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Three Approaches to Opioid Use Disorder Treatment in State Departments of Corrections
As drug overdose fatalities continue to rise and incarceration rates remain high nationwide despite recent declines, states are increasingly developing opportunities for incarcerated individuals to access evidence-based opioid use disorder (OUD) treatment in state prison facilities.
While the forced abstinence during incarceration can temporarily pause substance use itself, providing comprehensive treatment that includes medications for opioid use disorder (MOUD) during incarceration is shown to result in better treatment engagement as well as long-term recovery upon re-entry. Providing this kind of treatment during incarceration represents a shift in criminal justice approaches to substance use disorders (SUD), one that relies on partnerships between state agencies and providers, as well as the adoption of an understanding of OUD as a chronic-yet-treatable disorder with effective medical interventions.
Any discussion of this shift toward reframing people with OUD as individuals in need of Treatment – including those incarcerated as a result of their substance use – must also recognize that racial bias across systems affects sentencing policies. While Black people use illicit drugs at similar or lower rates than the rest of the population, they are incarcerated at over five times the rate of White people. Black Americans have also been disproportionately affected by recent increases in overdose fatality due to synthetic opioids, underscoring inequitable systemic responses to prevention, treatment, and recovery for Black individuals with OUD. The incarceration-based treatment approaches emerging today stand in stark contrast to the policy response to the crack-cocaine epidemic and subsequent sentencing guidelines of the previous generation that saw millions of Americans, approximately 80 percent of whom were Black men, incarcerated without a similar focus on treatment.
Policymakers are currently charting a different course by offering evidence-based treatment that is initiated alongside incarceration, recognizing that systems can work together to support people with SUD. These programs represent an opportunity to address both the SUD that may be at the root of criminalized behavior, and the racial disparities in sentencing that foster health disparities.
Developing programs that emphasize treatment instead of incarceration ultimately requires not just a shift in perspective about the nature of SUD, but also the will of leadership to implement new policies and clinical practices – and the funding to do so. The National Academy for State Health Policy (NASHP) talked to leaders from three states – Kentucky, Maine, and Pennsylvania – about their approaches to SUD treatment within their state prison populations and how these approaches are evolving.
Maine
In early 2019, the Maine Department of Corrections (ME DOC) developed a pilot program to begin providing MOUD, starting in one secure state facility and two pre-release state facilities. Part of the impetus for this program was a 2018 lawsuit filed by the American Civil Liberties Union (ACLU) on behalf of an individual with OUD who was entering a Maine state prison and was going to be denied treatment, despite having been in recovery for five years with the assistance of prescribed medication.* ME DOC ultimately settled the case, agreeing to continue providing the individual with necessary medication. Prior to this, the state’s correctional facilities focused on providing residential and out-patient level of substance use treatment and continuity of care in the community upon release, but had no internal, evidence-based program that provided MOUD. In 2019, a new governor and administration initiated different priorities, including new approaches to address Maine’s opioid epidemic. Additionally, the state had just expanded Medicaid, which helped ME DOC to develop protocols that would ensure continuity of care upon release by enrolling participants in Medicaid coverage immediately upon re-entry.
To inform its planning process and learn about successful incarceration-based MOUD programming, Maine’s corrections leadership visited Rhode Island, a leading state in SUD treatment with incarcerated populations. ME DOC launched its buprenorphine pilot in July 2019 by engaging 50 individuals in the program, each of whom was three months from release. The size and scope of the initial pilot phase were intentional, as the state was limited to operating within its existing budget, staffing, and medical services contract. By November, with additional funding, a second facility was added, expanding the program to 75 to 90 participants, and by the end of that year, 115 individuals had successfully initiated treatment while incarcerated and transitioned back into the community.
In 2020, ME DOC expanded the program to all secure and pre-release state facilities and has nearly 200 participants enrolled in the program on average. ME DOC continued to expand eligibility policy over time. Currently, if a behavioral health or medical provider refers an individual for induction, regardless of entry or release date, ME DOC is able to provide MOUD. All program participants are released with a naloxone kit and a continuity of care plan in place, and internal data has shown that 84 percent of program participants attended their initial treatment appointment post-release.
Pennsylvania
Pennsylvania’s Department of Corrections (PA DOC) began offering injectable naltrexone in 2014 through a small pilot with women who were re-entering the community from one state correctional facility. Within two years, PA DOC had expanded this program to other facilities, identifying individuals at risk of overdose and providing injectable naltrexone prior to re-entry, as well as connections to Medicaid enrollment to support continued treatment in the community.
On June 1, 2019, PA DOC continued this development of treatment services through a formal policy change that supports provision of buprenorphine to anyone coming into state custody who was on a verified prescription upon entry, though not yet to other incarcerated individuals with OUD. While this did not replace the naltrexone program, it did introduce a second form of MOUD into the state corrections system, creating entirely new protocols and challenges and with them, opportunities. PA DOC also began inducting those individuals who entered prison due to technical parole violations on injectable buprenorphine before they returned to the community as an alternative to detoxing onsite. Buprenorphine provision, however, experienced serious disruption with the temporary loss of a provider to prescribe the drug, followed by the emergence of COVID-19, which has affected clinical and procedural protocols across the board for PA DOC.
Pennsylvania also brought on a full time medication-assisted treatment (MAT) coordinator for corrections in 2016, a move that led to planning and exploration of expanded treatment provision development, bringing significant growth to the program. In the first year, the state had fewer than 80 individuals receiving MOUD, but participation has grown annually and is on track to include over 1,000 people in all 24 state prisons in 2020.
Kentucky
Kentucky’s Department of Corrections (KY DOC) currently maintains about 6,000 SUD treatment beds within the state’s correctional facilities, though most of those do not include the provision of MOUD and instead promote an abstinence-only approach. In 2018, the state developed the Substance Abuse Medication Assisted Treatment (SAMAT) project in which at-risk individuals are identified pre-release and provided injectable naltrexone or buprenorphine. While still incarcerated, they are connected to Kentucky Medicaid and enrolled in a managed care plan, and prior authorization is completed for necessary continuity of medication upon re-entry.
In 2020, looking for ways to further support and sustain comprehensive treatment in state prisons, the Kentucky legislature passed a budget that included language directing the state Medicaid agency to develop and submit an 1115 demonstration waiver to the Centers for Medicare & Medicaid Services (CMS). This waiver is intended to create a mechanism for Medicaid coverage of SUD treatment while an individual is incarcerated, an approach that is currently prohibited by language known as the “inmate exclusion” in the Social Security Act.
This means that policymakers in Kentucky are simultaneously designing a DOC treatment program and the mechanism to administer and fund it. State leaders are currently exploring proposals to amend the current 1115 waiver to address anticipated clinical and policy challenges to providing MOUD, especially buprenorphine, to people who are incarcerated. All of this must be done while maintaining the budget neutrality required by 1115 waivers. This process also raises questions about when Medicaid coverage would begin, and what services would be absorbed by the DOC budget as opposed to those that would be reimbursable by Medicaid. A mechanism to provide Medicaid coverage to individuals within a 30- to 60-day window prior to release may mitigate some of these concerns. This approach would ultimately increase resources for KY DOC to improve its quality of services by moving toward a more evidence-based approach that includes MOUD.
Considerations for States
All three of the featured states started small, beginning their DOC-based MOUD provision in pilot programs, and with initial success and additional funding, scaled those programs up to meet demand. States had to account for multiple factors in deciding which forms of MOUD to use in their programs, including the expectations of DOC clinical providers, security within facilities, and community treatment supports upon re-entry.
Widespread concerns among corrections officials about potential diversion, as well as stigma about using agonists and partial agonists for treatment, has resulted in a slower adoption of their use in incarceration-based treatment. Though naltrexone has been more widely embraced by correctional facilities than agonists and partial agonists like buprenorphine and methadone, each state has included or is working to include at least two forms of MOUD. Beyond this, state officials also developed clinical protocols and program components based on state resources and needs, and certain experiences and design elements were common across the states.
- Decisions around specific forms of MOUD. Maine’s program currently primarily utilizes buprenorphine, recognizing that methadone provision would require significant administrative and clinical policy change. Federal methadone treatment regulations require accreditations and standards that are challenging to meet for an existing correctional facility. ME DOC is, however, exploring opportunities to expand the program to include methadone over time. Additionally, because naltrexone has limited availability in the community for individuals upon release, policymakers were concerned that a program utilizing naltrexone may make connections to ongoing treatment challenging.
While Maine has had success with buprenorphine, current PA DOC policy does not provide for induction on buprenorphine to most incarcerated individuals with OUD – a challenge that is both clinical and administratively-based. Like many states, Pennsylvania contracts for medical care in state prisons, and the current contract was not written to include the provision of MOUD, particularly buprenorphine, which can be clinically intensive and comes with provider waiver requirements.
Per the Request for Applications (RFA) issued by PA DOC, the next iteration of the contract will include a requirement that the state’s corrections medical provider provide MOUD. The RFA stipulates that:
- An Addiction Specialist, certified through the American Board of Preventative Medicine, be identified among the contractor’s leadership to support SUD treatment needs;
- All providers are educated in SUD treatment;
- The contractor must register each correctional institution in the Risk Evaluation and Mitigation Strategies (REMS) program in order to safely order, store, and administer buprenorphine.
- Subcontracts are developed with opioid treatment programs to provide methadone at certain facilities; and
- A sufficient number of provider staff hold a waiver to prescribe buprenorphine.
Regardless of current challenges, Pennsylvania is prioritizing buprenorphine induction for individuals with OUD who are re-entering communities, similar to the way in which they are currently providing naltrexone. Further, there is a push to be able to induct those who are using contraband opioids, often as a means of harm reduction, while incarcerated. While the state uses injectable buprenorphine for a small minority of program participants, state leaders are awaiting the late 2020 release of a shorter-acting, non-refrigerated formulation that may be less cumbersome to administer.
- Attention to correctional workforce needs. Recognizing that addressing staff concerns about the provision of MOUD, including issues of security and diversion, would be necessary for the program to succeed, ME DOC leadership arranged a second site visit specifically for security staff to meet with their counterparts in Rhode Island. To gauge staff culture, ME DOC leadership also conducted an internal survey among staff to assess the general understanding of MOUD, the results of which were used to tailor subsequent staff training and education prior to program implementation.
Kentucky is contemplating the development of new workforce protocols to provide these services as part of the state’s proposed Medicaid waiver. The current approach uses KY DOC counseling staff who are not licensed as behavioral health professionals. The state may consider developing a new provider type of DOC-based professionals, requiring new or amended professional licensing regulations, reimbursement policy changes, and facility licensure changes if needed. The state is also deliberating what utilization of peers may look like in such a program, as well as what supervision for unlicensed staff would include.
- Ensuring continuity of care upon re-entry. Individuals leaving incarceration face a host of risk factors for return to substance use and potential overdose, including lack of access to treatment and limited financial resources. In recognition of this, all three states ensure that program participants are enrolled in Medicaid coverage, safeguarding their access to continued treatment in the community. The ME DOC also contracts with Groups Recover Together, a community recovery organization that helps to ensure that individuals are connected to and engaged in recovery services upon re-entry.
