Archive for: Medicaid Expansion

Where States Stand on Medicaid Expansion

March 14, 2016/in Policy Charts, Maps Health Coverage and Access, Medicaid Expansion /by NASHP Writers

The State of State Health Policy: Governors’ 2016 State of the State Addresses

February 22, 2016/in Policy Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming Charts Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Expansion, State Insurance Marketplaces /by NASHP Staff

State of State speeches provide governors with an opportunity to highlight recent policy successes as well as outline key plans and issue areas of focus for the coming year. These speeches are generally strong indicators of governors’ main priorities and sometimes also include specific proposal suggestions and funding recommendations for deliberation by legislatures.
Currently, 31 governors are Republican, 18 are Democrats and one is an Independent. Two states—Kentucky and Louisiana—elected new governors in 2015. So far this year, 40 governors have outlined policy priorities through state of state speeches and/or budget addresses.[1] The chart and descriptions below summarize some of the main health-related themes from these speeches.
See a state-by-state comparison

Six governors mentioned the issue of more broadly addressing population health and building healthy communities.

Alabama	Launching Great State 2019 Plan in honor of state’s upcoming 200th birthday; initiative will focus on addressing longstanding problems from healthcare to prison reform and will involve building opportunities for citizens, and promoting education, healthcare, access to technology, job growth and economic opportunity
Colorado	Highlighted poverty’s negative effects and mentioned state’s Two Generation initiative to address poverty that links with the state’s efforts to be the healthiest in the nation; initiative recognizes that residents’ health has economic and overall quality of life impacts; also importance of reducing children’s screen time and the need to promote healthier behaviors such as involvement in outdoor activities
Hawaii	Will be investing in issue of homelessness, which will include addressing the needs of the most vulnerable homeless, such as those with chronic health conditions
Illinois	Need to make more coordinated investments and transform towards focusing more intensely on prevention and public health and paying for outcomes rather than volume and services
New Hampshire	Noted that safe and healthy communities are the foundation of the state; to maintain the state’s high quality of life investments should continue in priorities that support economic growth
New York	Mentioned consumer health concerns regarding access to safe and healthy food and the need for meaningful food labeling

In addition to mentioning health care costs within the context of Medicaid, eight governors also spoke about state health care costs more broadly; often mentioning costs associated with state employee health benefits.

California	Noted that state has not allocated enough funding to cover future retiree health benefits for state workers
Delaware	Identified sharply rising health care costs as the state’s biggest challenge, particularly costs of state employee health plans; also importance of shifting from fee-for service health care to a system focused on high quality and affordable outcomes, and ensuring that individuals appropriately use care to help reduce overall costs
Georgia	Commented on the rising costs of mandated health care expenditures for state employees
Hawaii	Mentioned state employee health care obligations as one of the state’s biggest fixed expenses, but recent changes to how these obligations are funded will save costs in the future
Louisiana	Noted state budget crisis and need for new revenue to avoid severe cuts in assistance programs for disabled individuals and other health programs and potentially having to close safety net hospitals
Pennsylvania	Noted that if state does not address $2 billion budget deficit will have to make significant cuts to basic state services, including health programs such as prescription drug assistance for seniors, services for individuals with mental illness and disabilities, and home and community-based services
Vermont	Mentioned the rising cost of health care as the most significant challenge to the state’s budget and the overall economy as well as creates challenges for families and businesses; noted state’s current work to shift from fee-for-service to an all-payer model focused on better health outcomes and targeted provider spending
Wisconsin	Commented on the need to reform the administration of state employee health insurance to achieve savings

Alaska	Mentioned commitment to implement Medicaid reforms to improve the state’s Medicaid program
California	Noted positive benefits of state’s Medicaid program but that there has been a significant rise in state Medicaid costs; requests legislature consider proposal to restructure taxes on Medicaid managed care organizations
Georgia	Commented that state Medicaid costs have increased from $2.6 billion in FY2013 to $3.1 billion in FY2017
Iowa	Mentioned plans to move to a Medicaid managed care system to improve care coordination and address significantly rising state Medicaid costs
Kansas	Recent reforms and modernizations to Medicaid program have demonstrated cost savings and also resulted in more client services and increased provider reimbursement rates
Missouri	Access to in-home Medicaid services for individuals with developmental disabilities has significantly improved
Nebraska	Noted significant rise in state Medicaid costs
Tennessee	Highlighted the success of TennCare as a well-run system with high customer satisfaction ratings

In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs. Thirteen governors mentioned Medicaid expansion in their speeches. Eight were governors that have not implemented expansion, and five of these governors spoke about the need to expand Medicaid or find another state-specific solution to cover the uninsured (Missouri, South Dakota, Utah, Virginia, and Wyoming). Two governors (Kansas and Nebraska) expressed continued opposition to expansion. Kentucky’s newly elected governor mentioned plans to transform the delivery of publicly assisted health care and to make changes to the state’s traditional Medicaid expansion, although the proposed budget contains funding for expansion in its current form.

