Condensed Version of a Primer on How to Use Medicaid to Assist Persons Who Are Homeless to Access Medical, Behavioral Health, and Support Services

A Primer on How to Use Medicaid to Assist Persons Who Are Homeless to Access Medical, Behavioral Health, and Support Services: Condensed Version Prepared for the Homelessness Committee (Federal Regional Council, Region IX)

A Primer on How to Use Medicaid to Assist Persons Who are Homeless to Access Medical, Behavioral Health, and Support Services pulls together information about Medicaid that is especially relevant in assisting homeless individuals, including people who experience chronic homelessness. The Primer is intended to serve as a resource for state officials and homeless program managers to support your efforts to access and coordinate services and supports for homeless people. 

Chapter 1: Medicaid’s Basic Features

Medicaid was originally formulated as and remains a cooperative federal-state venture through which the federal government financially assists states to provide medical assistance, rehabilitative and other services to eligible low-income individuals and families. Within the broad national guidelines contained in federal law, regulations and other policies, states obtain federal financial participation in their costs of furnishing services to Medicaid beneficiaries. This federal-state relationship is a cornerstone of Medicaid. Federal policy dictates that states operate their programs in compliance with fundamental federal policies (including providing core mandatory services to mandatory eligibility groups) but leaves it to the states to determine the overall scope and extent of their programs.

Each state’s Medicaid program is unique and operates differently. Each state bases the design of its Medicaid program on the state’s demographics, health policy goals, objectives, needs, and financial capabilities. States are responsible for: (1) establishing eligibility standards within federal parameters; (2) selecting the services that they will offer and specifying the amount, duration, and scope of services; (3) designing the delivery of services; (4) determining payments for Medicaid services; and, (5) administering the program.

Medicaid is a linchpin in meeting the health needs of low-income individuals and families in the United States. It has grown enormously in its scope and depth over the past four decades. During that time, federal policy has constantly evolved. Within federal parameters, states have considerable flexibility in crafting their Medicaid programs with regard to who will be served and which services will be offered. People who experience homelessness are poor. For many of them, Medicaid can provide a way to secure essential health and support services.

Chapter 2: Medicaid Eligibility

Basic Elements of Medicaid Eligibility

Medicaid eligibility has two fundamental dimensions: (a) whether a person meets specific categorical criteria (e.g., age) and (b) whether a person’s income and resources are within the state’s threshold standards that apply to the eligibility group under which the person qualifies. Medicaid eligibility rules fall into two basic groups: categorical and financial.

Categorical eligibility

In order to secure Medicaid eligibility, a person must fall into a statutorily recognized “category” or “eligibility group.” There are six broad coverage groups: children, pregnant women, adults in families with dependent children, people with disabilities (adults and children), persons who are blind, and older persons.

Income eligibility

Medicaid is a means-tested program. An individual not only must fit one of the program’s specific categories/eligibility groups included in the State plan but also cannot have income that exceeds the income standard for the category. Medicaid income standards vary by beneficiary group (and by state) and are expressed in different ways. Some standards are expressed as percentages of the officially established Federal Poverty Level while others are keyed to cash assistance programs (e.g., SSI). Some standards are set in federal law and others by the states within federal guidelines. Some vary based on household size.

Medicaid eligibility is complicated due to the combination of categorical and financial factors, the mixture of mandates and options, and the discretion afforded each state to select coverage categories, establish income and resource standards, and decide how income and resources are treated. As a consequence, eligibility varies considerably state-to-state.

That said, federal law provides that every state must provide coverage to:

  • Very low income families through the Section 1931 Family coverage. In some states, this coverage is more generous and permits additional families to qualify;
  • Pregnant women, infants and children in low-income households; and,
  • People with disabilities and older persons who receive SSI cash assistance, except in §209(b) states where individuals must meet somewhat more stringent criteria.

Generally, every state has adopted several eligibility options to extend Medicaid to additional groups of low income individuals. Federal policy, however, generally prevents the extension of Medicaid eligibility to childless, non-disabled, non-elderly adults (except by demonstration waiver) and individuals who have primary addictive disorders.

