Medi-Cal Insurance policies Enhancing Housing Safety Amongst Older Adults

Introduction

In California, almost 186,000 individuals are presently unhoused,^[1] with older adults over age 50 representing the quickest rising demographic affected by homelessness, surpassing each youngsters and youthful adults.^[2] Alarmingly, many older adults are dealing with homelessness for the primary time later in life.^[3] Black, Latino, and Native American individuals are overrepresented – for instance, Black older adults solely make up 5.4% of California’s general inhabitants, however they make up 26% of California’s unhoused inhabitants.^[4]

California’s Medicaid program, Medi-Cal, gives important well being protection to over 15 million Californians and performs a key position in addressing homelessness for older adults. Of California’s whole inhabitants of individuals experiencing homelessness, not less than 75% have been coated by Medi-Cal.^[5] For older adults 50 and older experiencing homelessness, 64% had Medi-Cal and seven% have been dually eligible for Medicare and Medi-Cal.^[6]

In recent times, California has carried out a number of Medi-Cal insurance policies to extend the variety of folks eligible for Medi-Cal protection, scale back obstacles to sustaining protection, and supply new providers designed to forestall and scale back homelessness. This factsheet outlines these insurance policies and the way they may also help to boost housing safety for older Californians.

Medi-Cal: An Overview

Medi-Cal is California’s Medicaid program and gives well being care protection to nearly 15 million low-income Californians, together with low-income youngsters, households, single adults, older adults and individuals with disabilities.^[7] Over two million folks qualify for Medi-Cal on the premise of age, blindness or incapacity and 73% of them are dually eligible for Medicare and Medi-Cal protection. Medi-Cal is a joint state and federal medical insurance program, administered by the Division of Well being Care Companies (DHCS) and overseen by the federal Facilities for Medicare and Medicaid Companies (CMS).

Eligibility Primarily based on Age or Incapacity

Older adults and folks with disabilities may be decided eligible for Medi-Cal via a number of pathways. Some individuals are routinely granted Medi-Cal as a result of they’re already receiving different public advantages, together with Supplemental Safety Revenue/State Supplementary Cost (SSI/SSP) and California Work Alternative and Accountability to Children (CalWORKs).^[8] These individuals are termed “categorically eligible” for Medi-Cal. Anybody who receives SSI/SSP or CalWORKs is routinely granted Medi-Cal protection with out the necessity for a separate software.

For all different older adults, the revenue restrict without spending a dime Medi-Cal beneath the Aged and Disabled program is 138% of the Federal Poverty Degree (FPL), which in 2024 is $1,732 a month. Individuals with larger incomes can qualify for Medi-Cal through the Medically Needy Share of Value program however solely after considerably lowering their revenue by paying for medical bills.

Medi-Cal Protection

California’s Medi-Cal program gives complete medical protection together with doctor providers, specialty care, in addition to imaginative and prescient, dental, and listening to aids. Past medical care, Medi-Cal additionally covers transportation to medical appointments, mobility gear comparable to energy wheelchairs, and providers that deal with the social determinants of well being comparable to meals and residential modifications to assist older adults stay dwelling at dwelling. Importantly, Medi-Cal is the first payor of long-term providers and helps for older adults and disabled folks, together with private care providers via the In-Residence Supportive Companies program, dwelling and community-based waiver providers, and long-term care in nursing amenities.^[9]

For folks dually eligible for Medicare and Medi-Cal, Medicare is main and Medi-Cal fills within the gaps for what Medicare doesn’t cowl – together with long-term providers and helps. Medi-Cal additionally pays for Medicare out-of-pocket prices like premiums and price sharing.

Medi-Cal’s Function in Enhancing Housing Safety

More and more, the Medi-Cal program acknowledges that housing is a key social determinant of well being. Frequent components that result in housing insecurity amongst older adults embrace lowered or misplaced revenue because of a job loss, the demise of a relative or liked one, incapacity or medical disaster, hire will increase or inflation, a hospitalization or discharge from a nursing facility—all of which disproportionately influence communities of coloration because of systemic racism and discrimination.^[10] On the identical time, housing insecurity and homelessness are social components that negatively influence an individual’s general well-being and well being.

To assist improve housing safety, California has carried out quite a lot of adjustments to Medi-Cal, together with eligibility expansions, offering assist with discovering housing, paying for first month’s hire and safety deposits, and housing arrange charges like utility providers. A brand new short-term rental help profit can also be starting January 2025 for qualifying teams of individuals.

Medi-Cal Eligibility Expansions

California has carried out two latest adjustments to eligibility guidelines that increase entry to protection to 1000’s extra low-income older adults and folks with disabilities: 1) the Older Grownup Growth; and a couple of) Asset Restrict Elimination. Collectively these adjustments increase protection to low-income older adults beforehand not eligible, make it simpler for low-income older adults to acquire and preserve protection, get monetary savings for emergencies, keep away from out-of-pocket prices for well being care, and entry providers to remain housed.

