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. 

OFFICE OF INTIGATIONS 

The OIG's Offce of Investigations (01) conducts criminal, civil, and administrative 

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. 

OFFICE OF EVALUATION AN 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 

Jennifer Antico 

Susan E. Hardwick 

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 

Medaid is import because it provi acces to prry car and seres in genaL It also wi acces to mel helt or sustae abuse seres. 
Nea two-th of th ADMS gr are Medaid-reiur Medaid is a greate resOUe for th me helt gr th th sustance abuse gr. Prvi peeie a diri betwee th nuer of homele in who are 

eligile for Medaid an th nuer who actull receie 

Th cloe ti betwee Medaid and SSI eligiil in mot State ma li acces to 

Medai for homele inls partrl drg adts an alcoholi. 

Prvi say tht homele in face nuus prble accesg Medaid tht 

th cant overome by thelves. 

A majori of ADMS gres help th homele apply for Medaid me helt gr are more li to help th suste abuse gr. 

McKi gres sugges many ways in whih proble in accesg Medaid for 

homele inls can be overome. 

The is li eve of gover inties whih hae ma Medaid more 

. availle accesle or apprprite for homele inls. 

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: 

Work wi th So Sec Admtrtin (SSA) to deelop a join strte 

ineae acces to Medai for eligile homele inls. 

Cons wi th Puli Hea See (PHS) and SSA to deelop mols to help

home in apply for Medaid Diemte the mols wily to prvi. 

Prvi tehnal ase to State, to promote th deelopm of State stte 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 to enourge SP stte an prmote

formlige to make Medaid more accesle to homele inls. 
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. AAPPENDIX B: Data Verification Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . .. BAPPENDIX 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 

greater Federal and State efforts through on-going, mainstream programs. 

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 

Federal/State outlay of $54.5 bilion; the Federal portion of 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. 

In 12 States, both eligibilty criteria and the 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 ages of 22-64 at institutions for mental 

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 298 respondents in these States. There 

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 

priar cae, and to servces in genera. It al widens acc 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 number of homeless 

individual who are eligible for Medicad and the number who act 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. 
, 

Findig #5: Provders say that homeles indidua face numerous problems 

accssing Medicad that they caot 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; 

menta health grtees are more liely to help th 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 

grantee than a substance abuse grantee. Of the 34 ADMS respondents who said 

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 

individuals 'Who you think are eligible? 

roaUnely 

.. lomeUmel 

DJ:. No r_pan.. 

0.. 20.. .. 0.. 60.. 80" 1 DO'" 

M.ntal hUh grant... E2 ... ..t all.... 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 

N-132 grantees grantees 

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 selfsufficiency; or (4) it is easier to qualify for Medicaid on the basis of mental ilness 

than substance abuse. 
Finding #7: McKiey 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. 

Findig #8: There is lited evidence of governent intiaties which have made 

Medicad more avaiable, accssible, or appropriate for homeless indidua. 

Few States appear to be delierately targetig homele invils un 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 

local level, many providers see a need to assist homeless individuals in applying for 

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 Sety Administration 

(SSA) to develop a joint strtegy to increa..acc 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) 

and SSA to develop models for States and loc provders to us to help homeles indidua apply for Medcad, and then dimiate 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, (4) cross-training, whereby welfare workers and 

SSA district office staff learn effective ways of dealing with this population, and PHSfunded 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 McKinneyfunded 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 

the development of State strtegies and liges designed to us Medcad more 

effecely to serve th 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. 
Recmmendation 4: HCF A should us the Interagency Counci on the Homeles as 

a vehicle to provde technca asistace to other Federa agencies and McKiey provders. Technca asistace should encoure spe strtegies and promote formal liges 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. 

STATE 

ESTIMTED ADMS FUS FOR FY 1991 

PERCENT OF TOTAL 

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 

NEW JERSEY 

MISSOURI 

CALIFORNIA 

OHIO 

ILLINOIS 

NEW YORK 

Strata Avg 

TEXAS 

MAYLD


OREGON 

HAWAII 

Strata Avg 

Overall A vg


Std. Err.


Precision 

L 90% CI


U 90% CI 

Mental Health


Grantees 

100. 

92. 

45. 

75. 

66. 

71.5% 

82.4% 

87.5% 

98.9% 

38. 

72.4% 

71. 

21.8% 

49. 

35. 

107. 

Substance 

Abuse Grantees 

64. 

91. 7% 

77. 

83.


93.3%


64. 

72.4% 

75. 

100. 

84. 

60. 

74. 

75. 

21.8% 

47. 

39. 