Alaska	Noted expansion has resulted in greater health coverage for residents and state has benefited from increased federal revenue from expansion
California	Mentioned expansion has resulted in greater health coverage for residents
Idaho	Highlighted the work of cabinet in exploring Medicaid expansion alternatives; also mentioned recently released plan to provide state-funded primary care
Indiana	Mentioned state’s unique expansion program has resulted in increased access to health care and is based on personal responsibility
Kansas	Noted continued opposition to implementing expansion
Kentucky	Mentioned plans to transform delivery of publicly assisted health care and to make changes to the state’s current Medicaid expansion; proposed budget contains funding for current expansion
Missouri	Suggested state should act to cover the uninsured through expansion; can develop a state-tailored solution that rewards work and incorporates personal responsibility
Nebraska	Noted continued opposition to implementing expansion
New Hampshire	Urged legislators to support continuation of the Health Protection Program, the state’s Medicaid expansion program, which has increased access to behavioral health services but will end in December 2016 without legislative action
South Dakota	Noted opposition to ACA but importance of considering expansion to make the best decisions for the state; current negotiations with federal officials to change reimbursement process for services provided to Indian Health Services enrollees could cover the state’s expansion costs; will not move forward on expansion without legislative budget authority or if any new general funds are needed; also detailed how cost projections for the expansion population were developed; encouraged any expansion legislation to include language to end expansion if the federal match is reduced
Utah	Noted flaws of ACA but urged legislators to find a state-tailored solution to covering the uninsured
Virginia	Urged legislators to consider Medicaid expansion through a bipartisan, state-tailored solution
Wyoming	Noted opposition to ACA overall but that state should craft tailored expansion plan; commented on loss of federal revenue from not expanding affecting hospitals and businesses, and uninsured individuals lacking coverage; cited many organizations that support expansion (e.g. state business alliance and chambers of commerce)

Two governors spoke about the topic of the ACA’s exchanges in their speeches.

Kentucky	Mentioned plans to cease operations of the state’s exchange, Kynect, and that individuals will enroll through the federal exchange
Massachusetts	Noted improvements in eligibility determinations and access to the state’s Health Connector in the past year

Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors’ frequently highlighted strategies that have been implemented or that they plan to implement to increase access to behavioral health services.

Arizona	Highlighted the issue of drug addiction; plans to convene a group of experts on substance abuse issues, recovering addicts and providers to identify appropriate treatments and reduce barriers to care
Colorado	State is working to improve access to mental health care through State Innovation Model project; also plans to address links between suicide, mental illness and guns
Delaware	State has significantly increased access to substance use treatment and is working with law enforcement to address overdoses; budget includes funding to provide team-based care for individuals in need of intensive treatment services; also plans for the Department of Health and Social Services to work with primary care providers to identify substance abuse issues earlier
Hawaii	Mentioned behavioral health issues as the underlying cause of many social, health and economic challenges and that mental health is the most pressing unmet health issue facing the state
Idaho	Local behavioral health crisis centers have been effective; proposed budget includes funding for an additional center
Indiana	Need to increase treatment options for drug addiction; will create task force on enforcement, treatment and prevention; also plans to build the first new mental health hospital in a generation
Missouri	Highlighted the importance of addressing the needs of individuals with severe mental illnesses; will be launching a crisis prevention program for individuals ages 21 to 35 with severe mental illnesses and substance use disorders
New Jersey	Recent passage of state laws that increase access to substance abuse treatment; state still needs to “double down” on drug addiction and to treat it as an illness; committed to providing $100 million to improve access to mental health and substance use treatment by providing higher reimbursement rates for services and providers; plans to increase funding for three Accountable Care Organizations focused on providing coordinated physical and behavioral health treatment for Medicaid patients
Oklahoma	In the past five years the highest amount of funding in the state’s history has been provided for mental health; legislation was passed to reduce prescription drug and substance abuse fatalities
Washington	Recent investments of over $700 million in the state’s mental health system to restore prior service cuts, but additional focus on the issue is still needed; proposed budget includes funding directed towards building a stronger mental health system
West Virginia	Substance abuse has become one of the most significant challenges in the state; have invested in treatment services and resources to publicize services, updated prescription drug monitoring efforts, and implemented other measures to reduce the oversupply of pain medication

Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. The issue of heroin and other types of opioid abuse and overdoses were specifically mentioned by a number of governors in their remarks.

