those who answered the question "How many of your homeless 
individual clients are eligible for but do not receive Medicaid?", three-quarters 
estimated that half or more fell in this category.  Finding #4: The close tie between Medicad and SSI eligibilty in most States may 
lit accss to Medicad for homeless indivdual, parcularly drg addict and 
alcoholics. 
In our review of State Medicaid plans, we found that homeless individuals are not 
subject to eligibilty requirements or criteria different from those for other Medicaid 
applicants in these States. However, our discussions with State officials highlighted 
the strong relationship between eligibility for SSI and Medicaid. These officials 
confirmed that homeless individuals are eligible for Medicaid in their States if they 
are determined to be disabled based on the SSI definition of disability. 
We found that five of these 10 States provide Medicaid automatically to individuals 
who receive SSI. The other five apply the SSI disabilty criteria but use more 
stringent income and resource eligibility criteria. In our related study on SSI and 
homeless individuals, a fifth of the ADMS respondents said that none of the 
homeless individuals they serve received SSI. Two-thirds said that less than 20 
percent receive it. We therefore conclude that the tie between SSI and Medicaid 
may serve to reduce access to Medicaid for homeless individuals. 
Furthermore, Medicaid officials acknowledged that there are added 
diffculties for 
people with an alcohol or other drug problems who try to get Medicaid. 
In six of 
the 10 States, officials told us that individuals with strictly a substance abuse problem 
might have more difficulty obtaining the disability determination 
necessary to receive 
Medicaid. They also noted that this group finds it especially difficult to provide the 
documentation needed to prove eligibility. 
We did not discuss Medicaid eligibility specifically with other respondents. However 
in discussing the issue of accessing Medicaid, McKinney grantees named several 
factors which, they believe, limit eligibilty for homeless 
individuals in their States. 
These factors include: (1) criteria excluding individuals, or alcoholics or drug addicts; 
(2) State cuts which have tightened or restricted Medicaid 
eligibilty for individuals 
as compared with women and children; (3) the close tie between Medicaid and SSI 
which they say is very diffcult to get; (4) Medicaid workers who deny benefits on the 
mistaken assumption that such individuals can work; and (5) "easier
" eligibility 
standards for the mentally il than alcoholics or drug addicts who, some believe, must 
have a physical disabilty to qualify.  , "
indidua 
Findig #5: Provders say that homeles  face numerous problems 
caot 
accssing Medicad that they  overcome by themslves. 
A strong majority of both ADMS (72 percent) and McKinney (30 of 33) providers 
described problems that homeless individuals face when tryng to get on Medicaid. 
Most of the McKinney respondents named multiple problems. The problems they 
mentioI)ed are portrayed in Figure 

Problems Accessing Medicaid

as percent of those mentioning problems 
proC.18 too cOlIple:z

Hmls don t understd 
Hrnls are Iranslent

Documentation

Long waitl

Difficult cl1ents

Don t knoW' qaalily 
Don t want help 
10%  20%  30%  40%  50%  60%  70% 
ADMS grantee.  E: M c:K:lnney gran tee. 
Many mentioned multiple problem. 
Figure 1

As the reader will note, these problems are not only numerous, but diverse and 
interrelated. Despite this variety, however, we find it interesting that the highest 
proportion of respondents in each group named two closely related problems: the 
complexity of the application process, and the inability of the homeless to understand 
the process 
A high proportion of ADMS grantees say that the transient lifestyle of many of these 
individuals makes it diffcult to notify them of upcoming appointments, needed 
documentation, or decisions. Long waits for appointments or approval are also a 
problem, according to both ADMS and McKinney providers. They said many 
homeless individuals, given their instabilty and transient lifestyle  disappear" during 
the long wait and fail to follow through. 
According to a quarter of the McKinney respondents, welfare offices do not welcome 
homeless individuals because they are particularly diffcult 
to deal with: look or act 
strange, are dirty or unkempt, don t follow through, or cannot conform to procedures 
or rules.
 ..., 

, "
Some McKinney respondents also commented that Medicaid budget problems in 
their States have made welfare offces alternately tighten and loosen eligibility 
standards or cut staff, limiting the number of workers available to take applications. 
Others complained that policies and procedures vary between offce, makig it
diffcult to understand how decisions are made or appropriately advise applicants. 
Few providers, ADMS or McKinney, mentioned that the homeless do not want or 
seek help. Those who did often qualified their remark by saying this is not because 
the homeless are unwiling to get help, but because they are not "
tuned in enough" 
to recognize the value of Medicaid. Or, providers said  health care is not the first 
thing on their minds" compared to food or shelter. Some said that the mentally il 
especially if not taking medication regularly, may not seek help due to paranoia or 
fear that providers will hospitalize them. 
Findig #6: A majority of ADMS grtee help the homeless apply for Medicad; 
th 
menta health grtees are more liely to help  substace abuse grtees. 
Seventy percent of the ADMS respondents said that they routinely try to help the 
homeless get Medicaid; another 10 percent said they sometimes help. However
, as 
Figure 2 shows, a homeless individual is more likely to get help from a mental health 
Of the 34 ADMS respondents who said 
grantee than a substance abuse grantee. 
they did not help, or did not respond to the question, all but three were substance 
abuse grantees. 
Do you try to get Medicaid for homeless 
you think are eligible? 
individuals 'Who 
roaUnely 
.. lomeUmel 
r_pan.. 
DJ:. No 
0..  20..  .. 0..  60..  80"  1 DO'" 
E2 ... ..t all.... grant... 
M.ntal hUh grant... 
N-168 
Fiqure 2  Mental health respondents were more likely to name several ways in which they help 
clients and to say that they tailor their assistance to the client, providing the greatest 
help to the most dysfunctional. They were also much more likely to say that helping 
get Medicaid for all clients is routine, especially as part of case management. 
contrast, substance abuse grantees were more likely to say that they simply refer 
homeless clients to a welfare office to apply; of the 17 who said that they only refer 
14 were substance abuse grantees. 
How do you help homeless individuals 
get Medicaid? 
Re.er only 
Accompany to apply 
Accompany: follow up 
Help with paperwork 
Help: doca:zentatlon 
20""  40"  60""  eo..  100"  120"" 
Mental health  Sab.t aba.e 
grantees  grantees 
N-132 
Figure 3 
This same trend is apparent in Figure 3, which portrays responses to a question 
about how grantees help clients get Medicaid. 
Although ADMS grantees said they help homeless individuals get Medicaid 
McKinney grantees say that only "some" or "a few" mental health and substance 
abuse providers in their areas help. Their opinions reinforce our conclusion that