Pennsylvania is also considering how individuals progress with treatment upon re-entry based on the treatment provided to them while still incarcerated. Currently, PA DOC is providing up to three naltrexone doses prior to release and is reviewing state Medicaid treatment data to understand the impact of multiple doses versus one dose on treatment outcomes in the community.
- Coordination between state leadership. Because these programs often emerge from previously existing social or abstinence-based approaches, the development of protocols and resources must be coordinated under the direction of high-level state leadership. Officials in all three states indicated they had leaders who not only authorized but championed treatment in incarceration settings. These leaders were critical to developing treatment policy, and their continued focus on OUD-related initiatives was a key component to maintaining services. In 2018, Pennsylvania’s governor declared the overdose epidemic a statewide disaster, and he continues to renew that declaration to ensure that initiatives it supports – including treatment within PA DOC – are maintained. The declaration established a cross-agency Opioid Unified Coordination Group composed of cabinet-level health and public safety officials that meets weekly.
Kentucky is one of few states to have a dedicated Office of Drug Control Policy, which led the charge for them to be among the first states to fund and implement an incarceration-based naltrexone program in corrections. The state legislature is unique in the nation in its decision to direct the state Medicaid agency to explore and submit a Medicaid waiver to provide SUD treatment to incarcerated individuals.
Maine’s current governor appointed a cabinet-level State Opioid Response Director, and she included incarceration-based treatment among her top priorities for the state upon assuming office. The governor’s second Executive Order, signed less than a month into her term, directed the development of OUD treatment in criminal justice settings, and the state’s DOC commissioner was working to implement this within the first few weeks of her administration.
Funding and Support for Incarceration-Based Treatment Sustainability
Because of the inmate exclusion that prevents correctional facilities from receiving Medicaid reimbursement for services in incarceration settings, states are relying primarily on federal grant funding to support these programs.
Maine launched its pilot program without using any additional funds beyond its internal budget, receiving an additional $1 million in funding from the Maine Office of Behavioral Health’s federal substance abuse block grant to support the program later in 2019. Concurrently, ME DOC realized savings in its health care budget as a result of the state’s recent Medicaid expansion. With these additional funding streams, Maine was able to make its final program expansion by adding its last remaining correctional facility to the program and expanding program eligibility to allow individuals who entered a facility from a local jail to continue on a course of MOUD that had been established previously. This also allowed Maine to expand treatment to individuals who are 180 days pre-release.
Kentucky’s initial provision of naltrexone was supported through state legislation that allocated $3 million to the program, and the current program is supplemented through federal State Opioid Response funds provided via the Kentucky Opioid Response Effort (KORE). Pennsylvania similarly uses their SOR funding to support current programming.
Looking Ahead
States are looking to the future as they plan what OUD treatment services for incarcerated populations will look like, as well as how to fund such services with increasingly limited resources and current reliance on federal grants. There may be an emerging appetite to address the inmate exclusion and develop new approaches through Medicaid, though as the COVID-19 pandemic increases Medicaid enrollment and drives state revenues down, any new Medicaid-funded services will be challenging to state budgets.
Even in successful corrections treatment programs, lack of insurance coverage upon re-entry is a barrier to long-term treatment and recovery outcomes. A House bill introduced in 2019, known as the Re-entry Act, was written to allow states to reinstate eligibility for Medicaid for incarcerated individuals in jails and state prisons up to 30 days prior to re-entry. Recognizing that the COVID-19 pandemic has disrupted, if not altogether halted, re-entry services across the country, the bill’s language was integrated into pandemic response legislation as a part of the Heroes Act, which has yet to be passed.
Treatment programs in incarceration settings are helpful tools that states are using in hopes of reducing opioid overdoses, but also in reducing the stigma around SUD and the racial disparities in health outcomes for people with OUD. As states continue to take steps to tackle the opioid epidemic, state corrections settings are proving to be an innovative access point for evidence-based treatment.
*See Smith V. Fitzpatrick, et al. The lawsuit argued that the DOC was violating the Constitution and the Americans with Disabilities Act by denying treatment to prisoners with OUD. At the time, the Maine DOC had a policy generally prohibiting medication-assisted treatment, under which Smith would have been prevented from taking his medication and forced into acute withdrawal.
Acknowledgements: The National Academy for State Health Policy is providing this case study with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. Further, the authors would like to thank Allen Brenzel, medical director of the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities; Steven Seitchik, Statewide Medication Assisted Treatment Coordinator for the Pennsylvania Department of Corrections, and Ryan Thornell, Deputy Commissioner of the Maine Department of Corrections for contributing their expertise and state experiences to this brief.
Promising State Strategies to Improve Continuity of Substance Use Disorder Treatment following Incarceration
Corrections-involved populations have higher rates of opioid and substance use disorders (SUD) than the general population, with more than 75 percent of recently released individuals reporting an SUD or a chronic medical and/or psychiatric condition. These individuals face numerous barriers to receiving treatment, including stigma, limited access to medication-assisted treatment (MAT), and disconnected systems of care.
While many states have begun to increase access to MAT in jails and prisons, coordinating continuous treatment following release remains a challenge. This disruption contributes to recidivism, drug use, and poor and costly health outcomes. Researchers in Washington State estimate that the risk of death from overdose was 12-times greater for a recently released individual than among the general public, resulting in high health care costs. Those costs, particularly to treat overdose episodes, are affecting state budgets in multiple ways. Researchers in Kentucky estimated that 12 months of overdoses cost the state $7 million in charity care in addition to $59 million in annual Medicaid expenditures.
To address the range of physical and behavioral health care needs during this critical transition period, states are working to streamline enrollment and re-enrollment in Medicaid, provide care management and supports, and better address social determinants of health for this vulnerable population.
States have implemented various initiatives across agencies to address the need for continuity in coverage post-release. Policymakers are focusing on different entry points and policy levers, all of which are aimed at easing transitions to ensure care across systems, including clinical-level interventions to coordinate care between corrections and community settings. While health care in the corrections system is subject to internal procedures and regulations, providing continued coverage upon release requires significant coordination at both policy and clinical levels.
Care Management and Supports for Continued Medicaid Coverage
Application and enrollment assistance: States are dedicating staff to conduct screenings and help complete and process Medicaid applications to address individuals’ literacy and access challenges. States may mandate Medicaid enrollment within legislation or may include such requirements in their state Medicaid plan.
A 2015 New Mexico law states that incarcerated individuals must be allowed to submit a Medicaid application. In 2018, the state expanded this when it passed an additional legislative directive to enhance data-sharing activities among state agencies in support of Medicaid eligibility and care coordination for corrections-involved populations. This legislation also mandates that correctional facilities must:
- Facilitate Medicaid eligibility determinations during an individual’s incarceration or upon re-entry, and
- Require that county jails be provided with technical assistance, training, and certification of county jail presumptive eligibility determiners upon written request.
Suspension – rather than termination – of Medicaid during incarceration: In 2016, the Centers for Medicare & Medicaid Services (CMS) clarified that states may suspend rather than terminate Medicaid on incarceration. Suspension – rather than termination – allows for quicker reinstatement of coverage after incarceration and may be a cost-saving option for both Medicaid expansion and non-expansion states. Examples of states moving in this direction include:
- California passed legislation in 2014 to suspend rather than terminate Medicaid benefits upon incarceration. Benefits may be suspended for up to one year of incarceration.
- Washington State passed SB 6430 in 2016, which allows for indefinite suspension of Medicaid benefits during incarceration.
Managed care contracting: States are exploring ways to establish routine and robust care transition processes by leveraging managed care organization (MCO) contracts to support care coordination.
Arizona contractually requires MCOs, Regional Behavioral Health Authorities, and community-based behavioral health entities to provide “reach in” care coordination services in correctional settings. Detailed “reach in” plans must be submitted to the Arizona Health Care Cost Containment System (AHCCCS).
Health homes: Health homes are integrated, team-based clinical approaches through which providers coordinate care for people with serious or multiple chronic conditions. States, through state plan options within Medicaid, may have multiple health home models, serving beneficiaries with different types of chronic conditions and/or beneficiaries in different geographic areas. States may draw down a 90 percent federal match for specified care coordination services for two years for each health home.
- Through an 1115 waiver, New York policymakers want to implement a prerelease, in-reach transitional service in order to ensure corrections-involved populations receive needed care management and critical social supports on release into the community. A large part of this waiver includes criminal justice health home pilots to provide integrated, person-centered care for Medicaid enrollees with chronic conditions.
Data sharing and exchange to support care continuity: Research indicates that disruption in care for this vulnerable population can be especially detrimental to recovery. States are creating processes to share and use data to ease the transition from incarceration to community settings:
- Ohio developed the Medicaid Pre-Release Enrollment Program, a pre-enrollment system for corrections-involved populations not already enrolled in Medicaid. The program requires data to be shared between the Medicaid agency and the Ohio Department of Rehabilitation and Correction to coordinate efforts and ensure direct enrollment into manage care plans upon release.
- Arizona’s Data Exchange System is an automated data-exchange system that identifies when a Medicaid beneficiary is released from jail, developed through intergovernmental agreements between counties and the Arizona Department of Corrections and administered by the Arizona Medicaid agency, AHCCCS. The data within this system is also used by managed care plans to better provide support to recently released individuals.
Areas to Explore
Recovery support innovations: State officials are interested in implementing collaborative strategies that can support recovery and address re-entry-related social determinants of health as part of comprehensive case management.
- The Pennsylvania Department of Corrections has established a program that allows qualifying incarcerated individuals to become certified peer support specialists to help others in the facility identify and meet recovery goals. Such initiatives provide incarcerated individuals with a potential career path and build in recovery supports on re-entry into their communities, dramatically decreasing the risk of recidivism.
As state policymakers explore strategies to provide treatment (medical/psychological interventions) and support (non-medical, recovery activities) to corrections-involved populations, they may consider:
- Policies to ensure the continuation of coverage;
- Cross-sector collaboration; and
- Comprehensive, patient-centered approaches.
For more information about how states can promote treatment coverage and continuity for justice-involved populations, explore the National Academy for State Health Policy’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage Toolkit.
States May Soon Have to Provide Medication-Assisted Treatment to Inmates, Here’s How to Fund It
State policymakers on the frontlines of the opioid epidemic understand that treating justice-involved individuals with opioid use disorder (OUD) offers a critical opportunity to expand access to treatment. While there is strong evidence that medication-assisted treatment (MAT) promotes recovery, saves lives, and reduces re-incarceration, states must surmount significant policy and financial challenges to provide MAT in correctional settings.
Does MAT in jails curb costly recidivism and drug use?
Without MAT, 77 percent of inmates with OUD relapse within three months of their release, even if they receive counseling in jail.According to a SAMSHA report, MAT has been found to “reduce criminal activity, arrests, as well as probation revocations and re-incarcerations.”
Without MAT, 77 percent of inmates with OUD relapse within three months of their release, even if they receive counseling in jail.According to a SAMSHA report, MAT has been found to “reduce criminal activity, arrests, as well as probation revocations and re-incarcerations.”
