1. Health Care Reform: What’s in it for
Homeless Families and Youth?
Presented by: Martha Knisley
Technical Assistance Collaborative, Inc.
National Conference on Ending Family and Youth Homelessness
February 18, 2014

2. Overview
 Health Care Reform: What’s In it For
Homeless Families and Youth?
 Core Medicaid Concepts with HCF Updates
 Medicaid Managed Care
 Introduction: Louisiana’s PSH Program
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3. What’s in Healthcare Reform
for Families and Youth
 An opportunity to extend Medicaid coverage for youth;
 For families, it reduces potential burden of crippling
healthcare costs;
 If a parent gets sick, they can go to a doctor, miss fewer
days of work and address potential complications from
chronic disease; and
 Eliminates denial for pre-existing conditions.
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4. What’s in Healthcare Reform
for Families and Youth
Coverage Details:
• ACA increases mandatory eligibility for youth ages 6 to 19 to
133% from 100% of FPL; children 0-5 already at 133% although
some states are up to 185% for this age group (state option);
• The ACA imposed MOE: states cannot reduce child eligibility for
Medicaid or CHIP until after September 30, 2019;
• Potential eligibility issues for some parents in states not
expanding;
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5. What’s in Healthcare Reform
for Families and Youth
• States must provide Medicaid for youth through their 19th birthday and
some states are taking option to provide coverage up through age 21;
• Under ACA states may not enroll parents and caretaker relatives in
Medicaid unless the child(ren) that live with them are enrolled in
Medicaid, CHIP, or other minimum essential coverage;
• If child was enrolled in Title IV-E foster care at age 18, then they can
stay on Medicaid until age 26;
• Thirty-three states have continuous eligibility option (“churn”) that allows
youth to stay on Medicaid/CHIP for a full year before renewal.
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6. What’s in Healthcare Reform
for Families and Youth
• Providers can assist families and youth by providing enrollment
information and assistance, helping gather documentation and
providing assistance to make choices and better understanding
options and categorical programs;
• For providers serving youth this includes understanding EPSDT
benefits, optional benefits and the CHIP (Children’s Health
Insurance Program) in their state.
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7. Core Concepts of
Medicaid Coverage
• Medicaid is first and foremost an Insurance Plan
• Established through a Medicaid State Plan
Key issues:
• Contrast between Medicaid and Medicare
• Eligibility and coverage groups
• Means for covering services
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8. Medicaid: Insurance Plan and More
• Medicaid is a major payor of health care services in this
country—over $500 billion annually with 55 million people
enrolled;
• Regardless of your state’s position on expansion, states
cover a portion of Medicaid costs and the federal
government pays a portion (FMAP);
• The Medicaid “insurance plan” includes both mandatory
and optional services; CMS and state Medicaid agencies
also shape health policy;
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9. Medicaid State Plan
• The Medicaid State Plan is a written plan between a State
and the Federal Government that outlines Medicaid:
– eligibility standards;
– provider requirements;
– payment methods; and
– health benefit packages;
• A Medicaid State Plan is submitted by each State
(continuously) and approved by the Centers for Medicare
and Medicaid Services (CMS).
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10. Medicaid State Plan
States must, among other requirements:
• ensure that services are provided in all parts of the state (the
“statewideness” requirement);
• establish or designate a single State agency to administer the plan;
• require the State health agency to establish health standards for
medical providers;
• provide coverage to certain categorically eligible individuals;
• provide services for all recipients in the same amount, duration and
scope (the “comparability” requirement);
• provide individualized plans of care for recipients.
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11. Contrasting Medicaid and Medicare
• The Medicaid program is a medical welfare program
based on financial and functional need;
• Applicants must meet income and asset eligibility
requirements, or must demonstrate a qualifying disability or
functional need for services;
• Eligibility for Medicare is not based on financial need;
• Medicare provides a standard benefit that provides partial
coverage
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12. Eligibility and Coverage Groups
• Federal law and the state Plan establish:
– eligibility rules, which include income, asset, citizenship, and
residency requirements;
– Mandatory and optional groups;
– There are many requirements—and new options with ACA;
• There are many “means” for covering services;
• Regardless of target population, category of service or
means, providers must meet state specific requirements and
enroll in the state Medicaid program.
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13. Eligibility and Coverage Groups
• Optional coverage varies by type service and is
influenced by categorical and mandatory requirements;
• States analyze their costs
• The ACA presents many new options and expanded
FMAP for newly eligible beneficiaries, for Health Homes,
other increases in expansion states.
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Mandatory Benefits Optional Benefits Essential Benefits
• Inpatient hospital services
• Outpatient hospital services
• EPSDT
• Nursing Facility Services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center
services
• Laboratory and X-ray services
• Family planning services
• Nurse Midwife services
• Certified Pediatric and Family
Nurse Practitioner services
• Freestanding Birth Center services
(when licensed or otherwise
recognized by the state)
• Transportation to medical care
• Tobacco cessation counseling for
pregnant women
• Prescription Drugs
• Clinic services
• Physical therapy; occupational
therapy
• Speech, hearing and language disorder
services
• Respiratory care services
• Other diagnostic, screening,
preventive and rehabilitative services
• Podiatry services; Optometry
• Dental Service; Dentures
• Prosthetics; eyeglasses
• Other practitioner services
• Private duty nursing services; personal
care
• Hospice
• Case management
• Inpatient psychiatric services for
individuals under age 21
Market Place (10 essential
services):
1. ambulatory patient services
2. emergency services
3. Hospitalization
4. maternity and newborn care
5. mental health and substance
use disorder services, including
behavioral health treatment;
6. prescription drugs
7. rehabilitative and habilitative
services and devices
8. laboratory services
9. preventive and wellness
services and chronic disease
management
10. pediatric services, including
oral and vision care
Coverages