mental health providers are the most likely to help; 15 of the 33 made comments to 
this effect. . These comments include: (1) more mental health than substance abuse 
providers are reimbursed by Medicaid, thus have a fiancial incentive to help clients 
get it; (2) mental health providers often have case managers to help clients get 
benefits but substance abuse providers do not; (3) some substance abuse providers 
do not encourage clients to apply because they believe that getting public assistance 
(including Medicaid) runs counter to their treatment philosophy of self-help or self-
sufficiency; or (4) it is easier to qualify for Medicaid on the basis of mental ilness 
than substance abuse.  " "
McKiey 
Finding #7:  grantees suggested many ways in which problems accssing
Medicad for homeless indiduas ca be overcome. 
McKinney respondents strongly advocate a number of measures to help this 
population get on Medicaid. These include: 
Case management to shepherd homeless individuals through what they call an 
intimidating,  degrading," or "confusing" Medicaid application process. They 
call case management critical: "We need to advocate to push the client 
through because so much is riding on whether or not (the 
client) is eligible. 
They also strongly recommend stationing case managers at shelters as well as 
day programs that function as "one-stop shops " where they can help the 
homeless get Medicaid and all the other 
servces they need. 
Outreach by Medicaid workers to the homeless in shelters and on the streets. 
Cross-training between Medicaid workers and homeless providers. This should 
increase the sensitivity of Medicaid workers to the special characteristics of 
the homeless and help homeless providers understand Medicaid eligibility and 
the application process.

Simplification of the application process could be done by shortening forms or 
processing times, and working with homeless providers locally to develop 
special procedures to expedite the process. 
Out-stationing Medicaid workers at shelters or "one-stop shops " where the 
homeless can receive a variety of servces in one place. 
lited 
Findig #8: There is  evidence of governent intiaties which have made 
Medicad more avaiable, accssible, or appropriate for homeless indidua. 
invils un 
Few States appear to be delierately targetig homele  Medicaid 
Discussions with State Medicaid officials revealed few formal State Medicaid efforts 
to specifically target homeless individuals, whether through special eligibilty criteria 
optional servces or an expedited application process.

These respondents told us that mental health and 
substance abuse servces are 
available to everyone who receives Medicaid, but they also said that there are 
probably fewer substance abuse than mental health servces reimbursed by Medicaid.

However, some emphasized that their States are now focusing more attention on 
expanding coverage for substance abuse services, in general. 
Seven Medicaid officials reported linkage of some kind between their agency and 
other State agencies. However, none of them mentioned any such collaborative 
effort relative to the homeless. In each of these States, the link was with the State  mental health agency; only one was with the substance abuse agency. Some of these 
respondents said that the State Medicaid agency is under the same umbrella as the 
mental health agency; this, they said, facilitates coordination between the two 
agencies in a general sense.

Few provirs said that a government inittie ha le them to help homele
inivls 
get Medicaid 
Only 18 percent of the ADMS grantees said that a State or Federal initiative has 
influenced them to help homeless individuals get Medicaid. Most of them mentioned 
a State initiative; the highest proportion were from Missouri, where 11 of 25 grantees 
mentioned an initiative to expand substance abuse coverage, an emphasis on servng 
the homeless, or Medicaid case management for the severely mentally ill. 
Few McKinney respondents spoke of any government initiative which had led them 
to try to help get their clients get Medicaid. Eight knew of Federal initiatives to 
increase SSI outreach and enrollment or widen Medicaid access for children and 
pregnant women. Only one mentioned a specific State homeless initiative.  RECOMMENDATIONS

This study points out that while Medicaid could be a valuable resource to homeless 
individuals, at the very least in terms of providing access to primary care, a number 
of factors limit its usefulness for this population. 
One of the most significant barrers, we believe, is State eligibilty criteria. In 39 
States, individuals must qualify for SSI in order to get Medicaid; yet our 
study on SSI 
found many providers who believe that a small number of the homeless individuals 
they serve are getting SSI. Furthermore, 12 other States use even more stringent 
criteria. Thus we conclude that many homeless individuals may not even 
qualify for 
Medicaid, greatly limiting its availabilty to this population. 
Another factor which limits the usefulness of Medicaid is that State coverage of 
mental health and substance abuse treatment, particularly the latter, is often lacking. 
Our respondents Pbinted to a number of problems which affect the availabilty of 
such servces in their areas. In this light, a June 1991 report by the General 
Accounting Office found that Medicaid generally limits coverage for substance abuse 
treatment, and that multiple barrers prevent States from expanding such servces 
under Medicaid.