• A Sacramento County Jail MAT program with 174 inmates found only 31% were arrested for new offenses.
• A study of 370 individuals who completed a MAT program in Middlesex County, MA, found only 19% were rearrested.
• A MAT study of 200 in Louisville, KY, jails found 47% remained arrest-free.
Source: Jail-Based MAT: Promising Practices, Guidelines and Resources, National Commission on Correctional Health Care and the National Sheriffs’ Association
A recent federal court decision indicates that states may need to take a close look at how to overcome barriers to expand access to FDA-approved MAT — methadone, buprenorphine, and naltrexone — in jails. In that decision – which could have nationwide implications – the court ruled that preventing access to MAT is a violation of the Americans with Disabilities Act and the 8th Amendment.
A growing number of state legislatures and governors, through executive orders, have mandated MAT in their correctional facilities. Last month, Maryland passed legislation that requires facilities to assess inmates’ substance use status, treat those with OUD with MAT, and provide follow-up treatment and care coordination after release.
Erek L. Barron, a member of Maryland’s General Assembly and a cosponsor of the new law, suggests the treatment could eventually pay for itself in avoided costs from reduced incarceration rates. “States need to understand that there is a high return on investment in MAT,” he told NASHP. “Addressing this high-risk population will enhance states’ response to the opioid crisis and crimes by reducing overdoses and recidivism rates. The key is understanding that substance abuse is a health care problem, not a crime problem.”
Initially, Maryland’s new treatment requirement will be phased into correctional facilities. The program begins in four counties and will cover the entire state and the Baltimore Pre-trial Complex within two years. The screening and treatment program is funded by the state’s initial allocation of $2 million. A report on the initiative’s impact on recidivism, treatment uptake, and crime will be submitted annually to the state’s General Assembly so lawmakers can assess MAT’s impact and its return on investment.
Barron and bill supporters faced challenges from the state’s various political subdivisions that ran local jails and the state prison system, so they took a “health-focused” approach when negotiating with correctional officials. “My primary partners were the county and local health officers,” he explained, “There was also media attention that helped educate the public about this gap in our response to the opioid crisis. I also learned that states are getting substantial amounts of federal funding from the State Opioid Response Grants that can be directed towards MAT in correction facilities.”
But funding MAT implementation in county and state facilities and after inmates are released remains a challenge for many states, particularly in states that did not expand Medicaid, according to states working with the National Academy for State Health Policy (NASHP) and reports from the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Commission on Correctional Health Care, and the National Sheriffs’ Association.
To start or sustain MAT during incarceration and after, states may want to consider the following strategies:
- Tap state block grants and the federal grant funds recently allocated to states for OUD and substance abuse disorder (SUD) treatment by the SUPPORT for Patients and Communities Act and other federal programs.
- Encourage criminal justice agencies to participate in group purchasing organizations in order to negotiate more affordable rates for MAT medications on their formulary. (Read Cross-Agency Strategies to Curb Health Care Costs: Leveraging State Purchasing Power for more information.)
- Medicaid agencies that do not provide coverage for all three medications approved for MAT may consider including them on their formularies.
- States can consider the use of Medicaid options and funding vehicles – such as 1115 waivers – to cover reentry support services, peer services, outreach services, and wraparound case management services for people with opioid use disorders.
- Review Medicaid suspension/termination rules. These rules may present barriers for individuals to re-activate their Medicaid coverage and obtain MAT following release from jail. Read NASHP’s report, Opportunities for Enrolling Justice-Involved Individuals in Medicaid.
- Despite the passage of the Mental Health Parity and Addiction Equity Act of 2008, the essential health benefits of many health plans do not cover OUD/SUD treatments the same way that other chronic diseases are covered. Oversight of private insurance plans can help to ensure coverage of MAT so that individuals reentering the community from jail or prison can access medication in a timely manner.
- To obtain lower-cost drugs, agencies can also participate in the federal 340B Drug Discount Program, which allows certain entities that serve large numbers of uninsured patients to obtain drugs from pharmaceutical suppliers at the same discounted rates that Medicaid pays (about 25 to 50 percent less).
In the months ahead, NASHP will be publishing additional reports detailing effective strategies that states are employing to address the opioid epidemic.
Updated HHS Guidance on Improving Health Care Access for Justice-Involved Individuals
Last Thursday, the Department of Health and Human Services (HHS) released new guidance to clarify and update policies related to how states can improve access to Medicaid coverage and services for incarcerated individuals transitioning back into communities. Based on data from a newly published HHS report, currently 2.2 million individuals are incarcerated and an additional 4.7 million are on probation or parole in the U.S. Further, over 95 percent of incarcerated individuals will eventually be released to the community. As many of these individuals are now eligible for Medicaid through the ACA, these new federal guidelines provide important parameters for states to help connect justice-involved individuals to physical and behavioral health services critical to their successful reentry into the community.
Previous federal guidance did indicate that Medicaid-eligible individuals who become incarcerated retain their eligibility and can be enrolled in the program. (Existing federal law prohibits using federal Medicaid funds to pay for medical care provided to incarcerated individuals, unless the individual is admitted to an inpatient facility for at least 24 hours.) However the newly issued guidance explicitly defines who is considered to be an inmate of a public institution. It also clearly delineates that states must accept Medicaid applications from incarcerated individuals, and if they are determined to be eligible they may be enrolled in Medicaid while they are inmates of a public institution. States can either place the enrolled individual in a suspended eligibility status during the incarceration period, or can create claims processing markers to limit Medicaid billing to only qualifying inpatient services.
The guidance also reinforces that individuals who are on parole, probation, under home confinement, or are in the community awaiting trial are not considered to be inmates of a public institution. Consequently these individuals can receive Medicaid-covered services and Federal Financial Participation (FFP) is available for these services.
Other key points from the guidance include:
- FFP and Medicaid coverage are available for eligible individuals residing in state or local corrections-related community residential facilities (such as halfway houses), as long as individuals have freedom of movement while living at the facility, defined by criteria identified in the guidance.
- FFP is not available for health care services provided to individuals in residential reentry centers that are operated by the Department of Justice’s Bureau of Prisons.
- FFP is not available for mental health or substance use disorder services provided to inmates involuntarily residing in residential treatment facilities, as these are considered to be correctional institutions.
The guidance strongly encourages state Medicaid agencies and correctional institutions to work together to enroll eligible justice-involved individuals in Medicaid. It also provides clarification on interstate Medicaid application processes, such as how state agencies should handle Medicaid coverage when incarcerated individuals are transferred to other states or move to another state upon release.
HHS also notes that states can encourage or require Medicaid managed care entities to coordinate with corrections agencies to promote access to care for individuals reentering the community. Further, the guidance indicates that federal matching funds are available to states for application assistance, eligibility determination, and enrollment system upgrades, as well as to transfer medical records from correctional institutions to community health care providers to promote care continuity.
For more information, see the HHS press release here. For resources about justice-involved individuals and health coverage, see NASHP’s toolkit featuring states’ efforts to enroll justice-involved individuals in Medicaid.
Corrections and Medicaid Partnerships: Strategies to Enroll Justice-Involved Populations
Date: November 17, 2015
Time: 3:00-4:00pm EST
View Webinar Here
Download Webinar Slides
Many individuals involved in the criminal justice system are now eligible for Medicaid in states that expanded the Medicaid program under the Affordable Care Act. Health coverage can provide individuals who are leaving incarceration with access to physical and behavioral health services critical to their successful reentry into the community. In some states, correctional agencies have partnered with Medicaid agencies to implement procedures to begin the Medicaid application process as individuals are nearing their incarceration release dates. This webinar features three states—Colorado, New Mexico and Wisconsin—that have initiated efforts to enroll justice-involved individuals in health coverage and explores some of the following questions:
- How are states developing procedures to enroll justice-involved individuals in Medicaid, and what types of policy or process changes have they implemented?
- What specific assistance is provided to incarcerated individuals who are enrolling in health coverage and how are applications processed?
- What strategies have been most successful for states, and what are some of the operational challenges that states are in the process of addressing?
- What types of interagency partnerships and coordination are needed to facilitate the enrollment of justice-involved individuals?
- How are states promoting access to care for the justice-involved population upon their release from incarceration?
Toolkit: State Strategies to Enroll Justice-Involved Individuals in Health Coverage
Executive Summary
Under the Affordable Care Act (ACA), many individuals involved in the criminal justice system are now eligible for Medicaid, including many young, low-income males who did not previously qualify. More...
States confront considerable costs associated with addressing the complex health care needs of individuals involved in the criminal justice system—in fiscal year 2011, states spent $7.7 billion on correctional health care.[1] Health insurance options available through the ACA offer new opportunities to enroll individuals involved in the criminal justice system into coverage and provide access to physical and behavioral health services critical to their successful reentry into the community. Additionally, states and localities have the potential to benefit from cost savings from enrolling this population in health coverage because of possible reductions in uncompensated care costs and the potential for reduced recidivism rates.
Of the approximately 10 million individuals released annually from prisons or jails, 70 to 90 percent are estimated to lack health insurance.[2] Without health coverage, these individuals are much less likely to receive the services or treatment they need to improve and maintain their health and well-being. Lacking coverage and a regular source of care, these individuals may seek treatment in hospital emergency departments, which shifts health care costs to states and localities. Additionally, for individuals with mental illness or substance use disorders in particular, a lack of access to health care is correlated with increased recidivism rates.[3]
Although individuals are not permitted to receive Medicaid benefits while incarcerated, Medicaid enrollment processes can begin prior to an individual’s release from incarceration. In some states, prisons and jails have taken steps to implement procedures to begin the Medicaid application process as individuals are nearing their incarceration release dates. NASHP conducted a series of interviews with state officials and found strategies states are using that have made these efforts successful:[1] The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, State Prison Health Care Spending: An Examination, July 2014.
Of the approximately 10 million individuals released annually from prisons or jails, 70 to 90 percent are estimated to lack health insurance.[2] Without health coverage, these individuals are much less likely to receive the services or treatment they need to improve and maintain their health and well-being. Lacking coverage and a regular source of care, these individuals may seek treatment in hospital emergency departments, which shifts health care costs to states and localities. Additionally, for individuals with mental illness or substance use disorders in particular, a lack of access to health care is correlated with increased recidivism rates.[3]
Although individuals are not permitted to receive Medicaid benefits while incarcerated, Medicaid enrollment processes can begin prior to an individual’s release from incarceration. In some states, prisons and jails have taken steps to implement procedures to begin the Medicaid application process as individuals are nearing their incarceration release dates. NASHP conducted a series of interviews with state officials and found strategies states are using that have made these efforts successful:
- Identifying simple and streamlined ways to integrate Medicaid enrollment procedures with existing correctional institution processes, such as incorporating enrollment efforts into existing discharge planning activities or centralizing application processing functions
- Developing strong partnerships between state Medicaid agencies and correctional authorities to support enrollment efforts, characterized by effective communication and backing from organizational leadership
- Implementing flexible approaches that can be adapted and improved over time, such as moving from a paper Medicaid application for incarcerated individuals to an electronic process
Implementing processes to enroll justice-involved individuals in health coverage on a large scale is a new endeavor for states and their efforts are in the early stages. Given this, many states are currently working through various policy and operational challenges. For example, some state officials noted the challenge of identifying an individual’s specific release date, especially for the jail population. However state officials reported that overall they viewed these efforts as successful considering the large number of enrollments that have occurred.