Older Grownup Immigrant Growth: Could 2022

In Could 2022, the Older Grownup Growth to folks age 50 and over additionally allowed greater than 765,000 immigrants who have been beforehand ineligible to entry complete well being protection.^[11] Beforehand, people with no qualifying immigration standing couldn’t qualify for full-scope Medi-Cal even when they met all different eligibility standards, limiting them to receiving emergency providers solely beneath “Restricted Medi-Cal.” Now, all older adults and folks with disabilities, no matter immigration standing, have entry to the total vary of Medi-Cal providers, together with main and specialty care, dental, behavioral well being, transportation, and long-term providers and helps.^[12] With entry to complete Medi-Cal advantages and well being care protection, undocumented older adults can obtain better monetary safety, permitting them to pay for housing and save for emergencies, thereby lowering the danger of homelessness.

Two Phased Asset Elimination: July 1, 2022 and January 1, 2024

In figuring out Medi-Cal eligibility, an individual’s property –money, checking or financial savings financial institution accounts, automobiles, or houses – is not thought of to qualify for Medi-Cal advantages. As of January 1, 2024, an individual’s revenue is the one monetary criterion thought of within the Medi-Cal software.^[13] Belongings are not counted.

This coverage change helps folks’s financial safety in a number of methods. First, it helps folks extra simply receive and preserve entry to Medi-Cal as a result of it removes the executive burden and obstacles of getting to show asset eligibility at software or throughout annual eligibility redeterminations – a really cumbersome course of that steadily leads to terminations of protection for people who find themselves eligible.^[14] Second, the prior asset restrict of $2,000 pressured people to stay in deep poverty with out the chance to avoid wasting for emergencies. The asset elimination permits folks to avoid wasting past $2,000, which may be the distinction between paying a rental deposit or changing into homeless. Third, the prior asset restrict excluded the worth of the house, a useful rule for householders, however ignored renters and disproportionately impacted Black and Latino older adults.^[15] The elimination now excludes all property, permitting renters and householders alike to take care of money financial savings.

The change to Medi-Cal’s asset restrict occurred in two phases: on July 1, 2022, property limits elevated from $2,000 to $130,000 (with an extra $65,000 for every further family member). This resulted in 12,189 folks gaining protection.^[16] The asset restrict was eradicated altogether on January 1, 2024. California didn’t see a big enhance in new enrollees after the elimination as a result of revenue limits are the actual barrier to Medi-Cal protection. Most individuals with incomes at or under 138% of federal poverty merely would not have important property and sources.^[17] But, as famous above, the elimination of the asset restrict considerably will increase the financial safety of older adults and folks with disabilities who beforehand may solely retain $2,000 in property.

Medi-Cal Funded Housing Helps

California has obtained federal approval to offer two new Medi-Cal providers via the state’s Medicaid waiver, CalAIM, that enhance housing safety: 1) Enhanced Care Administration (ECM); and a couple of) Group Helps (CS). Each are designed to enhance well being fairness and deal with the social determinants of well being (SDOH), comparable to entry to secure housing, meals, and transportation that influence an individual’s general well-being.^[18] An absence of housing, or unstable housing, results in poor well being outcomes and exacerbates current well being inequities that have an effect on low-income populations.^[19] These providers are restricted to Medi-Cal managed care enrollees solely; these in fee-for-service will not be eligible. Medi-Cal well being plans are chargeable for figuring out and connecting qualifying people to those providers and contracting with community-based organizations to ship the providers. ECM and Group Helps launched statewide in July 2022.

Enhanced Care Administration

ECM is a high-touch, particular person centered care administration program for folks with complicated and excessive wants. ECM is run by the Medi-Cal managed care plans, and case administration providers are delivered by contracted, community-based organizations with expertise in case administration. ECM is accessible to seven particular teams who meet particular standards, referred to as “populations of focus.” One of many key populations of focus are folks experiencing homelessness. Older adults and folks with disabilities who’re enrolled in Twin Eligible Particular Wants Plans (D-SNPs), will not be entitled to ECM however obtain equal case administration providers via the D-SNP. ECM is a crucial software that may assist forestall folks from changing into unhoused or transition folks briefly staying in a shelter or interim housing into secure housing.

By means of ECM, people are assigned a single care supervisor who’s chargeable for coordinating each scientific and non-clinical care throughout the medical, dental, behavioral well being supply programs and neighborhood social service packages. ECM providers are primarily offered in-person and in settings the place people stay, search care, or favor to entry providers. All ECM members have a documented care plan and a lead care supervisor overseeing the supply of ECM providers, which embrace outreach and engagement, enhanced care coordination, well being promotion, helps for people and their relations, complete transitional care, and coordination of and referral to neighborhood and social help providers.