We found little evidence that States are deliberately targeting this population under 
Medicaid, whether through special eligibilty criteria or targeted servces. On the 
, many providers see a need to assist homeless individuals in applying for 
local level
Medicaid, given the complexity of the process and the instabilty of such clients. 
However, not all of them - especially substance providers - are providing this needed 
assistance. 
In making recommendations to HCF A about how these problems can be addressed 
. we are mindful that Medicaid is in reality 50 different State programs, and that 
States are allowed considerable flexibilty in setting forth the populations they wish to 
target and the methods for doing so. We know that the IMD exclusion is being 
examined both in Congress and by HCFA. We are also aware of concerns about 
expansion of the program in general. The Medicaid director recently testified against 
a bil proposing expanded coverage specifically for the homeless, on the basis that 
Medicaid is not designed to address problems of specific groups in a piecemeal 
manner. 
For these reasons, we are not recommending that HCFA expand Medicaid eligibility 
or coverage for this population. Our focus, instead, is to suggest ways that HCF A 
can work with States and other Federal agencies to help make Medicaid more 
available and accessible to this population generally. We should also note that we 
have made recommendations to SSA about helping eligible homeless individuals get  SSI. Given the close association of these two programs, we believe that these 
recommendations can also increase access to Medicaid for such 
clients. 
The thrust of our recommendations is threefold. Through them, we are asking 
HCFA to support: (1) Departmental and inter-Departmental initiatives to increase 
servces for homeless individuals, (2) the development of similar initiatives by States 
and (3) the development of special strategies by local providers, including welfare 
offices, to expand access to Medicaid for homeless individuals with mental health 
alcohol, and other drug problems. 
Recmmendation 1: HCF A should work with the Soal  Administration 
acc  Sety 
(SSA) to develop a joint strtegy to increa.. to Medcad for eligible homeles
indidua. 
Our reports on both Medicaid and SSI highlight that this homeless population needs 
help to overcome the many problems they face in accessing these programs. 
have recommended to SSA that they work with other agencies in a variety of ways to 
help the homeless overcome problems related to accessing SSI. However, Medicaid 
and SSI are closely tied in most States. Thus we believe that a joint 
HCF A-SSA 
strategy to assist this population would have considerable impact in widening 
access 
to both programs for them. 
The goal of this joint strategy should be to help local welfare offces and SSA district 
offces work more closely together. It could address: publicizing Medicaid to 
homeless individuals, joint outreach, cross-training, expediting the application process 
and establishing formal linkages or coordination with local providers who serve the 
homeless. 
Recmmendation 2: HCF A should consult with the Public Heath Servce (PHS) 
loc 
and SSA to develop models for States and  provders to us to help homeles
indidua  dimiate 
apply for Medcad, and then  thes models widely. 
To help homeless individuals apply for Medicaid, HCF A, in cooperation with PHS 
and SSA, should develop models for formal linkages between local welfare offces 
SSA district offces, and other providers who serve the homeless. These models 
should address, at the very least: (1) publicizing Medicaid, (2) outreach, (3) an
expedited application process, and training, whereby welfare workers and 
, (4) cross-
SSA district office staff learn effective ways of dealing with this population, and PHS-
funded providers learn more about Medicaid eligibilty guidelines, the application 
process, and servces in their States. 
. The SSA should be included in developing such models given the close tie between 
Medicaid and SSI. As for PHS, at least four agencies should be involved: (1) the 
National Institute on Alcoholism and Alcohol Abuse, which administers McKinney
funded research demonstration grants; (2) the National Institute of Mental Health  which also administers such grants as well as the Projects for Assistance in Transition 
from Homelessness program for the homeless mentally il and dually diagnosed; (3) 
the Offce for Treatment Improvement, which administers the ADMS block grant; 
and (4) the Health Resources and Servces Administration, which administers Health 
Care for the Homeless. 
All three agencies should disseminate these models widely through their own 
networks. 
Recmmendation 3: HCF A should provde technca asistace to States to promote 
liges 
the development of State strtegies and  designed to us Medcad more 
th 
effecely to serve 
population. 
We believe that States could use Medicaid more effectively to serve homeless 
individuals - for example, using optional servces to expand community-based 
treatment, developing model application forms or other ways to expedite the 
application process, or developing a "freedom of choice waiver" targeted at them. 
Also, many providers of mental health and, especially, substance abuse treatment 
lack a good understanding of Medicaid eligibilty, coverage of treatment, and other 
policies that affect homeless individuals. Thus, they may not know about the model 
application form that HCF A is 
developing which could be adapted for homeless 
persons. Or, they may make incorrect assumptions about what Medicaid policies 
allow; they may erroneously assume that States are precluded from out-stationing 
Medicaid workers, havig workers help in the initial processing of applications, or 
developing systems to track whether homeless people receive the Medicaid servces 
for which they qualify. 

