Homeless Healthcare Services

New York State Medicaid Coverage Policy and Billing Guidance for Providing Services to Medicaid Members Experiencing Homelessness

  • Guidance is also available in Portable Document Format (PDF)

Introduction
The New York State (NYS) FY20-21 budget authorized the State Department of Health (DOH) to initiate a policy in support of street medicine, a form of medical outreach designed to engage individuals experiencing homelessness (IEH). Stakeholders subsequently identified certain Medicaid Managed Care billing requirements as a significant barrier to meaningfully engaging sheltered and unsheltered homeless individuals to improve health outcomes and reduce health crises and avoidable hospital use.

In response, DOH is requiring Medicaid Managed Care Plans (MMCPs) to reimburse in-network (i.e., contracted and credentialed) Homeless Healthcare Providers for primary care services provided to a MMCP member who is experiencing homelessness, regardless of whether the provider is the member's assigned Primary Care Provider (PCP), so long as the provider can be associated with a physical office location, as defined on pages 2 and 5 of this guidance. This guidance describes NYS's vision for a range of homeless healthcare services, including street medicine, and outlines associated billing procedures.

Overview of Homeless Healthcare Services

Research shows, individuals experiencing homelessness (both sheltered and unsheltered) have higher rates of serious mental illness, cognitive disorders, substance use disorders, co-occurring mental health and substance use conditions, and chronic physical health conditions compared to non-homeless individuals.1 In addition, IEH are often transient, moving between multiple shelters, and face barriers to care, such as difficulty obtaining transportation. Consequently, IEH may struggle to access consistent care providers or a single primary care provider (PCP), potentially leading to delayed treatment,2 increased use of emergency departments, and higher rates of avoidable hospitalization.3

The term "Homeless Healthcare Services" as used in this guidance refers to any primary care service delivered to IEH in their current lived environment, whether sheltered or unsheltered. Services may be provided at Article 28 clinics or physician offices that are co-located in shelters or transitional housing sites, or at other host sites that typically serve IEH, such as drop-in centers and food pantries. Services may also be delivered via mobile medical units or specialized street medicine teams affiliated with Article 28 clinics or physician offices.

The term "Homeless Healthcare Provider" as used in this guidance refers to a licensed medical provider (e.g., Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse Midwife (CNM)) or a licensed dental provider (e.g., Doctor of Medicine in Dentistry (DMD), Doctor of Dental Surgery (DDS)) who conducts patient visits with homeless individuals in a shelter location or outside in the streets (unsheltered). Medical providers who are not physicians (such as PA, NP, and CNM) must be supervised by a medical physician practitioner who also practices or has knowledge of and experience as a Homeless Healthcare Provider.

Policy
Beginning February 1, 2025, Medicaid Managed Care Plans (MMCPs) must reimburse Homeless Healthcare Providers enrolled in New York State's Medicaid program who deliver primary care services to homeless Medicaid Managed Care members, irrespective of the service provider's status as the assigned Primary Care Provider (PCP). Payment is conditioned upon the provider being enrolled in the NYS Medicaid program, contracted and credentialed by the MMCP as a PCP or Specialist Provider, and the member being enrolled in the NYS Medicaid program and assigned to the MMCP at the time of the encounter. As a further condition of receiving payment, the provider must have a physical office location from which they conduct clinical or administrative duties related to their role as a credentialed PCP or Specialist Provider, orthe providermust be affiliated with a healthcare provider organization (such as a hospital, clinic, or primary care provider association) that has a physical office location used by the organization for clinical or administrative purposes. The MMCP must reimburse billable services at the agreed upon contracted PCP rates. NYS Medicaid-enrolled Homeless Healthcare Providers who deliver primary care services to fee-for-service Medicaid members experiencing homelessness (i.e., Medicaid members not enrolled in Managed Care) will be eligible to receive reimbursement based on the most recent physician fee schedule for services provided.

Documentation of Member's Homeless Status
The provider will be responsible for confirming and documenting the member's Medicaid enrollment and homeless status as follows:

  • The provider should establish procedures for confirming the member's Medicaid enrollment and managed care plan at the time of encounter. Retroactive billing for services provided to homeless Medicaid members will notbe permitted.
  • If the individual is not actively enrolled in Medicaid, the provider should assist, either directly or through a referral, with Medicaid enrollment. This initial case management would not be billable to Medicaid.
    • Note: Options for confirming and obtaining information on Medicaid eligibility and managed care plan enrollment include the Name Search and E-PACES. For more information on these and other options for eligibility verification, call the NYS Department of Health Medicaid fiscal agent, Computer Sciences Corporation (CSC), at 1-800-343-9000 or, on the internet, visit www.emedny.org, click on Provider Manuals, and under the section entitled Supplemental Documentation, click on MEVS Provider Manual.
  • Homeless status may be self-reported by the Medicaid member; documented in the medical record, patient history, or provider notes; or confirmed by any care team member.
  • The provider must document the Medicaid member's homeless status at the time of encounter by recording the appropriate Z-code in the member's diagnosis list.
    • Z.59.01 – Sheltered Homelessness: Use for individuals who are living in a shelter, such as a motel, temporary or transitional living situation, or scattered site housing.
    • Z.59.02 – Unsheltered Homelessness:Use for individuals residing in places not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, streets.