For detailed information on selected states’ efforts to enroll justice-involved individuals in health coverage, click through the toolkit below.
[1] The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, State Prison Health Care Spending: An Examination, July 2014.
[2] The Council of State Governments Justice Center. Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System. December 2013.
[3] The Council of State Governments Justice Center. Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System. December 2013.
Health insurance options available through the Affordable Care Act (ACA) offer new opportunities to enroll individuals involved in the criminal justice system into coverage and provide access to physical and behavioral health services critical to their successful reentry into the community. Many individuals involved in the criminal justice system are now eligible for Medicaid under the ACA, including many young, low-income males who did not previously qualify for Medicaid.
With one exception
Federal law explicitly prohibits the use of federal Medicaid funds to pay for the medical care of incarcerated individuals, resulting in state and local correctional agencies covering these costs. One important exception to this restriction is when an incarcerated individual is admitted to an inpatient facility for at least 24 hours. The Department of Health and Human Services has indicated these inpatient services include admittance to a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility. In these cases, federal Medicaid funds can be used to cover the cost of inpatient health care services.
State and local correctional authorities in some states have established processes to bill Medicaid for qualifying inpatient events. As the ACA allows for a greater number of justice-involved individuals to be eligible for Medicaid coverage, implementing these procedures has helped reduce correctional health care costs for some states.
, federal law prohibits using federal Medicaid funds to pay for medical care provided to incarcerated individuals. However, Medicaid enrollment processes can begin prior to an individual’s release from incarceration, as there is no federal prohibition on incarcerated individuals being enrolled in Medicaid[1] and federal law requires states to permit individuals to apply for the program at any time.[2]State and local correctional authorities in some states have established processes to bill Medicaid for qualifying inpatient events. As the ACA allows for a greater number of justice-involved individuals to be eligible for Medicaid coverage, implementing these procedures has helped reduce correctional health care costs for some states.
Drawing on interviews with state officials, this toolkit highlights the efforts of selected states to enroll in health coverage individuals involved with the criminal justice system. The toolkit is designed to provide state officials with actionable information about policies and practices available to connect justice- involved individuals to health care coverage through Medicaid.
Methods
This toolkit does not provide a comprehensive examination of all states and their efforts to enroll this population in health coverage. Rather, it features information about efforts to enroll justice-involved individuals in seven states chosen for their varying enrollment strategies, as well as political and geographic diversity. The states include: Colorado, Illinois, New Mexico, Ohio, Rhode Island, Washington and Wisconsin. NASHP conducted telephone interviews with state officials from both Medicaid agencies and corrections departments from February to September of 2015. In all but one state, agency representatives were interviewed separately.[3]
[1] State Medicaid Director Letter from Glenn Stanton, Acting Director of the Disabled and Elderly Health Programs Group, Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services (May 25, 2004).
[2] 42 U.S.C. § 1396(a)(8)
[3] One exception for Illinois was that only one interview was conducted, with a state official from Governor Pat Quinn’s office.
For many states, enrolling justice-involved individuals in health coverage requires implementing new policies and procedures or modifying existing processes and rules. This section of the toolkit highlights how states instituted changes to policies and operations to facilitate the enrollment of incarcerated individuals prior to their release from correctional facilities. State officials noted the importance of beginning the application process prior to individuals’ release dates to increase the likelihood they will reenter the community with health coverage in place.
Policy Changes
Nearly all of the states interviewed for this project implemented some type of policy change, including enacting new state laws, amending Medicaid state plans or contracts with insurers, or developing new interagency agreements to support initiatives to enroll justice-involved individuals in health coverage. While it is permissible under federal law for individuals to enroll in Medicaid while incarcerated, some states have implemented these policies to reinforce their enrollment initiatives. The following descriptions provide state-specific examples of these kinds of policy changes. In some instances, states also made process changes that did not require a policy change in order to implement these enrollment efforts. See the changes in processes implemented by states to integrate health coverage enrollment procedures into correctional facilities.
State Legislation
Colorado: In 2008, the state legislature passed and the governor signed SB08-006, which allows for the suspension of Medicaid benefits upon incarceration (see Title 25.5-4-205.5). Specifically, if an individual enrolled in Medicaid becomes incarcerated, the state law allows for an individual’s Medicaid enrollment to be suspended rather than terminated.Despite federal rules prohibiting the use of federal Medicaid funds to cover the costs of medical care provided to incarcerated individuals, the Department of Health and Human Services has indicated that Medicaid-eligible individuals who become incarcerated retain their eligibility for the program. However in most states, when an individual enrolled in Medicaid is incarcerated, coverage is terminated rather than suspended and these individuals are removed from the Medicaid rolls. Federal policy does not require that states terminate these individuals’ Medicaid coverage.
Advocates of suspension policies have noted that one key benefit is that when individuals with suspended Medicaid coverage are released from incarceration, their Medicaid benefits can be more easily reinstated. Consequently these individuals have the potential to more readily access needed medical and behavioral health services once they reenter the community.
Now that more justice-involved individuals are Medicaid-eligible due to the ACA, states may want to consider enacting policies and procedures to implement suspension. Currently, only a relatively small number of states have implemented policies to suspend rather than terminate individuals’ Medicaid coverage upon incarceration. Additionally, some states that have established suspension policies have not implemented suspension features into their eligibility systems. Most commonly this is because the technical challenges and the considerable financial investments required are too significant to warrant the large system changes needed to implement suspension.
Furthermore, with the implementation of the ACA’s real-time eligibility determination and enrollment requirements, some state officials that NASHP interviewed indicated that there could be less of a need for individuals with Medicaid coverage to be placed in a suspension status upon incarceration. However other state officials noted the potential value of implementing suspension, particularly for individuals who lose Medicaid coverage during a short-term jail stay, because initiating and completing a new application for these individuals can be logistically challenging.
Advocates of suspension policies have noted that one key benefit is that when individuals with suspended Medicaid coverage are released from incarceration, their Medicaid benefits can be more easily reinstated. Consequently these individuals have the potential to more readily access needed medical and behavioral health services once they reenter the community.
Now that more justice-involved individuals are Medicaid-eligible due to the ACA, states may want to consider enacting policies and procedures to implement suspension. Currently, only a relatively small number of states have implemented policies to suspend rather than terminate individuals’ Medicaid coverage upon incarceration. Additionally, some states that have established suspension policies have not implemented suspension features into their eligibility systems. Most commonly this is because the technical challenges and the considerable financial investments required are too significant to warrant the large system changes needed to implement suspension.
Furthermore, with the implementation of the ACA’s real-time eligibility determination and enrollment requirements, some state officials that NASHP interviewed indicated that there could be less of a need for individuals with Medicaid coverage to be placed in a suspension status upon incarceration. However other state officials noted the potential value of implementing suspension, particularly for individuals who lose Medicaid coverage during a short-term jail stay, because initiating and completing a new application for these individuals can be logistically challenging.
However based on conversations with state officials from the Department of Health Care Policy and Financing (HCPF) – Colorado’s Medicaid agency – and this HCPF memo from March 2014, the department has not yet implemented a function within its systems to suspend Medicaid upon incarceration. Therefore correctional facilities are still required to terminate coverage for those individuals who are enrolled in Medicaid and become incarcerated. HCPF’s systems will have suspend functionality in 2016.
Illinois: HB 1046, introduced in the 2013-2014 legislative session, specifically allows incarcerated individuals to apply for Medicaid prior to the date of their release. If these individuals are found to be eligible for Medicaid, they will be able to receive coverage after their release. In addition, the bill allows for suspension of existing Medicaid benefits for persons who enter a correctional institution. Illinois is currently in the process of implementing this functionality. The bill was signed into law (see Sec. 1-8.5) in August of 2013 and became effective January 1, 2014.
New Mexico: During the state’s 2015 legislative session SB 42 was introduced, which includes language indicating that incarceration is not a basis for denying or terminating an individual’s eligibility for Medicaid. The bill also permits individuals to apply for Medicaid while incarcerated and directs correctional facilities to inform the state Human Services Department (HSD) regarding the incarceration status of eligible individuals. The governor signed the bill into law in April of 2015. HSD plans to implement this new law in October 2015, starting with the New Mexico Corrections Department; the New Mexico Children, Youth and Families Department; and Bernalillo County Detention Center.
Washington: Prior to passage of the ACA, processes to enroll justice-involved individuals with severe mental illnesses in Medicaid had been in place in Washington due to a directive based on state legislation. In subsequent years the state also enrolled Medicaid-eligible incarcerated individuals if they were admitted for inpatient health care services for at least 24 hours to cover the cost of their stay. The Department of Corrections (DOC) is also able to sign Medicaid applications on behalf of incarcerated individuals for qualifying inpatient events, which facilitates the processing of the applications as DOC often found it to be challenging to obtain an incarcerated individual’s signature. This experience with enrolling justice-involved individuals in health coverage, though limited, helped inform work to expand these efforts after more justice-involved individuals became eligible for coverage through the expansion of Medicaid.Additionally, in the 2015 legislative session, SB 5593 was introduced, which allows for individuals to be screened for Medicaid eligibility at the time of booking into jail and then enrolled in the program if found to be eligible. The advantage of conducting these assessments at intake is that beginning the application process at this stage increases the likelihood that a greater proportion of the Medicaid-eligible individuals in correctional facilities will have coverage upon release. The bill was signed into law in May 2015 and became effective in July of 2015.
State Plan Amendments
New Mexico: In 2013, New Mexico’s Human Services Department (HSD) recognized that with the state’s expansion of Medicaid there would be a significant number of justice-involved individuals eligible for coverage through the program. Considering this, HSD submitted an amendment to their Medicaid state plan to allow for the implementation of Medicaid presumptive eligibility (PE) in their correctional facilities. PE allows for the temporary enrollment of an individual in Medicaid, if based on available income information the individual appears likely to be eligible for the program. This initial assessment of PE helps to streamline the initial eligibility assessment process, which is then followed by a full eligibility determination.Memorandums of Understanding (MOUs) between state agencies
Ohio: The Ohio Department of Rehabilitation and Correction (ODRC) and the Ohio Department of Medicaid (ODM) have a MOU to facilitate the enrollment of justice-involved individuals via phone. The MOU describes how ODM telephone hotline representatives are provided with access to ODRC’s system which tracks information related to incarcerated individuals. This allows ODM representatives to verify data about individuals they are speaking with on the phone during the enrollment process. The MOU also specifies that ODRC must maintain the quality of the data, which includes identifying information along with individuals’ release dates. Ohio’s MOU can be viewed here.Washington: The Health Care Authority (HCA) developed a MOU for use between HCA and correctional facilities that outlines processes for enrolling incarcerated individuals in Medicaid prior to their release. In addition to defining roles and responsibilities for each agency related to conducting enrollment, the MOU describes guidelines for the application process. The MOU allows for the application process to begin 30 days prior to an individual’s release from incarceration, which can help to facilitate an individual’s Medicaid card being available to the individual on their release date. In addition to prisons, the HCA also signed MOUs with some of the state’s larger jails. Due to limited resources, the jails are primarily enrolling individuals in Medicaid to cover the costs of Federal law explicitly prohibits the use of federal Medicaid funds to pay for the medical care of incarcerated individuals, resulting in state and local correctional agencies covering these costs. One important exception to this restriction is when an incarcerated individual is admitted to an inpatient facility for at least 24 hours. The Department of Health and Human Services has indicated these inpatient services include admittance to a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility. In these cases, federal Medicaid funds can be used to cover the cost of inpatient health care services.