We recommend that HCFA undertake a national effort to encourage State Medicaid 
agencies to provide technical assistance and training to State mental health and 
substance abuse agencies. The goal of this effort should be three-fold: (1) to 
increase their understanding of Medicaid and how it can be used to serve this 
population; .(2) to encourage these agencies, including the Medicaid agencies, to 
develop strategies to use Medicaid more effectively to serve them; and (3) to 
encourage them to develop formal linkages for this purpose. 
As part of this effort, HCF A regional offices should do everyhing possible to 
encourage the other State agencies to disseminate information about Medicaid 
through their networks of local treatment providers.  us 
Recmmendation 4: HCF A should  the Interagency Counci on the Homeles as 
a vehicle to provde technca asistace to other Fsedperea  agencies and McKiey
provders. Technca asistace should encoure  strtegies and promote
liges 
formal  which wi make Medcad more accible to homeles indidua. 
Many other Federal agencies receive McKinney funding to serve the homeless. The 
Interagency Council on the Homeless provides a forum, both on the Federal and 
regional level, for these agencies to discuss ways to better serve the homeless. 
Besides bringing Federal agencies together, the Council holds a biennial conference 
in each region for providers of all kinds, to promote better understanding and 
coordination on behalf of the homeless.

We recommend that HCFA use the 
various forums of the Interagency Council, to 
pursue the activities outlined in the recommendations above with regional staff of 
other Federal agencies and McKinney-funded providers. The goal should be to 
increase their knowledge of Medicaid and promote special strategies and formal 
linkages between Medicaid and other servce providers, at the State and local level. 
The ultimate purpose of these activities is to increase access to Medicaid for eligible 
homeless individuals. 
COMMNT 
The Assistant Secretary for Planning and Evaluation, HCF A and SSA commented on 
this report; the full text of their comments is in Appendix C. We also received 
comments from PHS staff. We made editorial changes to the text of the report in
response to all of these comments and wish to thank all those who commented. 
In the text of their comments, HCF A concurred with all but 
the second 
recommendation (notwthstanding their cover memorandum). They agreed 
with the 
intent of the second recommendation but raised concerns that they lacked sufficient 
staff to carry it out. Also, SSA suggested that we include them, along with PHS, in 
Recommendation 2, to more effciently and effectively coordinate Departmental 
resources. In response, we revised the second recommendation to include both PHS 
and SSA We also modified it to recommend consultation between the agencies as 
opposed to a formal Memorandum of Understanding. We believe that this will 
accomplish the intent of the recommendation, which remains unchanged. 
We also made some revisions to the third recommendation. Although HCFA 
concurred with it, and described some of their current activities in this connection 
we were not convinced that these activities alone constitute an adequate response to 
the intent of the recommendation. We revised it to reflect these activities but also 
describe what we believe would be a better targeted 
technical assistance effort. 
believe that this recommendation as now written is better focused and will 
also not 
be overly burdensome to HCF A.  APPENDIX A

GENERA COMMNT REGARING 1H DATA 
We collected both qualitative and quantitative data for this inspection. The qualitative 
data presented in the reports is not weighted. Quantitative ADMS data was used to 
make national projections (described later in this Appendix) based on weighted State 
averages for our sample States. For the most part, data collected from ADAMHA 
States and respondents was for 12 month periods representing 
fiscal years 1989 or 
1990. 
In general, data from States and respondents regarding ADMS expenditures was very 
difficult to obtain as well as extremely variable. They rarely kept this data in a 
complete or uniform manner. Also, State fiscal years varied, as did those of 
respondents. 
STATE SAMLE SELECTON 
We used a stratified, multi-stage methodology in choosing States, since we intended to 
make national projections with the quantitative data. We wanted to talk to ADMS 
grantees and certain McKinney-funded grantees (described later in the Appendix), 
who could discuss Medicaid and SSI. Thus we divided the 50 States into two 
categories: those with both ADMS grantees and more than one McKinney grantee 
and those with ADMS grantees and one or no McKinney grantees. (As noted in the 
Methodology section, McKiney respondents were Health Care for the Homeless 
grantees or grantees of research and demonstration projects funded by ADAMHA. 
We selected six States from the first category and four States from the latter. 
The 
sample States from each category were selected, with replacement, based on 
probabilty proportional to the estimated FY 1991 ADMS funding. 
The table lists the sample States, estimated amount of ADMS 
1991 funding, and the 
States' percent of total ADMS funding. The sample represents a signifcant portion of 
total ADMS funds. 
ESTIMTED ADMS PERCENT OF TOTAL 
FUS 
STATE  FOR FY 1991  ADMS FUNDS 
California  $151 048 450  13% 
Hawaii  077 746 
Ilinois  484 994 
Maryland  274 979 
Missouri  789 494 
New Jersey  169 435 
A 
 New Jersey  169 435 
New York  103 642 170 
Ohio  646 814 
Oregon  583 566 
Texas  804 
Total  $559 530 452  47% 
Total FY 1991 
Estimated 
ADMS Funding  187 357 962 
SAMLIG MEllODOLOY FOR ADMS REPONDEN 
We intended to sample 30 grantees from each State which would represent a 
proportional mix of mental health and substance abuse grantees. Respondents were 
program directors .or managers. The number of grantees sampled in each of these 
two categories was determined by the proportion of FY 89 mental health ADMS 
funding to substance abuse funding in each State. This was the most recent year for 
which States had this information. We contacted the 10 States and asked for the 
amount of ADMS funds they received in FY 1989, and the total amount that went to 
mental health grantees and substance abuse grantees. In addition, we asked for a 
listing of the mental health grantees and substance abuse grantees and the amount of 
ADMS funding each received. 
In most States, mental health and substance abuse grantees were then selected with 
probability proportional to the amount of the ADMS grant received. In instances 
where the grant money was given to counties, we selected six counties proportional 
to mental health and substance abuse funding. We then selected five grantees 
within each county with probabilty proportional to the amount of the ADMS grant 
received. 
There wer  some exceptions to these two basic methodologies. In those States 
where the amount of ADMS grant money for 1989 was not readily available, we 
chose a simple random sample of grantees. In instances where a grantee 
subcontracted over 50 percent of its ADMS funds, we asked the grantee to identify 
the two subgrantees who received the largest proportion of grant funds, whom we 
then intervewed. 
Several grantees were dropped because they were no longer receiving ADMS funds 
in FY 1991. Our final sample consisted of 224 grantees in 10 
States. There were 95 
mental health and 129 substance abuse grantees. The subs amp ling in each State was 
independent of that conducted in any other State. 
A 
 This methodology enabled us to capture, in most cases, a significant portion of 
States' ADMS funds in our sample. The following table gives the percent of ADMS 
mental health and substance abuse FY 1989 funds sampled in each State. 
PERCENT OF SAMPLED  PERCENT OF SAMPLED 
ADMS MENTAL HEALTH  ADMS SUBSTANCE ABUSE 
FUNDS TO TOTAL STATE  FUNDS TO TOTAL STATE 
ADMS MENTAL HEALTH  ADMS SUBSTANCE ABUSE 
ST ATE  FUNDS  FUNDS 
California  24%  12% 
Hawaii  82%  54% 
Ilinois  62%  46% 
Maryland  41%  35% 
Missouri  77%  39% 
New Jersey  45%  22% 
New York  12%  28% 
Ohio  12%  44% 
Oregon  68%  39% 
Texas  78%  14% 
We spoke with sampled respondents by telephone. Our first objective was to learn if 
the grantees served homeless individuals. We did not pursue further questions with 
the 56 grantees who said they do not serve the homeless. We discussed the 
availabilty, accessibility and appropriateness of their servces and 
Medicaid and SSI 
for this homeless population, with 168 grantees who did serve them. We also asked 
respondents to provide basic data on their total agency budget and ADMS grant 
clients served, including homeless clients, and Medicaid reimbursement. 
ADMS PROJECTONS