Documentation of Place of Service (POS)
The provider must use the appropriate place of service (POS) code on claim forms to indicate where service was provided. The following POS codes may be especially relevant to Homeless Healthcare Providers:

  • POS – 04 Homeless Shelter:A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).
  • POS – 10 Telehealth Provided in Patient's Home: The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
  • POS – 11 Office: A location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
  • POS – 15 Mobile Unit: A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
  • POS – 27 Outreach Site/Street: A non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals.

Core Homeless Healthcare Services
Homeless Healthcare Providers must be qualified and capable of providing (either directly or via referral to other providers), a full array of primary care services (including treatment of acute and chronic conditions) within their scope of practice to Medicaid members who are experiencing homelessness. Providers may only deliver services within the scope of their professional license.When referring members to other providers or organizations, the provider should identify as many options as possible. Financial, geographical, and other barriers should be minimized as much as possible.

Comprehensive primary care may include, but is not limited to:

  • Physical exams
  • Diagnosis and treatment of acute medical conditions
  • Routine management and treatment of chronic conditions (e.g., diabetes, hypertension, etc.)
  • Prescriptions provided for minor problems, acute problems, and chronic conditions
  • Laboratory testing
  • Immunizations
  • Reproductive healthcare
  • Basic oral healthcare (e.g., cleaning, simple extractions, fillings, x-rays)
  • Healthcare navigation and referrals to specialists including behavioral health as needed
  • Basic care coordination and social services referrals

Additional Considerations for Healthcare Providers Serving Homeless Medicaid Members

  • Homeless healthcare services must be consistent with state and local laws and regulations, established standards, and community practice.
  • Care should be trauma-informed, patient-centered, and sensitive to the needs of IEH.
  • Homeless Healthcare Providers must give IEH in their care written information, including:
    • The scope of services offered and any options to have the provider serve as the member's designated PCP or to collaborate with the member's current PCP; and
    • How individuals can access care elsewhere when the provider is not present or available.
  • Homeless Healthcare Providers must develop and maintain protocols for identifying and transferring members to a higher level of care if needed and when the member's service needs are beyond the capacities and/or qualifications of the provider.
  • Homeless Health Care providers that are not the member's assigned PCP must, to the extent possible, coordinate care with the Medicaid member's PCP (if applicable), other medical providers, social service agencies, mental health providers, and other agencies, programs, and organizations to ensure continuity of care.

Billing

  1. Members must be actively enrolled in Medicaid at the time of the encounter for the Homeless Medicaid Provider to receive reimbursement for services.
  2. Providers rendering services to Medicaid-enrolled individuals experiencing homelessness are to bill NYS fee-for-service Medicaid (FFS) or the MMCP with which the individual is enrolled for services within their scope of practice.
  3. For services provided to Medicaid members experiencing homelessness who are enrolled in fee-for-service (FFS) Medicaid and not enrolled in a MMCP at the time of the encounter, providers must bill NYS FFS. Reimbursement will be based on the most recent fee schedule, which can be found HERE.
  4. For services provided to Medicaid members experiencing homelessness who are enrolled in an MMCP, providers must bill the member's MMCP. Reimbursement must be made at the agreed upon contracted PCP rates, provided all payment conditions are met.
  5. Providers must be contracted and credentialed by the MCO and be associated with a physical (clinical or administrative) office location, either because the provider holds such a location directly or because the provider is affiliated with a provider organization (such as a hospital, clinic, or primary care provider association) that holds such a location. The visit itself does notneed to take place in that physical location in order for the provider to receive reimbursement on par with PCP levels. Additionally, an individual provider does not have to provide services at that physical location for a certain minimum number of hours per week in order to receive reimbursement equivalent to PCP levels.
  6. Providers that are Federally Qualified Health Centers (FQHCs) will be reimbursed at their applicable prospective payment system (PPS) rate or ambulatory patient group (APG) rate for services provided to FFS Medicaid members experiencing homelessness. For services provided to Medicaid members experiencing homelessness who are enrolled in an MMCP, the FQHC must bill the MMCP and be reimbursed at the contracted rate.
  7. Encounter forms should be generated for all billable services/visits.
  8. Procedures should adequately address follow-up on any denied Medicaid or other third-party claims.

Questions about this guidance should be directed to: SDH@health.ny.gov.

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1. Shern DL, et al. (2000). Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health, 90(12): 1873-8. 1

2. Ku, BS, et al. (2014). The urban homeless: super-users of the emergency department. Popul Health Manag,17(6):366-71. 2

3. Baggett TP, O'Connell JJ, Singer DE, Rigotti NA (2010). The unmet health care needs of homeless adults: a national study. Am J Public Health,100(7):1326-33. 3