State and local correctional authorities in some states have established processes to bill Medicaid for qualifying inpatient events. As the ACA allows for a greater number of justice-involved individuals to be eligible for Medicaid coverage, implementing these procedures has helped reduce correctional health care costs for some states.
State and local correctional authorities in some states have established processes to bill Medicaid for qualifying inpatient events. As the ACA allows for a greater number of justice-involved individuals to be eligible for Medicaid coverage, implementing these procedures has helped reduce correctional health care costs for some states.
Wisconsin: In 2004, the Department of Health Services (DHS) and the DOC in Wisconsin established their first MOU (see more information in the Process Changes section) related to developing processes to allow eligible incarcerated individuals to enroll in Medicaid prior to release. The MOU was updated in January 2015 with revised language to reflect changes to the state’s Medicaid program and in the procedures for processing incarcerated individuals’ applications. The updated MOU describes each agency’s roles and responsibilities, such as how DOC facilities will designate ACA site coordinators to address specific needs and how DHS will monitor and resolve any issues related to the enrollment process.Contract Modifications
Rhode Island: Taking into consideration the needs of the justice-involved population newly eligible for Medicaid following passage of the ACA, the state negotiated new contracts with their Medicaid health plans and implemented certain changes to the benefit packages for these plans. For example, many behavioral health services that had previously been separately administered were integrated into the health plans to help improve connections to mental health and substance abuse services for these individuals. Also, the Executive Office of Health and Human Services specifically required certain care management protocols, making it a contractual requirement of the health plans that they conduct outreach and health risk assessments for individuals being released from incarceration. Currently, health plan representatives are providing corrections staff with information about how individuals reentering the community can contact plans for further assistance. This policy change has the potential to improve care coordination for individuals needing mental health and substance abuse treatment.Eligibility Determination Changes
Wisconsin: The Department of Health Services (DHS) implemented a new policy of allowing incarcerated individuals with explicit dates of release to apply for health coverage prior to release. Additionally, the DHS revised existing policy to allow for Medicaid eligibility to begin the day prior to an individual’s release from incarceration. DHS reported that they specifically selected the 20th of the month prior to the month of release as the date that individuals could apply for coverage in order to increase the likelihood that there was an adequate amount of time for the Medicaid card to be mailed back to the correctional facility prior to the individual’s release date.
Process Changes
States that are enrolling the justice-involved population in coverage have also implemented changes to processes and procedures in their Medicaid and corrections departments that make it easier to enroll eligible individuals. While some states noted they already had in place certain processes to enroll Medicaid-eligible incarcerated individuals to cover the cost of inpatient hospital stays or when they were nearing their release date, others had not done so. With the implementation of the ACA and a greater number of individuals eligible for Medicaid, some states developed new procedures for enrolling eligible individuals or modified their existing processes.
Application Process Changes
Colorado: The Department of Health Care Policy and Financing (HCPF) and the DOC worked together to develop procedures to efficiently process Medicaid applications for incarcerated individuals. DOC officials indicated that when Colorado implemented the ACA’s Medicaid expansion, initial enrollment efforts focused on enrolling individuals in Medicaid for qualifying inpatient health care services. To broaden the scope of these efforts to include individuals leaving incarceration, the DOC hired two full-time nurse case managers to specifically focus on processing applications as part of pre-release planning. Case managers at the correctional facilities send a permission form signed by the incarcerated individual to the nurse case managers at the DOC’s central office. The nurse case managers complete applications electronically based on information in the DOC’s database. Most of the individuals transitioning to the community who are found to be Medicaid-eligible are able to leave the correctional facility with a Medicaid card. If the card is not available prior to an individual’s release, the nurse case managers contact the correctional facility case managers to provide them with the individual’s Medicaid eligibility number and the contact number of a nurse case manager who can provide further assistance.
To ensure accurate and timely eligibility determinations, HCPF has given the DOC limited access to PEAKPro, an online tool to help authorized state agents assist Coloradans. DOC may apply for Medical Assistance on the individual’s behalf if the individual agrees. Most eligibility determinations are made in real time, although in some cases a manual determination must be made. In spring of 2015, HCPF transferred the responsibility for processing manual DOC applications to an eligibility and enrollment contractor that regularly handles a large volume of applications.
HCPF has also provided the DOC with other types of assistance. For example, they developed software specifically for the DOC to enter in and track the status of applications, which has helped streamline the overall application process. Additionally, they have provided the DOC’s nurse case managers who process applications with direct support to address issues. Previously the enrollment applications were handled through a hybrid paper-electronic process, but as of spring 2015 the application process is conducted entirely online. The DOC has reported that the short-turn around time of the application processing is very efficient and that this has helped with their overall ability to handle a large volume of applications.
Illinois: Local assister entities have conducted the majority of the enrollment for justice-involved individuals. Some of these assister community organizations have reached out directly to county jails to provide enrollment assistance and help individuals understand how to appropriately access care once they reenter the community. At the state level, Get Covered Illinois, the state/federal marketplace partnership organization in Illinois, supports these efforts by providing the assister organizations with information about how the ACA affects justice-involved individuals. Get Covered Illinois has also offered suggestions and technical assistance to these organizations about how to connect with criminal justice entities and ways to potentially integrate enrollment processes into these facilities. View the enrollment guide.
New Mexico: Officials from the Human Services Department (HSD) indicated that overall the presumptive eligibility (PE) process has been working well. HSD staff members indicated that they have been working with the DOC as well as Santa Fe and Bernalillo Counties, since the spring of 2014 to facilitate their ability to conduct PE determinations. HSD provided the staff at state prisons and these two county jails with extensive training to allow them to become PE determiners. View training materials here and here. View New Mexico’s PE Submission Checklist here. Related: You can view a fact sheet about New Mexico’s Enrollment in Medicaid for Incarcerated Individuals Released (IIR) & Short Term Medicaid for Incarcerated Individuals (STMII) here.
HSD officials reported that the PE process includes a full Medicaid application, and that for the majority of individuals the necessary information can be obtained electronically through state and/or federal databases. The HSD indicated that there are some challenges in obtaining the necessary paperwork from individuals when they do not have mailing addresses for cases that require follow-up with individuals after their release from incarceration to complete the eligibility determination.
Ohio: In those Ohio Department of Rehabilitation and Correction (ODRC) prisons that have begun enrollment efforts, the Medicaid application process is initiated via phone with paper follow-up. First, optional classes led by peer educators are offered to individuals 90-120 days prior to their release. The classes provide information about Medicaid coverage and preview the questions that will be addressed during the enrollment application phone call. During the classes individuals also sign authorization and other pre-enrollment forms, which ODRC collects and maintains. After completing the classes, individuals use designated phones in each correctional facility to connect directly to the Medicaid enrollment center at specified times. Enrollment center phone staff as well as the trained peer counselors can assist with the process. The phone call allows the individual to select a Medicaid managed care plan, but does not entail official Medicaid eligibility determination and enrollment. After all necessary forms have been collected, the ODRC sends individuals’ information in batches to the state’s Medicaid portal, where the eligibility determination is conducted.
The Medicaid agency indicated that while initially the enrollment process has been done manually, they are currently transitioning to automating the process. Generally, individuals begin the enrollment process approximately 90 days prior to release, and in most cases those who choose to apply and are found to be eligible are able leave the correctional facility with a Medicaid card.
Rhode Island: The DOC integrated the Medicaid application process into existing discharge planning services. Due to the DOC’s security concerns regarding incarcerated individuals using computers, individuals complete paper Medicaid applications that are then hand-carried by DOC staff to the Executive Office of Health and Human Services (EOHHS). Current practice is to submit the paper applications two weeks prior to individuals’ release dates to allow time for their information to be entered into the system. However, the actual Medicaid eligibility determination process does not occur until the individual’s incarceration release date. Individuals being released from incarceration are provided a phone number to initiate the activation of their benefits.
Rhode Island’s EOHHS worked closely with the DOC to increase the accuracy of incarceration status data and to address challenges related to identity and income verification. One of the issues the departments encountered was that federal data sources did not have information about an individual’s incarceration release date and the system often indicated an individual was still incarcerated even though s/he had been released. After discussions between the two agencies, the DOC and EOHHS revised processes and implemented system changes so that the DOC’s databases could be more easily accessed to obtain real-time data on incarceration status.
Also recognizing the need to address the issue of income verification, EOHHS developed a self-attestation form for individuals to indicate lack of income, and then informed exchange contact center staff and Navigators to accept this as a valid document. In terms of identification, the DOC provides each individual released to the community with two forms of photo identification—one form of general identification and a copy of a page from the DOC database that indicates their release date. This information can be provided to assisters who might be working with these individuals to enroll them in coverage.
Washington: Staff members in state correctional facilities regularly facilitate group meetings with individuals nearing their incarceration release dates to provide information about Medicaid coverage and assist with completing paper applications. The DOC designated three staff members in the state’s central office to process applications from all of the state’s correctional facilities. The DOC chose to centralize the process of inputting application information into the Medicaid eligibility system both because of limits on the number of staff members able to access the system but also to minimize staff work at the correctional facilities. An agreement with the Health Care Authority permits Medicaid application information to be entered into the system 30 days prior to individuals’ release dates, which allows time for the Medicaid cards to be sent to correctional facilities prior to the date that the individuals leave. Preceding the receipt of a Medicaid card, individuals receive a letter informing them that they have been approved for coverage and that they will receive related mailings with plan information; this letter also acts to confirm that the address for the individual is correct and will work for these future mailings.
Wisconsin: In November 2014, the DHS issued a memorandum developed in conjunction with the DOC that builds on the MOU between the two agencies and provides further detail about the roles and responsibilities of each. The operations memo describes new processes for accepting telephonic Medicaid applications from incarcerated individuals. The new policy allows individuals with explicit dates of release to apply for health coverage on or after the 20th day of the month prior to the month of the individual’s scheduled release date. This allows enough time for the Medicaid card to arrive at the correctional facility. Individuals are able to apply via phone and can telephonically sign the application. The memo also provides guidance to the DOC regarding the length of time permitted for the individual to complete the application via phone and for providing application assistance. Additionally, the memo eliminates the need to verify prison income for these applications being submitted by incarcerated individuals and it provides instructions for verifying certain eligibility information and issuing identification cards.