We made two national projections in this inspection: (1) the percent of ADMS going 
to grantees othat told us that homeless individuals were among their served 
population, and (2) Medicaid funds as a percent of total budget of the grantees. 
The projections are based on what these ADMS respondents told us. In some cases 
they could not give us numbers, or could only give estimates. The Data Verification 
Sheet we sent to respondents prior to calling them is in Appendix B. 
The definition of "homeless" we asked respondents to use in providing this 
information was: "A person who is not a member of a homeless family, and who 
lacks stable housing (including a person whose primary residence during the night is 
a supervsed public or private facility that provides temporary living accommodations 
or a person who is a 
resident in transitional housing. 
A  These projections are based upon unbiased estimates derived from the sample of 
grantees within each State. Estimates of the totals, and the variance 
associated with 
each total, accounting for the sub-sampling within each State, were calculated using 
methods described by Cochran . Given these totals, the percentages, as ratios, were 
easily derived. 
The results of these estimates are presented, by State and overall, in the following 
tables. 
Percent of ADMS Money Associated with 
Grantees Servng Homeless 
Mental Health
 Substance 
Grantees  Abuse Grantees 
NEW JERSEY  100.  64. 
MISSOURI  92.  91. 7% 
CALIFORNIA  45.  77. 
OHIO  75.  83.

ILLINOIS  66.  93.3%

NEW YORK  64. 
Strata Avg  71.5%  72.4% 
TEXAS  82.4%  75. 
MAYLD

87.5%  100. 
OREGON  98.9%  84. 
HAWAII  38.  60. 
Strata Avg  72.4%  74. 
Overall A vg
 71.  75. 
Std. Err.
 21.8%  21.8% 
Precision  49.  47. 
L 90% CI
 35.  39. 
U 90% CI  107.  111.6% 
1 Cochran, Wiliam G. Sampling Techniques. John Wiley & Sons, New 
, (1977) 
York, Sec. 11.9, pg. 306. 
2 The 
precision is defined as the semi-width of the confidence interval as a 
percent of the estimated mean. 
A  Because of the extreme variabilty in the data, the upper 90 percent confidence limit 
exceeds 100 percent. Logically, the upper limit should be truncated at 100 percent. 
The coefficient of variation for Mental Health programs is 30 percent and that for 
Substance Abuse programs is 29 percent. 
Medicaid Funds as a Percent of Total Budget 
by Type of ADMS Grantee 
NEW JERSEY  18.9%

MISSOURI  8.1%  13.

CALIFORNIA  16.

OHIO  25.  12.

ILLINOIS

NEW YORK  35.