Of the seven Populations of Focus, 5 embrace older adults experiencing, or vulnerable to, homelessness:

• People and households experiencing homelessness
• Adults transitioning from incarceration
• Adults with a critical psychological sickness or substance use dysfunction
• Grownup nursing facility residents who wish to transition to the neighborhood
• People at Danger for Institutionalization and Eligible for Lengthy-Time period Care Companies

As a result of ECM care managers are chargeable for overseeing an individual’s general care, ECM connects folks to helps out there to search out housing, but in addition different providers that stabilize an individual’s present housing scenario and/or forestall homelessness.^[20] For instance, the ECM case supervisor can join members to housing providers that can be utilized to stabilize present housing, comparable to counseling and one-time hire funds. For people already experiencing homelessness, ECM can establish the steps wanted to determine housing long-term and join them to the related providers and helps to attain that objective. ECM providers are offered by organizations well-suited to offer any such excessive contact care. For instance, for people experiencing homelessness, ECM suppliers embrace homeless navigation facilities or road drugs suppliers. The ECM care supervisor will meet members in a shelter, a physician’s workplace, or on the road.

From the information printed up to now, 13% of all ECM members have been age 65 or over as of 2024.^[21]

Group Helps

Group Helps are providers provided by Medi-Cal plans to deal with health-related social wants, together with entry to housing and neighborhood dwelling.^[22] Group Helps assist people discover, safe, and preserve housing. Research affirm that having protected and secure housing will increase optimistic well being outcomes and life expectancy, whereas additionally lowering over-utilization of emergency and different high-cost providers.^[23] Group Helps can be found to adults and folks with disabilities enrolled in D-SNPs and are delivered via the Medi-Cal managed care plan.

There are fourteen whole Group Helps plans can provide^[24] and three particularly deal with housing:

• Housing Transition Navigation Companies – providers to assist people discover and safe housing, comparable to assist with the housing software and negotiating with the owner.
• Housing Deposits – funds to pay the housing deposit to safe housing.
• Housing Tenancy and Sustaining Companies – providers to navigate the tenant/landlord relationship, linking to neighborhood sources to forestall eviction.

Group Helps will not be a Medi-Cal state plan profit, which means they’re non-obligatory for a plan to offer. Nevertheless, all of the Medi-Cal managed care plans have chosen to offer the housing-related Group Helps, making them out there statewide.^[25] Group Helps should be medically acceptable and can be paired with ECM for a complete bundle of providers. An individual receiving ECM as a result of they’re experiencing homelessness can have a case supervisor that refers them for Group Helps housing transition navigation providers and housing deposits.

Two different Group Helps, Recuperative Care (Medical Respite) and Brief-Time period Put up-Hospitalization Housing, additionally assist to take care of housing for older adults, not less than briefly. Older adults with documented care wants however with out protected and secure housing can profit from short-term housing via these two Group Helps till they get well. For individuals who would not have housing and are recovering from an sickness or damage and needing care, dwelling on the road or in a shelter just isn’t a viable possibility for long-term restoration and dignity. Different Group Helps that help secure housing embrace Residence Modifications, Nursing Facility Transition/Diversion to Assisted Dwelling Amenities, and Sobering Facilities.^[26]

In January 2025, Medi-Cal may even start protecting short-term hire funds beneath the Transitional Hire Group Assist.^[27] Not like the opposite fourteen Group Helps, that are non-obligatory—plans are required to offer Transitional Hire. This profit will probably be out there to folks experiencing homelessness, these vulnerable to homelessness, unsheltered populations, these leaving institutional settings or incarceration, and a number of other different inhabitants teams.^[28] Eligible people might obtain as much as six months of Transitional Hire funds. California has not launched the ultimate restrictions and standards for the Transitional Hire profit on the time of this publication. The short-term cost of hire via the Medi-Cal program has immense potential to enhance the lives of low-income older Californians experiencing homelessness or in danger. The dearth of entry to housing is the one biggest barrier that forestalls people from having the ability to transfer from being unhoused, or transition out of establishments and to the neighborhood.

Of all Medi-Cal people who obtained Group Helps in 2024, 23% have been over age 65.^[29]

Conclusion

Medi-Cal is an extremely expansive and complete public insurance coverage program that serves tens of millions of low-income Californians. Medi-Cal’s position as the first medical insurance program for older adults experiencing homelessness implies that it has a significant affect on lowering and stopping homelessness for older Californians. The latest Medi-Cal expansions in eligibility standards and new providers to deal with housing insecurity, are comparatively new and their means to straight enhance outcomes long-term just isn’t but measured, however they maintain nice potential to enhance the standard of life and well being outcomes of older Californians vulnerable to, or experiencing, homelessness.