In terms of implementing the processes at the correctional facilities, the DOC recognized that their reentry social workers already had many tasks and so the department focused on implementing streamlined procedures with minimal staff involvement. Some facilities use the regular phone system but others have set up special conference rooms or call booths for greater privacy for individuals who are calling to apply for coverage. Also, the DOC indicated that there are ACA “site coordinators” at the correctional facilities who serve an important role in the internal implementation of the telephone enrollment processes at each facility and address any questions related to enrollment in health coverage.
In many states, health and corrections agencies fold enrollment processes into pre-release planning since health coverage to meet physical and behavioral health needs is important for ensuring an individual’s future success and reduces the chances for recidivism. This section of the toolkit highlights various state strategies to incorporate enrollment into pre-release planning.
Medicaid Enrollment Education/Training for Incarcerated Individuals
Ohio: As part of the Ohio Department of Medicaid (ODM) and the Ohio Department of Rehabilitation and Correction (ODRC)’s Medicaid Pre-Release Enrollment (MPRE) program, incarcerated individuals are selected (or volunteer) to be trained to act as peer-to-peer educators (Peer-to-Peer Medicaid Guides) in a voluntary pre-enrollment classes for others. The classes educate participants on the importance of health coverage and walk applicants through the enrollment process. A pre-release enrollment worksheet guides incarcerated individuals through the items they may need to research or ask family members about and lists questions they may be asked as part of the application process. The classes also use a video, created by justice-involved individuals, to educate participants about coverage and the Medicaid enrollment process. Currently, Ohio Medicaid and corrections officials are working to add one prison per month to the statewide program (there are a total of 27 facilities in the state – you can view a programmatic overview of the program’s rollout here). As a prison is added, ODRC staff members are notified about the MPRE program via an email memo. The memo is also meant to act as a reference so staff members can more easily field questions about the Medicaid pre-release enrollment process at the facility. View an overview of the Peer-to-Peer Medicaid Guide portion of MPRE here (this resource also contains a copy of the pre-enrollment worksheet, as an attachment). For more information about MPRE, see this presentation produced in partnership by the Ohio Department of Medicaid (ODM) and the Ohio Department of Rehabilitation and Correction (ODRC). Rhode Island: Within Rhode Island’s unified prison-jail system, there are two discharge planning tracks. On the first track, incarcerated individuals attend group education classes and participate in individual discharge planning that occurs closer to the release date. A community agency conducts the education for the pre-release groups, providing information about Medicaid enrollment and distributing paper applications. Discharge planners also give incarcerated individuals information about how to access local offices if they wish to enroll after being released. On the second track, individuals being released are given a form, and Department of Corrections (DOC) staff assists in filling out the form with identifying characteristics. This form can be given to Navigators outside of the facility to confirm that the person is no longer incarcerated (even if internal systems have not yet been updated to reflect their release). Then, enrollment can take place at that Navigator Center. Washington: Ninety days prior to release, the Washington State DOC sends a letter to incarcerated individuals informing them about coverage options under the ACA, and notifying them that part of their release process will involve applying for Medicaid benefits. The DOC has created a FAQ for distribution during the pre-release process and is also in the process of creating a video to inform individuals about Medicaid benefits to help ensure that there is a consistent message about the availability of health coverage.Single adults without dependents complete a paper application. The facility staff members are trained to send scanned applications to the DOC headquarters, where they are reviewed for any possible problems (e.g. an incorrect Social Security number, missing information, etc.) After this, DOC staff members at the headquarters manually enter the information into Medicaid’s enrollment system.
Wisconsin: In many Wisconsin prisons, approximately one month prior to release, incarcerated individuals attend a one-hour long group session specifically focused on enrollment to prepare them to submit applications by phone. Four online modules are used to train DOC staff to facilitate the session.Application Assistance
Colorado: In the state’s prisons, enrollment is folded into already-existing processes the DOC uses to help released individuals gain or regain benefits as part of their transition back into the community. Two nurse case managers based at the DOC central office complete applications electronically for incarcerated individuals in all 24 facilities, including private facilities. Once an individual is enrolled, DOC ensures that they have their Medicaid card within their possession upon release. If a Medicaid card is not received prior to release, the DOC ensures that the individual knows their Medicaid number and has access to a phone number to reach the case manager/nurse if they have any questions. Additionally, individuals who may have opted out of enrollment assistance pre-release can later choose for parole staff to connect them to the case manager/nurse. New Mexico: As part of Presumptive Eligibility (PE) in New Mexico, the Medicaid Division of the New Mexico Human Services Department (HSD) has worked with the DOC to train staff to assess eligibility within the corrections facilities as part of pre-release planning. Once PE is assessed, the DOC submits assessments to HSD with information regarding their release date, if available (when release dates change, this sometimes poses a challenge for HSD, which they are in the process of addressing as this program grows). Individuals are enrolled after they are released from correctional facilities. Ohio: Two to three days after attending a pre-enrollment class, incarcerated individuals review the forms necessary for the ODM to allow individuals to enroll in Medicaid, including an authorization form that allows ODM to conduct a background check. At this stage, already knowing what questions they will be asked, incarcerated individuals can use a specific phone to directly connect to ODM to select a managed care plan. As part of a hybrid telephonic-electronic process, the ODRC batches individuals’ information to ODM’s Medicaid portal for eligibility screening. The applications and forms are maintained within the individual’s master records. Ohio is working towards automating these processes by early April 2016. Additionally, all individuals who are being released receive a standard notice informing them about the Affordable Care Act, their potential eligibility for Medicaid, and resources for enrollment outside of the incarceration facility.During this part of the process, incarcerated individuals are also asked to fill out a medical release summary. Ohio screens every survey participant to identify individuals with complex health needs or indicators for complex health needs, referred to as “critical risk indicators” or CRIs. Individuals with CRIs have the opportunity to participate in a videoconference with a representative from a managed care plan selected by the individual prior to release. Together, the managed care plan and individual create a transition plan for that individual, scheduling doctor’s appointments, and organizing transportation and communication.
If an incarcerated individual is approved for Medicaid and signs onto a managed care plan, ODRC extracts the Medicaid card information and managed care plan card information, and scans both so that incarcerated individuals have both within their possession upon release.
Rhode Island: Correctional facilities provide application assistance in three different ways and at varying points in the pre-release planning process. Interns from Brown University’s Center for Prisoner Health and Human Rights directly assist incarcerated individuals awaiting trial with completing Medicaid applications, or follow up to ensure that an application has been completed. Additionally, pre-release planners assist incarcerated individuals, especially those going into residential treatment upon release, in completing paper applications. The Executive Office of Health and Human Services (EOHHS) temporarily allocated funding from their Navigator Program to staff corrections facilities with mobile navigators to answer questions and assist incarcerated individuals visiting the Exit Resource Center, although this service is no longer available. Wisconsin: In all Wisconsin prisons, corrections staff screen incarcerated individuals who may fall into one or more of the four categories potentially indicating a need for application assistance: those with 1) mental health issues; 2) lower reading scores; 3) language barriers; and/or 4) developmental disabilities. If an individual is identified as falling within one of these categories, social workers screen further to determine if the inmate can complete the telephonic enrollment application independently. If they cannot, the social worker facilitates the call process. The social workers are employed by the DOC, which also rotates three additional contracted benefits specialists between six DOC facilities who schedule and facilitate calls with incarcerated individuals at those six facilities.Some states engage in outreach after justice-involved individuals return to their communities in order to enroll them in or maintain health coverage. For some states, this is in addition to pre-release enrollment activities, and in others, it is in place of pre-release planning efforts.
From our interviews, we found there are two main types of outreach: (1) activities within parole offices, and (2) mailings or phone calls conducted by state health and corrections agencies.
Parole Office
Colorado: Parole staff and community reentry specialists offer application assistance to anyone who did not have the opportunity to be enrolled while they were still incarcerated or if they previously declined to be enrolled but since changed their mind. Illinois: During Get Covered Illinois’s first open enrollment period in Fall 2013-Winter 2014, the state used the Department of Corrections (DOC) Parole Division’s automated messaging system to inform individuals they were likely eligible to enroll into health coverage, when in-person assistance was available at their nearest parole office, or how to enroll by phone. In Illinois, parolees must call the system using a toll free number to check-in, and often receive messages this way, rather than having parole agents call them. This allowed the state to pre-record a message describing parolees’ potential eligibility for health insurance and providing information about where to apply in person or online. Additionally, assisters were available once a week at parole offices around the state to enroll individuals. Flyers were created for parole agents to distribute to individuals on their caseloads, which provided information about when in-person assistance would be available at the parole office.Justice-involved individuals have also received assistance at the Illinois Department of Corrections’ Summit of Hope events at various sites around the state. At a Summit of Hope, community organizations and social service agencies gather together to engage individuals in the reentry process and connect them with resources. The intent is to provide a smooth transition back into civilian life and to reduce recidivism. Get Covered Illinois has connected assister organizations with their local Summit of Hope events in order to conduct outreach and to enroll eligible individuals in health coverage on-site.
Rhode Island: Health insurance is a requirement for individuals to participate in certain parole programs, and former inmates must be in parole programs to remain in the community. Although the program is no longer funded, the DOC contracted with an application assister working with the Rhode Island Parent Information Network to provide application assistance to individuals on parole who needed health insurance. The DOC had two staff members also helping with applications: one in the DOC office and another that helped individuals checking in on probation. There are plans in the future to involve interns from Brown University with enrollment efforts at parole programs.Mailings and Calls
Illinois: Prior to the Get Covered Illinois’ second open enrollment, trying to capitalize on earlier outreach efforts, the state worked with the parole department to carry out an outbound calling campaign in targeted regions across the state. An automated message was delivered that encouraged these individuals to enroll in health coverage and directed them to local enrollment sites. The state believes this aggressive outbound calling campaign was not as effective as the first effort; however, identifying how many of these justice-involved individuals eventually sought assistance at local enrollment sites and enrolled in coverage through this effort was a challenge because they were directed to enrollment sites in the community rather than at the parole office. New Mexico: When an individual is determined presumptively eligible for Medicaid in New Mexico, the Human Services Department’s (HSD) eligibility system also submits a full application. Although HSD is able to verify most of the required information for the full application electronically, the agency engages in post-release outreach mailings to individuals who need to submit documents that can’t be provided electronically. They send a “help us make a decision” form that the individual must return if their application is still pending. The form requires that the state have their address, which can be challenging given the transiency of this population. Individuals must follow-up to provide the additional information in order to complete the application.States recognize that while enrolling justice-involved individuals into health coverage is important, the next crucial step is to facilitate access to both medical and behavioral health care for these individuals upon their release from incarceration. While most states have initially focused their efforts on implementing enrollment procedures, many are beginning to think about the next steps necessary to connect individuals to care. The following section outlines states’ efforts to promote access to care and help individuals reentering the community best utilize care.