15. Means for Covering Services
• Medicaid is an individual benefit—thus costs for care vary
by individual based on their use and need;
• CMS and State Medicaid programs are continuously
analyzing and creating options and costs: costs incurred
and costs avoided;
• CMS offers different “means” to states for flexibility---
including managing care through waivers and options;
• State plan options
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16. Health Care Reform:
Medicaid Costs
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Basic and preventive services —for all
Extensive Use/ Chronic care
Deep End

17. Coverages
• The Early and Periodic Screening, Diagnostic and Treatment
(EPSDT) benefit provides comprehensive and preventive
health care services for children under age 21 who are
enrolled in Medicaid;
• Under EPSDT, states are required to provide comprehensive
services and furnish all Medicaid coverable, appropriate, and
medically necessary services needed to correct and
ameliorate health conditions, based on certain federal
guidelines.
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18. Coverages
EPSDT is made up of the following screening, diagnostic,
and treatment services:
– Screening Services
– Vision Services
– Dental Services
– Hearing Services
– Other Necessary Health Care Services
– Diagnostic Services
– Treatment
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19. Coverages
• Another means of covering services is through “waivers”;
• Waivers permit states to be excused from one or more of
the Medicaid State Plan requirements – an example of
this is the “statewideness” requirement;
• The Affordable Care Act also provides some new options
for coverage through State Plan Amendments;
• One word on HCBS.
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20. Homeless Service
Provider Options
• Many organizations serving homeless families and youth
are also Medicaid providers;
• And/ or organizations can assist with enrollment and
helping families and youth gain access to needed
services;
• How do you decide what works for your organization?
– There is a role for every organization, healthcare matters
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21. Three Steps for Providers to
Examine Options
• Crosswalk your services, provider qualifications, mgmt.
capacity with requirements for specific Medicaid programs/
services;
• “Map” the Medicaid system for persons who you serve from:
enrollment referral assessment individualized plan
service delivery (may need to authorized or approved at
several points) and then repeated with re-evaluations and
redeterminations.
• Establish an agency business plan with multiple options.
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22. Basics: Medicaid Managed Care
• States “manage” care by enrolling people into managed care
plans; either on a voluntary or mandatory basis;
• States can implement a managed care delivery system using
three basic types of federal authorities:
• State plan authority [Section 1932(a)]
• Waiver authority [Section 1915 (a) and (b)]
• Waiver authority [Section 1115]
• Regardless of the authority, states must comply with the
federal regulations that govern managed care delivery
systems.
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23. Basics: Medicaid Managed Care
• All three types of authorities give states the flexibility to not
comply with statewideness, comparability and freedom of
choice requirements;
• States also have options types of approaches and for paying
managed care organizations:
– MCOs through a fully capitated model or
– Primary Care Case Management arrangements.
• There are literally dozens of models and hundreds of
organizations managing Medicaid benefits across the country.
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24. What’s In It: Medicaid Managed Care
• Components (established with a mix of federal and state
requirements) :
– Establish networks;
– Qualify providers;
– Establish medical or clinical homes;
– Pay providers negotiated or fixed fees for services, per diems or
per episode;
– Authorize and/or approve services;
– Assure access---to programs and services;
– Manage utilization and care; manage formulary;
– Meet quality standards.
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25. Louisiana PSH
• A strong coalition of advocates, state leaders,
providers and political leaders created the
Louisiana PSH program as part of the state’s
recovery hurricane effort in 2006;
• This effort grew to include 3000 subsidies
including 2000 PBV and 1000 S+C subsidies
and $69 million for “start up” services; and
• a significant change in Louisiana’s Medicaid
program five years later;
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Single family units in
Jefferson Parish

26. Louisiana PSH
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• PSH model is permanent, cross
disability largely scattered site with
families and single adults holding their
own leases and getting assistance from
local service providers;
• Early efforts created nearly 1,000 units
as set asides in LIHTC programs—today
tenants in those units get Section 8 PBVThe Preserve in New Orleans
• Over 60% of participants were homeless at time they entered
the program

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Good Luck!!
Resources:
http://www.nationaldisabilitynavigator.org/
http://www.enrollamerica.org
TAC Website: www.tacinc.org
Contact Info: mknisley@tacinc.org