Endnotes

1. Marisa Kendall, Unique: California’s homeless inhabitants grew once more this yr, particularly in these counties, CalMatters, (Could 2024). ↑

2. Monica Davalos, The Rise of Homelessness Amongst California’s Older Adults, California Finances & Coverage Heart, (Could 2024). ↑

3. Id. ↑

4. Monica Davalos, The Rise of Homelessness Amongst California’s Older Adults, California Finances & Coverage Heart. ↑

5. Margot Kushel, MD and Tiana Moore, PhD, Towards a New Understanding: The California Statewide Research of Individuals Experiencing Homelessness, College of California, San Francisco, (June 2023), Determine 26 at web page 57. ↑

6. Id. ↑

7. Creator evaluation of January 2024 knowledge of Medi-Cal Enrollment by Eligibility Group, accessed November 22, 2024. ↑

8. CalWORKs gives money funds to eligible California households. CA Dept of Social Companies, California Work Alternative and Accountability to Children (CalWORKs), accessed December 9, 2024. ↑

9. Medicare covers time-limited expert nursing care and few folks can afford to privately pay for nursing dwelling care. ↑

10. Carrie Graham, Sarah Triano, and Torshira Moffett, Making CalAIM Work for Older Adults Experiencing Homelessness, California Well being Care Basis, (July 2023). ↑

11. Creator evaluation of Could 2024 knowledge on the Older Grownup Growth, California Well being and Human Companies, accessed November 25, 2024. ↑

12. As of January 2024, immigration standing just isn’t thought of within the Medi-Cal software course of for all age teams. Welf. & Inst. Code 14007.8. ↑

13. Immediately, monetary eligibility for Medi-Cal protection relies solely on revenue for all Medi-Cal classes, together with the Aged, Blind and Disabled, Lengthy-Time period Care, Medicare Financial savings Program, Share of Value, and the 250% Working Disabled Program. ↑

14. MACPAC, Rising the Charge of Ex Parte Renewals, (September 2023), at pg. 6. ↑

15. See e.g. Carmel Ford, Nationwide Affiliation of Residence Builders, Homeownership Charges by Race and Ethnicity, (March 1, 2018). This report discovered Black homeownership to be 29 share factors decrease than white households and Latino homeownership to be 26 share factors decrease. ↑

16. Creator evaluation of DHCS Datasets on Newly Eligible inhabitants from July 2022 to December 2023. DHCS, Asset Restrict Adjustments for Non-MAGI Medi-Cal, accessed November 25, 2024. ↑

17. Marc Cohen and Jane Tavares, How Medicaid Monetary Eligibility Guidelines Exclude Financially and Medically Weak Older Adults, (March 29, 2023), at pg. 12. ↑

18. DHCS, Enhanced Care Administration and Group Helps. ↑

19. California Division of Public Well being, An Replace on the Portrait of Promise: Demographic Report on Well being and Psychological Well being Fairness in California. A Report back to the Legislature and the Individuals of California by the Workplace of Well being Fairness, (February 2020), at pg. 13. ↑

20. DHCS, Enhanced Care Administration For People Experiencing Homelessness, accessed December 16, 2024. ↑

21. DHCS, ECM and Group Helps Quarterly Implementation Report, ECM Member Traits by Age Group, accessed November 21, 2024. ↑

22. DHCS, Transformation of Medi-Cal: Group Helps. ↑

23. Invoice J. Wright, et al., Previously Homeless Individuals Had Decrease Total Well being Care Expenditures After Transferring Into Supportive Housing, Well being Affairs, (January 2016); Margot Kushel, M.D., et al., Emergency Division Use Among the many Homeless and Marginally Housed: Outcomes From a Group-Primarily based Research, American Journal of Public Well being, (Could 2002). ↑

24. DHCS, Group Helps Coverage Information, (July 2023). ↑

25. CalAIM Group Helps – Managed Care Plan Elections, July 2024. Medi-Cal plans might select to cease providing a particular Group Assist at their discretion. ↑

26. DHCS, Group Helps Coverage Information. ↑

27. DHCS, Transitional Hire Idea Paper, (August 2024). ↑

28. Further teams embrace these dwelling in residential settings, the kid welfare system, recuperative care amenities, short-term post-hospitalization housing, transitional housing, homeless shelters, interim housing, and Full Service Partnership members. See DHCS, Transitional Hire Idea Paper, (August 2024), at pg. 14. ↑

29. DHCS, ECM and Group Helps Quarterly Implementation Report, Group Helps Member Traits by Age Group, accessed November 21, 2024. ↑