Many people who experience homelessness or who are at risk of homelessness can and do qualify for Medicaid under various eligibility pathways. This is important because access to health care is important for avoiding homelessness or assisting people who are homeless to secure health care. Moreover, features of Medicaid eligibility permit the continuation of Medicaid services once individuals secure jobs. This is why such eligibility options as the Medicaid Buy-In are important.

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Chapter 3: Medicaid Benefits and Service Delivery

Federal law requires that each state must provide a core package of fourteen mandatory benefits in its Medicaid program. These required services may be supplemented by many optional benefits. Also, by operating one or more waiver programs, a state may provide still additional benefits. However, as is the case with eligibility, there are major differences among the states in the benefits that they offer.

Mandatory Medicaid Benefits  
  • Inpatient hospital services
  • Outpatient hospital services
  • Pregnancy-related services
  • Physician services
  • Nursing facility services for persons age 21 or older
  • Home health services for persons entitled to nursing facility services
  • Federally qualified health-center (FQHC) services and ambulatory services of an FQHC that would be available in other settings
  • Rural health clinic services
  • Laboratory and x-ray services
  • Nurse-midwife services
  • Vaccines for children
  • Family planning services and supplies
  • 60-days of postpartum-related services
  • Certified pediatric and family nurse practitioner service
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21

Federal law permits states to supplement mandatory Medicaid benefits with a wide range of [34] optional services. When offering a service under Medicaid, states must fashion their coverages to comply with certain federal requirements.

States may employ alternative arrangements, including managed care, to deliver services to beneficiaries. Some of the alternative arrangements that states employ are aimed at improving the care of beneficiaries with specific health care conditions or integrating the delivery of health and long-term services. States are required to pay for services furnished by Federally-Qualified Health Centers. Such centers are an important source of health care for people who experience homelessness.

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Chapter 4: Critical Medicaid Benefits for Chronically Homeless People

Medicaid is an important avenue for individuals and families who experience homelessness to secure basic health care services. In addition, there are certain Medicaid benefits that can play an especially important role in assisting people who are at risk of or experience chronic homelessness to achieve greater self-sufficiency and independence. This chapter provides in-depth information about the following critical Medicaid benefits:

  • Behavioral health services, including mental health and substance abuse services;
  • Case management;
  • Personal care/personal assistance services; and,
  • Home and community-based services

Federal policies concerning each of these benefits are summarized and additional information is provided concerning how the benefits can be used to assist people who are at risk of or experience homelessness[1].

Through the Medicaid program, states may offer a wide-range of services and supports that can assist individuals who experience or are at risk of chronic homelessness to function successfully in the community and become more self-sufficient. The provision of effective behavioral health services can address the root causes of chronic homelessness for individuals who have serious mental illness and/or addictive disorders. Services such as personal assistance and home and community-based services can also assist individuals to obtain the assistance that they require to lead more stable lives in the community.

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Chapter 5: Connecting People Who are Homeless to Medicaid Benefits

Securing Medicaid eligibility can be complicated in the best of circumstances. Medicaid eligibility determination is an application-driven process that frequently requires the applicant to produce considerable documentation. Since Medicaid is a means-tested program, applicants also must provide information about their income and assets. In the case of people with disabilities, Medicaid eligibility processes are intertwined with the necessity of determining that a person meets applicable Social Security disability tests.

People who experience homelessness often benefit from third-party assistance in securing and maintaining Medicaid eligibility because they are displaced or have impairments that make it difficult for them to navigate the Medicaid application process. In this regard, agencies and organizations that assist people who experience homelessness can play a critical role in brokering benefits on their behalf. In addition, states can take additional steps to facilitate access to Medicaid benefits.

People who experience or are at risk of homelessness frequently can benefit from third-party assistance in securing and maintaining Medicaid eligibility and, therefore, continuous access to Medicaid benefits. Federal policy permits third-parties to provide such assistance and affords opportunities for Medicaid agencies to partner with community agencies to increase access to Medicaid. States can take steps to avoid disruptions in Medicaid eligibility when people who have Medicaid eligibility are incarcerated or placed in psychiatric facilities. Other steps can be taken to address securing Medicaid benefits before people are released or discharged back to the community.

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Content created by Assistant Secretary for Planning and Evaluation (ASPE)
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