Health Literacy Materials
Illinois: Recognizing that justice-involved individuals reentering the community may be unfamiliar with how to appropriately utilize health care services, officials from Get Covered Illinois have developed health literacy materials designed to help them more easily access care upon release. These materials include a palm-sized card with information on how to choose and access primary care providers, obtain prescriptions, and appropriately use emergency care. The card also includes important contact numbers, as well as space where individuals can write in information about their physicians and prescriptions. The materials were developed with input from probation offices and advocacy groups and are based on some of the most common questions they receive from the justice-involved population regarding their health care benefits. The cards are being distributed in probation offices as well as during the intake process at the Cook County jail. See palm-cards for: Medicaid and Using Insurance (in English and Spanish). Ohio: Upon release, all individuals–even those who did not participate in the pre-release enrollment program–are provided with a reference sheet with information about the importance of health coverage, how to enroll in Medicaid upon release, and how to use insurance coverage and access providers. Rhode Island: In partnership with the Center for Prisoner Health and Human Rights at Brown University, state officials from the Executive Office of Health and Human Services (EOHHS) are working on a health literacy initiative for the justice-involved population. Students from the university’s medical school provide information to individuals nearing release from incarceration about what to expect when calling for appointments with providers and how to access care appropriately in the community. Washington: The Department of Corrections (DOC) gives information and literature to individuals who did not enroll prior to release regarding how to access Navigators in their community to enroll in or use coverage. Wisconsin: The DOC developed and distributed informational pamphlets designed to help answer general questions related to health coverage through both Medicaid and the marketplace, as well as ways to access care.Access to Care
Colorado: Efforts are underway in the Denver region to connect individuals who cycle in and out of jail, often due to behavioral health issues, to intensive case management services available through Medicaid. The state Medicaid agency is considering how to replicate this model more widely across the state, and in 2016 is aiming to convene a workgroup of county and city leaders and other stakeholders to discuss best practices, challenges and opportunities to expand these types of services.In early 2015 the DOC hired specialized behavioral health parole coordinators to focus on helping individuals in need of more intensive support services upon release navigate the health care delivery system. These coordinators are licensed social workers located throughout the state, although due to capacity issues currently they are only serving a small number of individuals. They offer individuals intensive support services, provide them with information about how to best access behavioral health services, and assist with care coordination.
In the near future, the DOC plans to implement a new system to manage the health records of incarcerated individuals. The DOC anticipates that this will allow for case management services to begin as early as at the time of intake. State officials indicated that being able to start case management services earlier will make the overall process of connecting individuals to care after their release more streamlined and effective.
Ohio: When incarcerated individuals begin the Medicaid application process and are determined eligible, they then select a managed care plan. Additionally, the Ohio Department of Rehabilitation and Correction staff members assess their health records to determine if they might have a medical and/or behavioral health condition that would qualify them for case management. These individuals with complex needs are given a transition plan prior to release, which includes having a video conference with a representative from their managed care plan, scheduling appointments with providers, and coordinating support services such as transportation. Rhode Island: The DOC uses the same electronic health record system as the state’s Federally Qualified Health Centers (FQHCs). State officials recognize the potential of this shared system to better coordinate care, and are in the initial stages of planning for a more effective care transfer process, particularly for individuals with complex physical and/or behavioral health needs. Wisconsin: State officials emphasized the importance of ensuring that individuals connect with health services quickly after release from incarceration, in particular to avoid gaps in prescription use. Correctional facilities in Wisconsin begin the enrollment process early in order to ensure that there is enough time for a Medicaid card to be mailed to the prison so that individuals have the card in their possession upon release. Currently, individuals are provided with two weeks of prescription medications on the day of their release, with a written prescription for another two-week supply.This section describes the importance of partnerships across agencies to facilitate the enrollment of justice-involved individuals, and highlights some of the states with particularly strong relationships between the Medicaid and corrections departments. During interviews with both Medicaid agencies and correctional authorities, state officials strongly emphasized that a key factor in effectively implementing enrollment efforts for the justice-involved population required close working relationships and support from the leadership of both departments. Additionally, some of the states interviewed indicated that relationships with community-based partners and other entities have also played an important role in implementing initial and follow-up enrollment processes, as well as improving access to care for the justice-involved population.
Colorado: Officials from the DOC recognized the importance of developing a strong relationship with the Department of Health Care Policy and Financing (HCPF) to improve continuity and coordination of care for individuals leaving incarceration. Therefore, initial internal and interagency conversations began as early as 2011. Both DOC and HCPF reported that a strong partnership and good communication between the two agencies has existed for many years, which has helped greatly in the process of implementing enrollment procedures for the justice-involved population. The agencies credit this very good working relationship both to the long-standing partnership and the fact that there is support for these efforts from the leadership of both departments. Illinois: In Illinois, efforts to enroll justice-involved individuals in health coverage were led through the governor’s office, which established a Workgroup on Justice Populations (WJP) and multiple interagency and regional meetings were convened. Based on these meetings, the WJP developed a resource guide designed for criminal justice personnel and community partners. The guide provides background information about relevant ACA policies along with detailed process maps outlining steps to implement enrollment procedures in correctional facilities and other settings.Additionally, staff from Get Covered Illinois indicated that one of the primary successes has been the establishment of relationships between community organizations serving as assisters and criminal justice entities. These new partnerships have helped to bring to the forefront the importance of connecting individuals reentering the community to health coverage.
Ohio: Officials from both Ohio’s Department of Rehabilitation and Correction (ODRC) and the Ohio Department of Medicaid (ODM) indicated that communication between the two departments began in 2013 through efforts to ensure that the costs of inpatient hospitalizations of incarcerated individuals were billed to Medicaid. Then with the state’s expansion of Medicaid, the two agencies initiated conversations to determine how to implement enrollment processes for justice-involved individuals prior to their release, which led to a focus group of staff from the two departments, which met regularly for about a year. There are still weekly meetings between the two departments, and both the ODRC and ODM reported that these are critical for addressing issues efficiently. They also reported that these regular meetings have led to greater understanding of each department’s systems and processes. Additionally, in recognition of the fact that many justice-involved individuals reentering the community need to access behavioral health services, the workgroup includes representatives from the Department of Mental Health and Addiction Services. Rhode Island: Officials from the DOC indicated that prior to the ACA their office of transitional services had established efforts to enroll individuals reentering the community who had intense medical and behavioral health needs in health coverage. Recognizing that with their state taking up the Medicaid expansion option there would be a significant number of justice-involved individuals eligible for coverage upon release from incarceration, the DOC and the Medicaid agency held a series of joint meetings to begin planning for how to coordinate these enrollment efforts. Both the DOC and the Medicaid agency indicated that there has been very effective communication between the two departments, and that this strong partnership was crucial to implementation efforts.During the initial planning phases, the state’s health agency also initiated weekly face-to-face meetings with parole workers, unified jail-prison system discharge planners, and DOC nurses to provide greater support to them, understand what was working and what was not working in terms of providing application assistance and outreach.
Additionally, representatives of insurance plans attended some of the meetings between the DOC and the Medicaid department to discuss issues such as promoting continuity of care for the newly enrolled justice-involved population and potential challenges associated with the plans in terms of handling a larger volume of clients. Both departments indicated that it was very helpful to include the insurance companies in some of the initial planning meetings. Connections with the insurance companies are still continuing to some degree, with some attending discharge planning services to talk about substance abuse issues.
Rhode Island has also included the Center for Prisoner Health and Human Rights at Brown University as a partner in these enrollment efforts. The DOC is working with the Center to train university students to assist with applications and conduct post-release follow up in terms of accessing services upon release from incarceration. The DOC also emphasized the importance of having developed partnerships with local mental health agencies and other community-based organizations that work with the justice-involved population, as these entities are able to assist with follow-up enrollment efforts.
Wisconsin: Both the Department of Health Services (DHS) and the DOC indicated that they had an effective and established partnership and this was a key factor to the successful implementation of enrollment procedures for incarcerated individuals. The departments attributed the success of the partnership to good communication between the two agencies, support from both departments’ leadership, involvement of the appropriate staff from both agencies in the discussions, and taking time to carefully plan and think through the key issues. The agencies also attribute the success to existing working relationships between the two departments in the years prior to the implementation of the enrollment processes in correctional facilities. For example, DOC social workers conducting release planning had been sharing information with incarcerated individuals reentering the community, but had not been able to link them directly to those programs until after they were released. Also, there is a facility administered by DHS and staffed partially with DOC security employees, the Wisconsin Resource Center, which is a secure and specialized facility that houses incarcerated individuals with acute mental health issues to provide treatment and care for these individuals.In addition to the strong partnership between DHS and DOC, connections with local entities are also working well. Wisconsin’s Medicaid is locally based and eligibility offices are administered through groups of counties called consortia. While efforts to implement enrollment processes in local jails are in the early stages, DHS indicated that they have monthly meetings with the consortia to maintain effective communication channels, and the DOC has provided information to local jail administrators about possibilities for implementing more formalized enrollment procedures in these facilities. Both DHS and DOC indicated that because prior to the ACA many local jails would refer potentially eligible individuals reentering the community to connect with local income maintenance offices to apply for coverage, these existing community-based relationships provide a promising foundation to establish more formal local-level enrollment efforts.
Implementing processes to enroll justice-involved individuals in health coverage on a large scale is a new endeavor for states and their efforts are in the early stages. Given this, many states are currently working through various policy and operational challenges. The following are some examples of issues that states are planning to or are in the process of addressing to improve enrollment processes for the justice-involved population.