111.6% 

1 Cochran, Wiliam G. , (1977) Sampling Techniques. John Wiley & Sons, New 

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 specifically for us. We realize that 

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 

6. Total 
 homeless individuals 

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)


7. Total 
 homeless individuals over 

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 

10. Number OR percent of total 
 homeless 

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 

.lh41G Memorandum 

DEC I 9 1991 

Date 

Gail R. Wilensky, Ph.D. cpJ 

From Administrator 

Subject OIG Draft Report - "Medicaid and Homeless Individuals" (OEI-05-91-00063) 

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). 

This report found that access to Medicaid may be lited 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 

Financing Administration (HCF A) to support Deparmental and inter-Departmental 

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 

strategy to increase access to Medicaid for eligible homeless individuals. 

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 Social Security Act (the Act) and who are not 

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 

outstationing workers at specific areas where the homeless population is 

high. Workers could assist in the initial processing of applications. 

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


assistace should encourage special strategies and promote formal liges which 

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 

can provide the techncal assistance to make Medicad more accessible to ths population. 

Technical Comments: 

H the outreach effort suggested in ths report are successfu Medicad 

enrollment and expenditures wi increase. It would be helpfu if the fial 

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 

expenditures for the homeless. The fial report should clar whether 

this estimate includes both Federal and State exenditures. 
&. 

DEPARTMENT OF HEALTH HUMAN SERVICES	 Soial Seuri Adminiatration 

Refer to:	 Memorandum 

tI 26 19
 Date: 

From:	 Gwendolyn s. 

Commiss ioner


Subject: Office of Inspector General Draft Report, "Medicaid and 

Homeless Individuals" (OEI-OS-91-00063) --INFORMTION 

To:	 Mr. Richard P. Kusserow 

Inspector General 

Attached is our' response to the subj ect report. If we may be of furter 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 

must be eligible for Supplemental Secuity Income (SSI) based on a 

determination that they are disabled in order to be derivatively eliqible for Medicaid. This statement is inaccuate. Homeless 

individuals may be eliqible for SSI, and thus Medicaid, on the 

basis of age or blindness as well as on the basis of disability. 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 states which use more restrictive definitions. Moreover, 

in many States, the same state Aqency will mae the determination 

for both the SSI and the Medicaid proqram. 

OIG' s second recommendation call. for HCFA to sign a Memorandum of

Understanding (MOU) with the Pulic Health Service (PHS) to 

(1) develop models which states and local providers can use to help 

homeless individuals apply for Medicaid, and (2) disseminate these 

models widely. We support this recommendation and believe that the Social Secuity Administration (SSA) should also be a parter in this collaboration. (OIG Draft Report, "Supplemental secuity 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


available and appropriate benefits and services. 
,.. , 

/ 

DEPARTMENT OF HEALTH.. HUMAN SERVICES Of of th Se" 

'''IG 

.u'.shington , D. C. 2021. 

NO 2 2 199 PDIG 

TO: Richard P. Kusserow , Inspector General 


FROM: Assistant Secretary for Planning and AIG-MP Evaluation OO/IG

USEe 

SUBJECT : OIG Draft Reports: " DATE SE 

Supplemental Income for Homeless
 Individuals" Alcohol, Drug Abuse and Mental Health 'qI 

Services for Homeless Individuals"


Homeless Individuals. 
 , and "Medicaid and


1'0-0;/91- OcJt:&o OEI- 0,-
 po OG/- OS;-9/-ooo 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 who have (ADMS) block


mental health, alcohol or other drug 
problems. 

In general, the assessments found 

provide some that: 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 

program providers and SSA field office staff recognize that it is
 SSI. Another finding

especially difficult for the mentally ill or substance abusing


population to access SSI and Medicaid programs.


is that most


Overall, the findings 


in these assessments are consistent with
 what we are learning from other studies and program 


particularly with respect to the need for improved linkage and


coordination among different levels of 


government, between


monitoring,

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


allow for more specific findings concerning 


quality of services provided numers served, the
 , or for descriptions of generalizable models.
 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 


homeless individuals. Your staff has already briefed the Federal
 ill


Task Force on Homelessness and Severe Mental Illness and its


outside Advisory Committee regarding these assessments. 

Force will recommend a plan of action The Task
 of January, 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 

states award most of their PATH funds to ADMS grantees, 

those funds are not included by grantees that report 

providing services to the homeless mentally ill. 

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


that the dollars referred to go to grantees that use an


unknown but Drobablv small. Dortion 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


sample and with New York I s usual participation in sU. 

ograms that you may wish to re-check them.


SUDDlemental Securi tv Income and Medicaid for Homeless 

Individuals 

The same data issue concerning New York state de cribed 

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


the second sentence of the fourth paragraph: "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