13.  13. 
TEXA 
1.6%  1.8%
MAYLD 
15.  0.3%

OREGON  28.3 %

HAWAII

1.7% 
Weighted Avg 
Std Err  1.82%  87% 
Precision  33.  25.5 % 
20.  15. 
L 90% CI

U 90% CI 
12. 
This data demonstrates less variabilty than that in the ADMS funds data. However 
the coefficient of variation is below 10 percent for only one of the estimates, the 
percent homeless among Mental Health grantees. 
3 The precision is defined as the semi-width of the confidence interval as a 
percent of the estimated mean. 
A  SAMLIG MEllODOLOY FOR OrnR REPONDENT 
McKi 
Grantes 
The 33 McKinney grantees in our sampled States included 25 Health Care for the 
Homeless grantees and 8 other providers who have received McKinney research 
demonstration grants from either the National Institute for Mental Health or the 
National Institute on Alcohol Abuse and Alcoholism. We spoke by telephone or in 
person with these respondents. The focus of our discussions was the availabilty, 
accessibility and appropriateness of Medicaid and SSI. We were especially interested 
in comparing their perspectives - as providers whose mandate is to serve the 
homeless - with those of ADMS grantees, who have a much broader mandate. 
Socl Secu Ditrt Ofe Respond 
These 25 respondents included district managers, assistant district managers and 
claims and servce representatives in district offices near the McKinney grantees in 
the sample. We discussed their experiences servng this population, their opinions 
about how to enhance access to SSI for them, and their views on the role of SSI in a 
long-term solution to homelessness. 
State Medaid Staff 
For background, we reviewed portions of the Medicaid plan for each of the 
sample States, looking at eligibilty criteria and servces relevant to 
homeless mentally 
il or substance abusing individuals. We then talked by telephone with 16 Medicaid 
staff in the 10 States to clarify our understanding of eligibilty and servces
, and to 
ask if there were any special State Medicaid policies, procedures or special initiatives 
which affect this population. 
A 
 APPENDIX 

DATA VERICATION SHEET

Please have the following background information available for our telephone 
discussion; do not return it to us by mail. If possible, we want this data for Federal 
Fiscal year (FFY) 1990. However, if you maintain data on a State fiscal year (SFY) 
or calendar year instead, please tell us when we call. 
Please provide only the information that you maintain in your 
existing management 
information system; otherwse, do not generate it  We realize that 
specifically for us. 
you may not know or keep some of this information. In this case, we ask that you 
provide your best estimate, if you are comfortable with doing so. If not, just tell us 
you don t know. 
For FFY. SFY or Calendar 1990 ACTUAL or  ESTIMATED 
1. Total agency budget: 
2. Total ADMS  block grant 
funds received: 
3. Total McKinney funds 
received: 
4. Total clients served by your 
agency (unduplicated count; all 
programs or servces): 
5. Total clients served by your 
agency (unduplicated count) 
with ADMS dollars: 
1 Alcohol, Drug Abuse and Mental Health Servces Block Grant  ........................
DATA VERICATION SHEET

PAGE TWO 
homeless individuals 
6. Total 

over 18 served by your agency

( unduplicated count) .........

a. # 
mentally il (no

substance abuse problem):

b. # substance abusers (not

mentally il): 
c. # dually diagnosed 
(both problems)

homeless individuals over 
7. Total 

served by your agency

with ADMS dollars (unduplicated 
count) 
a. # 
mentally il (no

substance abuse problem):

b. # substance abusers (not

mentally il): 
c. # dually diagnosed

(mentally il and

substance abusing) 
8. Total Medicaid reimbursement 
OR percent of total agency budget 
that was Medicaid reimbursement 
9. Number OR percent of total 
clients served by your agency 
who were on Medicaid 
homeless 
10. Number OR percent of total 

individuals over 18 served by 
your agency who were: 
on Medicaid:

on SSI:

2Person who is not a member 
of a homeless family, and who lacks stable housing 
(including a person whose primary residence during the night is a supervsed public
or private facility that provides temporary living accommodations, or a person who is 
a resident in transitional housing.
 APPENDIX 

AGENCY COMMNT 
C -
 ..  &. 
Health Care 
DEPARTMENT OF HEALTH  HUMAN SERVICES  Financing AdmInistration 
Memorandum 
.lh41G 
DEC I 9 
1991 
Date 
D. cpJ 
Gail R. Wilensky, Ph.
From  Administrator 
OIG Draft Report - "Medicaid and Homeless Individuals" (OEI-05-91-00063) 
Subject 
Inspector General 
Office of the Secretary

We have reviewed the subject report which examined how Medicaid is used to 
serve homeless individuals with mental health, alcohol, or other drug problems. This 
report is one segment of a review of three major mainstream programs in the 
Department which could serve homeless individuals: Medicaid; the Alcohol, Drug 
Abuse, and Mental Health Services block grant (OEI 91-05-00062); and 
Supplemental Security Income (SSI)(OEI 05-91-00060). 
lited 
This report found that access to Medicaid may be  for many homeless 
individuals, especially given the close tie between eligibilty for 55I and Medicaid in 
most States. The report contains four recommendations which ask the Health Care 
Deparmental and inter-Departmental 
Financing Administration (HCF A) to support 
initiatives to increase services for homeless individuals, as well as the development of 
similar initiatives by States and local providers. HCFA agrees with two of the 
recommendations, but has some concerns with the other two. Our specific 
comments on each recommendation are attached, as well as technical comments on 
the report. 
Thank you for the opportunity to review and comment on this draft report. 
have no comments on the other two draft reports. Please advise us whether you 
agree with our position on the report s recommendations at your earliest 
convenience. 
Attachment  Comments o  h Care financing Aqministration ( 
on the OIG Draft Report 
Medicaid and Homeless Individuals 
05-9+-00063) 
Recommendation 
HCF A should work with the Social Security Administration (SSA) to develop a joint 
Medicaid for eligible homeless individuals. 
strategy to increase access to 
Response: 
We concur with this recommendation. Since the Supplemental Security Income 
program is closely linked to the Medicaid program, a joint strategy could be 
developed with SSA to increase access to Medicaid for eligible homeless individuals. 
Recommendation 2: 
HCFA should sign a Memorandum of Understanding with the Public Health Servce 
(PHS) to develop models which States and local providers can use to help homeless 
individuals apply for Medicaid, and should disseminate these models widely. 
Response: 
We agree with the intent of this recommendation. Unfortunately, we do not have 
the staff resources that would be needed to implement the recommendation and 
develop the recommended models. We would, however, be able to consult with 
PHS regarding this activity. 
Recommendation 3: 
HCF A should provide technical assistance to States to support or encourage the 
development of strategies to use Medicaid more effectively to serve this population. 
Response: 
We concur with this recommendation. We already provide technical assistance to 
States to support the development of strategies to use Medicaid more effectively. 
The following options are currently available to States and provide examples of our 
assistance:  Page 2

