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Medicaid is a government health insurance program that can be used to offer services in supportive housing programs. Under the new Health Care Reform law, virtually all homeless people will be eligible, and can benefit from configuring supportive housing services to take advantage of Medicaid reimbursement. Consideration will be given to the administrative and data burdens inherited when a housing provider becomes eligible for reimbursement from Medicaid/medical assistance, as well as the benefits of delivering a flexible array of supports to maintain persons in their homes.
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USING MEDICAID FOR HOUSING AND SERVICES
National Conference on Ending HomelessnessJuly 13, 2010
Mark HurwitzDeputy DirectorProject Renewal
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Project Renewal: Background2
Project Renewal offers innovative solutions to the intertwined problems of homelessness, mental illness and addiction
Founded in 1967 as a shelter-based detoxification program providing an alternative to incarceration for chronic alcoholics
Now 35 distinct programs, primarily serving chronically homeless single adults
Project Renewal: Key Services3
Residential programs: 1,487 beds 4 emergency shelters: 600 beds 4 congregate supportive
housing programs: 596 beds Scattered site housing: 291 beds
Integrated primary care, addiction treatment, and mental health
Education, training, and job placement
Today’s Presentation4
New York’s Medicaid Program How Project Renewal Uses Medicaid Policy Issues
Health Insurance Coverage
14.3
31.6
21.1
0
5
10
15
20
25
30
35
%
New York Texas All States
Percentage of adults 18-64 who lack health insurance
Source: CDC National Health Interview Survey
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New York State’s Medicaid Program
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New York has covered very low income childless adults on Medicaid since 1966
1997 - Sec 1115 managed care waiver approved
1999 - NYC began mandatory enrollment for families
2001 - Expanded coverage to include childless adults at 100% of FPL and families at 150% of FPL
2005 - NYC required mandatory enrollment for SSI recipients
Those that do not choose a plan or claim an exemption within 60 days are automatically enrolled in a plan
NY State Medicaid Managed Care: Exemptions From Mandatory Enrollment (partial list)
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Individuals who are HIV+ or who have AIDS
Individuals with chronic medical conditions who have been under active treatment for at least six months with a sub-specialist who is not a network provider for any Medicaid managed care plan in the service area
Individuals with End Stage Renal Disease (ESRD)
Homeless Individuals
Behavioral Health Carve Out8
NY’s waiver application originally called for the creation of Mental Health and HIV Special Needs Plans, but the legislature did not approve the enabling legislation for Mental Health SNPs
SSI recipients who are enrolled in managed care receive mental health and addiction treatment (except for inpatient detox) on a fee-for service basis by using their Medicaid card
How Does Project Renewal Use Medicaidto Deliver Services?
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Outpatient detoxification Mental health case management linked
with scattered site housing Federally Qualified Health Center
Project Renewal’s 30-bed Medically Supervised Detoxification Program is co-located with a 170-bed homeless shelter
Program provides 652 detoxifications annually
The daily cost of the program is $118 compared with $1,302 for inpatient detoxification
53% of patients are linked with continuing addiction treatment, compared with 20% for inpatient detoxification
Revolving door syndrome: one person spent 279 days a year in detox at a cost to Medicaid of $324,485
Funding Model:Outpatient Detoxification10
Funding Model: Transitional Housing with Case Management11
Project Renewal’s Parole Support and Treatment Program is a 50-bed scattered site transitional housing program for parolees with serious mental illness
Team of 4 Case Managers carries a caseload of 56 (50 in housing, 6 exiting prison)
Non-housing portion of program budget is $360,000 78% of this budget is funded by Medicaid Case managers must have a minimum of 4
(intensive) or 2 (supportive) encounters per month
Funding Model:Federally Qualified Health Center
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Any Health Care for the Homeless program receiving 330(h) funding from HRSA is an FQHC
State Medicaid programs pay an enhanced rate to FQHCs to subsidize uncompensated care
Managed Care Plans are required to contract with FQHCs
Project Renewal’s FQHC
Three freestanding primary care clinics and dental clinic in shelters
3 mobile vans, 2 for primary care: “MedVan”
1 mobile specialty care clinic: “ScanVan”
21,000 visits/year Budget: $5.5
million Medicaid covers
63% of primary care visits and 40% of budget
Patient Navigators Electronic medical
record
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Considerations in Forming an FQHC14
Developing in-house expertise Clinical Administrative Information Technology
Recent HRSA grants mostly for expansion or underserved areas
Billing and accounting requirements Fee-for service business carries financial
risk
Why Integrate Health Care & Housing?15
Practitioners partner with residential program staff to ensure follow-through: Diet Keeping Appointments Medication compliance
Collaboration on disability applications
Coordination of care with specialists and after hospitalization
Integration of Primary and Behavioral Care: Example
Patient complained to primary care physician of chronic pain that was preventing him from sleeping. With patient’s permission, physician consulted with the patient’s psychiatrist, who determined that sleeplessness was related to anxiety and prescribed anti-anxiety medication.
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Project Renewal’s MedVan17
Launched in 1986 Staffed by 2 providers and a driver/receptionist Provides full range of primary care, including:
Vaccinations Caridiography Blood draws Pregnancy Tests Wound care
Specialty care relationships including teledermatology consulting
Suboxone Rx privileges
Benefits of Mobile Primary Care vs. Traditional Clinic18
Mobile Primary Care Traditional Clinic
Single clinic can serve many locations
Limited patient base
Only space requirement is parking
Need to plan for space and capital cost during building design
Cost can be spread over multiple locations; locations can change over time with changing needs
Requires sufficient patient volume to justify up-front investment and ongoing staffing
Policy Questions
Should medical and behavioral services be provided in the community or on-site in shelter? In permanent housing?
Financing: Who takes the risk / who gets the reward?
How well does managed care work for chronically homeless individuals?
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Thank You
Contact:
Mark Hurwitz
212.620.0340
www.projectrenewal.org
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