Illinois: State officials indicated that it was helpful to have the governor’s office lead the state’s initial efforts to enroll the justice-involved population in health coverage. This is because of the executive office’s ability to bring together a wide range of stakeholders, such as state and local officials as well as community based organizations. However, they noted the importance of developing a strong relationship specifically between staff at the state Medicaid and corrections agencies to maintain and sustain enrollment processes. Institutionalizing this relationship can help collaborations continue beyond changes in gubernatorial leadership. New Mexico: State officials from the Medicaid agency indicated that they have begun planning efforts to implement care coordination for individuals leaving incarceration. They reported that they are having initial discussions with managed care organizations (MCOs) about ways to better connect these individuals to care providers in the community. Each individual that is enrolled undergoes a health risk assessment, but state officials noted that care coordination linkages could be strengthened. One of the ideas being considered is to have MCO representatives initiate the first contact in the correctional facility prior to the individual’s release date to develop a care coordination plan. Ohio: State officials from the DRC mentioned that they are working with the Medicaid department to develop procedures to be able to claim Medicaid administrative matching funds to offset some of the costs associated with implementing enrollment processes. Additionally, while ODRC noted that the peer-to-peer enrollment assistance program has worked well, their vision for the enrollment process is to have individuals apply on their own at kiosks or mini tablets within the correctional facilities. This would minimize staff involvement further, and the inputting of identifying information such as Social Security numbers could be automated which would also streamline the overall process. Rhode Island: According to current state procedures, the Medicaid eligibility determination process does not occur until the individual’s incarceration release date, which results in individuals generally not being able to leave the correctional facility with their Medicaid card unless their release date is postponed. This leads to a number of challenges because some individuals leaving incarceration do not have addresses where the cards can be mailed. The Department of Corrections staff indicated that this is a significant barrier and that it would be very helpful to be able to include the Medicaid eligibility cards in the individuals’ exit packages. Washington: Currently, after staff members at the central office for the DOC enter an applicant’s information into the eligibility determination system and an individual is determined eligible for Medicaid, multiple mailings for each individual are generated. Many individuals do not have a planned place of residence after their release from incarceration, and consequently these mailings are sent to DOC facilities. However, currently only individuals’ names are included on the mailings, and not DOC identification numbers. This limited amount of identifying information in addition to the volume of mail received results in challenges for correctional facilities in terms of ensuring that the mailings are distributed to the appropriate individuals. The departments have identified this as a barrier to being able to provide individuals with Medicaid cards upon release and are aiming to address this in the near future. Wisconsin: The state is pursuing a method to track the number of justice-involved individuals enrolling in coverage via the established telephonic application process. Title 32 U.S.C. § 405(c)(2)(C)(i) limits the state in its release of complete Social Security numbers (SSN) unless it is for “the administration of any tax, general public assistance, driver’s license, or motor vehicle registration law within its jurisdiction.” Consequently, the DOC may only release the last four digits of the SSN to the Department of Health Services. They may then match the individuals’ names, dates of birth, and last four digits of the SSN to analyze Medicaid enrollment data and share information with the DOC for the purposes of tracking recidivism and how that may correlate with enrollment. In addition, this system also allows for better tracking of the application rates at each correctional facility.View the information from this toolkit one state at a time:
| Colorado |
Illinois |
New Mexico |
Ohio |
Rhode Island |
Washington |
Wisconsin |
View Webinar Here
Download Webinar Slides
Many individuals involved in the criminal justice system are now eligible for Medicaid in states that expanded the Medicaid program under the Affordable Care Act. Health coverage can provide individuals who are leaving incarceration with access to physical and behavioral health services critical to their successful reentry into the community. In some states, correctional agencies have partnered with Medicaid agencies to implement procedures to begin the Medicaid application process as individuals are nearing their incarceration release dates. This webinar features three states—Colorado, New Mexico and Wisconsin—that have initiated efforts to enroll justice-involved individuals in health coverage and explores some of the following questions:
- How are states developing procedures to enroll justice-involved individuals in Medicaid, and what types of policy or process changes have they implemented?
- What specific assistance is provided to incarcerated individuals who are enrolling in health coverage and how are applications processed?
- What strategies have been most successful for states, and what are some of the operational challenges that states are in the process of addressing?
- What types of interagency partnerships and coordination are needed to facilitate the enrollment of justice-involved individuals?
- How are states promoting access to care for the justice-involved population upon their release from incarceration?
The following is a compilation of related resources on the topic of the justice-involved population and health coverage.
| Financing/Cost-Containment | ||
| Medicaid Expansion and Criminal Justice Costs: Pre-Expansion Studies and Emerging Practices Point Toward Opportunities for States | State Health Reform Assistance Network | November 2015 |
| Medicaid: Information on Inmate Eligibility and Federal Costs for Allowable Services | The U.S. Government Accountability Office (GAO) | September 2014 |
| Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice | Health Affairs | March 2014 |
| Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System | The Council of State Governments (CSG) Justice Center | December 2013 |
| Realizing the Potential of National Health Care Reform to Reduce Criminal Justice Expenditures and Recidivism Among Jail Populations | Community Oriented Correctional Health Services (COCHS) | January 2011 |
Enrollment Processes
Download Chart as PDFWhere
| Where is enrollment conducted? | |
| CO | At DOC’s central office; also Denver County jail |
| IL | Enrollment education provided in correctional facilities; enrollment at various jails across the state and through the reentry process |
| NM | In state prisons, two county jails and two state and county juvenile detention centers |
| OH | In correctional facilities; prisons |
| RI | In correctional facilities (state has a unified prison/jail system) |
| WA | In correctional facilities; mostly prisons, some larger jails |
| WI | In correctional facilities; mostly in prisons |
When
| When is enrollment conducted? | |
| CO | Prior to release |
| IL | At intake in Cook County jail; prior to release in other jails and during reentry for the correctional population |
| NM | Prior to release |
| OH | 90-120 days prior to release, individuals can attend classes led by peer educators to learn about enrollment process |
| RI | Prior to release, individuals are provided information and paper applications at group education classes |
| WA | 90 days prior to release information is provided to individuals; 45-60 days prior to release applications are provided |
| WI | Individuals with release dates can apply via phone on or after the 20th day of the month prior to the month of release |
Who
| Who conducts enrollment? | |
| CO | -Correctional facility case managers obtain signed permission forms from individuals which are sent to DOC central office -Nurse case managers at DOC central office complete applications |
| IL | Primarily ACA in-person assisters or Certified Application Counselors |
| NM | Corrections staff trained as presumptive eligibility (PE) determiners by Human Services Department |
| OH | -Individuals complete forms and begin application process via phone; peer educators can assist -Each facility has a liaison who selects the peer educators and assists with overall process |
| RI | -Brown University interns provide application assistance -Other assisters at probation offices/exit resource centers help individuals enroll |
| WA | Trained staff at the correctional facilities assist individuals with completing the application |
| WI | -Social workers facilitate calls for individuals facing challenges to successful application -ACA “site coordinators” at correctional facilities help with overall process |
How
| How are applications processed? | |
| CO | 2 nurse case managers at DOC central office complete and process applications electronically after receiving permission forms from facilities; data sent to HCPF |
| IL | In-person assister submits applications and applications are processed by state Medicaid agency |
| NM | All Medicaid applications filed by incarcerated individuals are processed by the Medical Assistance Division’s PE Applications Processing Unit |
| OH | -Telephone call is to select managed care plan -Enrollment is completed when corrections department sends information to the Medicaid portal for an eligibility screen |
| RI | Paper applications are hand carried by corrections staff to Medicaid agency |
| WA | -Applications are scanned and sent to central office (DOC) -Information is entered into system 30 days prior to release |
| WI | Through telephonic application process, which includes a telephonic signature |
Individuals leave facility w/ Medicaid card?
| Individuals leave facility w/Medicaid card? | |
| CO | Yes, generally; if not, then individuals are provided w/their Medicaid number and DOC nurse case manager phone number |
| IL | No; eligibility results, paperwork and Medicaid cards are mailed to individuals’ addresses upon release |
| NM | No; individuals are provided w/their Medicaid number and MCO contact numbers |
| OH | -Yes; and Medicaid information included on release paperwork -Individuals with two or more risk factors have transition plans |
| RI | No; eligibility determination is conducted after individual is released from incarceration |
| WA | Yes, generally |
| WI | Yes, generally |
This toolkit was made possible with support from the Jacob & Valeria Langeloth Foundation.
Opportunities for Enrolling Justice-Involved Individuals in Medicaid
Health insurance options now available through the Affordable Care Act (ACA) offer new opportunities to enroll individuals involved in the criminal justice system into coverage. In states that have expanded Medicaid, many newly eligible will be young, low-income males, some with involvement with the criminal justice system. Justice-involved individuals especially could benefit from coverage as they often have rates of mental illness, substance abuse, and other health conditions as much as seven times higher than the general population. Additionally, because approximately 70 to 90 percent of the 10 million individuals released each year from prisons or jails lack health insurance, coverage can enable these individuals to receive appropriate treatment services, potentially contributing to lower recidivism rates.
The ACA did not change existing federal law, which prohibits using federal Medicaid funds to pay for medical care provided to incarcerated individuals unless the inmate is admitted to an inpatient facility for at least 24 hours. Despite these Medicaid payment restrictions, Medicaid-eligible individuals who become incarcerated retain their eligibility for the program. While some states suspend Medicaid enrollment upon incarceration, the majority simply terminate it. This results in individuals having to reapply for Medicaid after their release from a correctional facility, and the process of regaining benefits can be lengthy and delay access to care. But enrollment processes can begin prior to an inmate’s release as part of any discharge planning services or at other points during an individual’s involvement with the correctional system, and a number of states are already implementing efforts to do this. For example:
- Illinois began planning efforts soon after passage of the ACA to leverage the new health coverage options for justice-involved individuals. In 2011, the Governor’s Office established the Workgroup on Justice Populations (WJP) and convened multiple interagency and regional meetings among state and local health and human services agencies, correctional authorities, and key advocate groups. These meetings helped identify collaborative strategies to enroll individuals involved in the criminal justice system into health coverage. To help put these ideas into practice, the WJP developed a resource guide designed for criminal justice personnel and community partners. The guide provides background information about relevant ACA policies along with detailed process maps outlining steps to implement enrollment procedures in correctional facilities and other settings. Cook County, IL has moved forward with enrolling offenders at intake, and as of January 2014 over 12,000 applications had been initiated at the county’s jail.
- In Utah, Salt Lake County’s Division of Behavioral Health Services reached out to state Medicaid officials prior to 2014 to explore options for enrolling eligible individuals in the criminal justice system into coverage. Presently, some justice-involved individuals leaving Salt Lake County’s jail who are currently eligible for Medicaid are being enrolled as part of their community reentry services. The county directly employs a small number of state Medicaid eligibility determination workers by paying the Medicaid administrative match rate to the state. At the state level, one of the prisons has implemented procedures to begin the Medicaid eligibility determination process 30 days prior to an inmate’s release. Planning efforts led by the county’s Criminal Justice Advisory Council to broaden these initiatives are outlined in the county’s FY2015 Area Plan for Behavioral Health Services. These plans included convening a training session to assist state and local criminal justice stakeholders in developing policy related to enrolling justice-involved individuals. In December 2014, Utah’s governor released a Medicaid expansion proposal, but the plan needs both state legislative and federal approval. As of early January 2015 the state has not officially implemented expansion, but if the state moves forward even more justice-involved individuals would become eligible for Medicaid.
- In Washington, the Health Care Authority (HCA) has created a memorandum of understanding (MOU) to establish agreements between HCA and correctional facilities that outline processes for enrolling incarcerated individuals in Medicaid prior to their release. In jails that have established these arrangements, selected staff members are being trained to become certified application assisters through the state’s marketplace.
California, North Carolina, Ohio, and Rhode Island are just some of the other states that have also established these types of enrollment processes within their correctional systems. To support these efforts, the Centers for Medicare and Medicaid Services created a fact sheet on the ways that correctional systems can help connect justice-involved individuals to coverage. Because there are inherent challenges such as staff capacity issues, states are developing new, broad-based partnerships among correctional personnel, health and human services agencies, organizations providing ACA consumer assistance, and other state and local officials. For example in Cuyahoga County, OH, one of the navigator entities, the Cuyahoga Health Access Partnership, is working closely with the county jail to enroll inmates.
Has your state considered or established processes to enroll individuals involved in the criminal justice system into health coverage? Through support from the Jacob & Valeria Langeloth Foundation, in the coming months NASHP will develop an online toolkit and host a webinar to help state officials learn about promising practices in states successfully implementing these types of initiatives. Share your state’s efforts in a comment below or on our discussion page on inmates.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