A model Medicaid application form is being developed in response to 
section 6506(b) of the Omnibus Budget Reconcilation Act 1989 for use by 
individuals who are not receiving cash assistance under Part A 
title IV of the  and who are not 
Social Security Act (the Act) 
institutionalized. Use of this model application is optional. 
While the development of this model application does not 
specifically target the homeless population, a State may adopt 
as part of its State Medicaid plan. The model application form 
should contain all the necessary criteria to make it less 
burdensome, and may make Medicaid more available and 
accessible. 
States could develop a section 1915(b) of the Act "freedom of choice 
waiver.!' The waiver could specifically target the homeless population with 
chemical dependency problems and provide for a priary cae case 
manager. 
There is no Federal requirement which precludes States from 
homeless population is 
outstationing workers at specific areas where the 
assist in the initial processing of applications. 
high. Workers could 
Further, States could create a process that ensures clients are tracked 
after they complete the application to ensure that they receive the servces 
for which they are eligible. 
A significant portion of homeless are substance abusers. 
ongoing function of the Medicaid Bureau, acting in accordance 
with the National Drug Control Strategy, is to develop materials 
to assist States in providing substance abuse servces under the 
Medicaid program. In fiscal year 1992 the Medicaid Bureau 
plans (1) to sponsor a national conference providing traing to 
regional office staff on Medicaid eligibilty, coverage, 
reimbursement and Federal financial participation issues 
involved with substance abuse, chemical dependence, and 
mental health and (2) to publish a document articulating 
Medicaid policy on chemical dependency, target populations 
and the Institutions for Mental Disease exclusion. 
Recommendation 4: 
HCFA should use the Interagency Council on the Homeless as a vehicle to provide 
technical assistance to other Federal agencies and McKinney providers. Technical 
C-4
 Page 3

liges 
special strategies and promote formal  which 
assistace should encourage 
will make Medicaid more accessible to homeless individual. 
Response: 
We concur with thi recommendation. We recogne that access to medica cae for 
the homeless is very importnt. Use of the Interagency Council on the Homeless 
cpano pprovuidlea thtei toechnnc.a l assistance to make Medicad more accessible to ths
Technical Comments: 
successfu Medicad 
H the outreach effort suggested in ths report are 
wi  fial 
enrollment and expenditures  increase. It would be helpfu if the 
report could address the issue of what the additional costs might be. In 
addition, it is not clear whether the Offce of Management and Budget 
would require offsetting savigs to ensure that spending stays withi the 
baseline under the Budget Enforcement Act. 
The report cites an estimate of $200 mion for current Medicad 
clar 
expenditures for the homeless. The fial report should  whether 
this estimate includes both Federal and State exenditures.  &. 
DEPARTMENT OF HEALTH  HUMAN SERVICES	 Soial Seuri Adminiatration 
Refer to:	 Memorandum 
tI 26 19

Date: 
Gwendolyn s. 
From:	
Commiss ioner

Subject: Office of Inspector General Draft Report, "Medicaid and 
Homeless Individuals" (OEI-OS-91-00063) --INFORMTION 
Mr. Richard P. Kusserow 
To:	
Inspector General 
our' response to 
the subj ect report.  If we may be
Aottachfed  furteirs   
assistance, please let us know. 
Attachment: 
SSA Response

C-6
 . - . I 
COMMS OF TH SOCIAL SECUITY ADMINISTRTION ON TH OFFCE 
INSPECTOR GENERAL DRAFT REPORT. "MEDICAID AND HOMELESS INDIVIDUALS" 
(OEI-05-91-00063 ) 
We have reviewed the Office of Inspector General (OIG) draft

report, and although its recommendations were addressed to the

Health Care Financing Administration (HCFA), we have the following

comments and observations to make.

The draft report notes on paqes 2 and 7 that homeless individuals 
Secuity 
must be eligible for Supplemental  Income (SSI) based on a 
determination that they are disabled in order to be derivatively
eliqible for Medicaid.  inaccuate. 
This statement is  Homeless 
individuals may be eliqible for SSI, and thus Medicaid, on the 
disability.
basis of age or blindness as well as on the basis of 
Fuermore , 
individuals may apply for Medicaid directly with the 
appropriate State agency, although the definition of disability for 
Medicaid eligibility is the same as used in the SSI proqram, in all
but thee  restrictive definitions. 
Moreover, 
states which use more  mae the determination 
in many States, the same state Aqency will 
proqram. 
for both the SSI and the Medicaid 
OIG' s second recommendation call. for HCFA to sign a Memorandum of
Pulic 
Understanding 
(MOU) with the  Health Service (PHS) to 
(1) develop models which states and local providers can use to help 
Medicaid, and 
homeless individuals apply for  (2) disseminate these 
models widely. We support this recommendation and believe that the
Social Secuity Administration  parter in
(SSA) should also be a 
this collaboration.  secuity 
(OIG Draft Report, "Supplemental 
Income for Homeless Individuals" recommends that SSA work with PHS 
to institute collaborative outreach and application processinq
proj ects . 
We sugqest that OIG expand the recommendation to read that "HCFA

