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.

1. USING MEDICAID FOR HOUSING AND SERVICESNational Conference on Ending HomelessnessJuly 13, 2010Mark HurwitzDeputy DirectorProject Renewal h 1

2. Project Renewal: Background 2 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

3. Project Renewal: Key Services 3 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

4. Today’s Presentation 4 New York’s Medicaid Program How Project Renewal Uses Medicaid Policy Issues

5. Health Insurance Coverage Source: CDC National Health Interview Survey 5

6. New York State’s Medicaid Program 6 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

7. NY State Medicaid Managed Care: Exemptions From Mandatory Enrollment (partial list) 7 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

8. Behavioral Health Carve Out 8 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

9. How Does Project Renewal Use Medicaidto Deliver Services? 9 Outpatient detoxification Mental health case management linked with scattered site housing Federally Qualified Health Center

10. 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 Detoxification 10

11. Funding Model: Transitional Housing with Case Management 11 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

12. Funding Model:Federally Qualified Health Center 12 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

13. 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 13

14. Considerations in Forming an FQHC 14 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

17. Project Renewal’s MedVan 17 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

18. Benefits of Mobile Primary Care vs. Traditional Clinic 18

19. 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? 19

20. Thank You Contact: Mark Hurwitz mark.hurwitz@projectrenewal.org 212.620.0340 www.projectrenewal.org 20