should sign a MOU with the PHS and SSA .... for Medicaid and

SSI ... . A memorandum that includes SSA as one of the signers

could more efficiently and effectively coordinate the resources of

all three agencies to improve homeless individuals' access to

services. 
available and appropriate benefits and  ~~~~~~
, "  / =

,..
DEPARTMENT OF HEALTH.. HUMAN 
SERVICES  Of 
of th Se" 
'''IG 
.u'.shington 
, D.C. 2021. 
NO 2 2 
199  PDIG 
TO:  Richard P. Kusserow 
Evaluati, Ionspectorn Genera l 

FROM:  Assistant Secretary for Planning and AIG-MP 
OO/IG
USEe  'qI 
SUBJECT :  OIG Draft Reports: " DATE 
Supplemental Income for SEH  omeless

Individuals" 
Alcohol, Drug Abuse and Mental Health
Services for Homeless Individuals"

, and "Medicaid and

Homeless Individuals. 
 1'0-0;/91-
OG/- OS;-9OcJt/:&-o ooo  OEI- 0,-
 po  Od 0", 
This memorandum provides comments on the three subject draft

inspection reports which examined the availability, accessibility

and appropriateness of the SUpplemental Security Income Program

(SSI), the Alcohol, Drug and Mental Health Services 

grant 
, and Medicaid programs for homeless individuals( AwDhMoS )h abvleock

mental health, alcohol or other drug 

problems. 
In general, the assessments found that: 
provide some 1) most ADMS grantees
, but usually not specialized, services to homeless
people; 
2) the type and adequacy of those services are unclear
due to the lack of data on the quantity of services or their

impact; 
3) access to SSI and Medicaid programs is limited

al though special 
efforts are now being made by most SSA Field

offices to increase access to SSI. 
program providers and SSA field officAnoeth ers fitndaingff recognize tthhaatt  imto sits
 

is 
especially difficult for the mentally ill or substance abusing

population to access SSI and Medicaid programs.

Overall, the findings 
 these assessments are consistent with

what we are learning frin om other studies and program 

particularly with respect to the need for improved limnokangiteo rainndg
,
coordination among different levels of 

government . government, between

agencies, and within local service systems.
Unfortunately, the data available for these assessments did not

allow for more specific findings concerning 

numers 
quality of services provided served, the

generalizable models.
 , or for descriptions of successful,
Nevertheless 
, the findings and recommendations from these three
assessments will help shape a current initiative to simplify

programs and make them more accessible to severely mentally 

ill

homeless individuals. Your 
staff has already briefed the Federal

Task Force on Homelessness and Severe Mental Illness and its

outside Advisory Committee regarding these assessments. 
The Task

oForcfe  wJilla rnecomumenad ra pylan,  of action 
1992.  tb  the end 
C-8  . .
Page 2 - Richard P. Kusserow

I have a few additional comments listed below and editorial

comments written in the attached copies of these reports.

Alcohol Drua and Mental Health Services for Homeless Individuals

The background section on page i should include a sentence

or two in the discussion of the McKinney Act programs, on

the Projects for Assistance in Transition from Homelessness

(PATH) program, its purpose, and a clarification that while 
grantees, 
states award most of their PATH funds to ADMS 
those funds are not included by grantees that report 
ill. 
providing services to the homeless mentally 
A statement in the background section indicates that the 
ADMS dollars spent for substance abuse treatment as a 
portion of state expenditures for this purpose is unknown. 
We understand that as of 1990, there is an indicator in the 
National Drug and Alcohol Treatment utilization Survey that 
provides this information. 
In the findings section on page 4, the third paragraph under

finding '1, this statement should be reworded to clarify

use an

that the dollars referred to go to grantees that 
small. Dortion 
unknown but Drobablv  of their grants to serve 
this population. One could interpret the current statement 
to mean that over 70% of their block grant funds serve this
population. 
Appendix A, pages 4 and 5 contain very low percentages for

New York state ADMS funds that go to grantees serving the

homeless, and the extent to which ADMS grantees in New York

state seek Medicaid reimbursement for services. These 
estimates are so at odds with those for other states in the

I s 
sample and with New York  usual participation in sU. 
ograms that you may wish to re-check them.

SUDDlemental Securi tv Income and Medicaid for Homeless 
Individuals 
cribed 
The same data issue concerning New York state de 
above for Appendix A of the ADMS Report applies to Appendix 
A of the reports on SSI and Medicaid as well. 
On page iii of the Executive Sumary, we suggest adding a

recommendation to ensure that a national survey of the

homeless population being planned for 1992/1993 incl de the

proportion receiving SSI benefits.  Page 3 - Richard P. Kusserow

The ' description of the targeted federal response to 
homelessness on page 1 of all three reports would be more

complete with the addition of the following sentence after

paragraph: 
the second sentence of the fourth  "An additional 
$200 million in non-McKinney federal funds is targeted at

the homeless population.  Total spending in these targeted

programs will rise to over $1 Billion in FY 1992. 
Martin