Indiana	Recently passed state law allowing healthcare providers to make an antidote available to address opioid overdoses and to allow Medicaid to cover inpatient detoxification
Kentucky	Plans to address heroin and opioid addiction; proposed budget includes funding for treatment programs and continuation of efforts to monitor prescription drugs
Maryland	State is working to address heroin and opioid addiction through a state-level task force
Massachusetts	Legislation being developed to address the heroin and opioid abuse epidemic by building capacity in prevention, education, and treatment efforts
Missouri	Need for a prescription drug monitoring program to address the opioid abuse epidemic
New Hampshire	State has worked to address the heroin and opioid abuse crisis but the issue remains the most urgent public health and public safety concern; efforts are underway to strengthen the state’s prescription drug monitoring program and improve access to treatment, but need further funding for law enforcement and efforts to strengthen prevention, treatment and recovery initiatives
New Jersey	Plans to launch a treatment intervention pilot program for individuals recovering from drug overdoses; individuals in recovery will help lead the intervention programs
Rhode Island	State views opioid overdoses as a public health crisis; aiming to reduce overdoses by one-third in the next three years by investing in treatment, overdose reversals, prevention and recovery
West Virginia	State has coordinated trainings for first responders on administering Narcan, an antidote for opioid overdoses; plans to introduce legislation to expand access to Narcan without a prescription
Vermont	Proposing funding to make a pilot program for overdose drug naloxone permanent; also funding for needle exchange programs, additional state staff resources and to develop a new treatment hub

Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals, and providing mental health and substance use treatment services rather than incarceration when appropriate.

Arizona	Will be focusing on providing drug treatment and counseling to justice-involved individuals to help reduce recidivism
Georgia	Mentioned justice reforms have diverted justice-involved individuals with substance use disorders to treatment rather than incarceration when appropriate
Illinois	Bipartisan commission to reform the criminal justice system recommended enhancing cognitive behavioral therapy and substance abuse treatment programs in the corrections system
Iowa	As part of the state’s justice policy reforms, will be focusing on rehabilitation instead of incarceration and on looking at funding models for drug and mental health courts
Missouri	Proposing $1.6 million to reduce the number of severely mentally ill individuals cycling through jails and emergency rooms and to direct them to treatment instead
New Jersey	With reductions in the state’s prison population, one of the correctional facilities has been closed and will be converted into a certified drug abuse treatment facility for justice-involved individuals
New Mexico	Importance of addressing the behavioral health issues of justice-involved individuals; proposed budget includes funding for new crisis triage centers, mobile crisis response teams, and community behavioral health clinics
South Dakota	State has significantly increased the number of drug and DUI courts; more non-violent justice-involved individuals are receiving community treatment rather than being incarcerated
Tennessee	State has increased the number of drug recovery courts, resulting in reduced incarceration costs; proposing to invest more in these courts in order to offer services in all counties
Washington	Need to address issue of individuals with severe mental illnesses who cycle between jails and emergency rooms; proposed budget includes funding for four new 16-bed crisis triage facilities and three new mobile crisis teams

Five governors noted issues related to the health care workforce, primarily commenting on strategies to address shortages.

Alabama	Mentioned physician and dentist shortage in nearly all of the state’s counties, and outlined plans to increase funding for medical scholarships and loan forgiveness for students committing to serve in underserved areas; also aims to create tax credits for rural providers and increase funding for 12 new residency programs
Delaware	Noted that programs to train individuals in the health care field are expanding
Idaho	Commented on need to address state’s lack of primary care physicians by maintaining funding for physician residency slots and providing medical loan reimbursement; also requests that the Board of Education work with the medical community and higher education institutions to develop plans to address the growing need for healthcare providers
Mississippi	Mentioned current state legislation that would permit the state to enter into a compact with other states to allow medical licenses to be interchangeable across states
New Hampshire	Commented on how plans to expand employment training programs will help address healthcare workforce shortages; a task force will focus on developing innovative solutions to further address these shortages

Some governors mentioned other specific health topics in their speeches, either as recent accomplishments or as future plans. These included topics such as enhancements to autism coverage, improvements in health coverage eligibility determinations, or lowered prison pharmacy costs.

California	Mentioned that state will be providing health care coverage to children of undocumented workers; also state leads the nation in providing Medicaid home-based care, which also gives jobs to health care providers
Delaware	Noted plans to partner with a national nonprofit organization to improve access to contraceptive options by offering better training for health care providers
Hawaii	Mentioned that in recognition of the need for private sector resources for Maui’s public hospitals, recently transferred hospital management to Kaiser Permanente
Kansas	Will be forming a working group to address rural health care delivery issues
Michigan	Addressed the water crisis in Flint and proposes support for increasing children’s access to health care and treatment for health issues associated with elevated blood lead levels
Missouri	Highlighted passage of autism legislation to ensure that appropriate services are available through health plans; will expand services at existing autism centers and build a new center
Nebraska	Mentioned improvements at state’s Department of Health and Human Services have streamlined low-income residents’ access to nutrition assistance and other assistance programs
Tennessee	Mentioned that Department of Correction worked with TennCare to lower prison pharmacy costs annually by $5 million; proposed budget includes funding for a mobile seating and positioning unit in the Department of Intellectual and Developmental Disabilities
Wisconsin	Noting the importance of helping individuals cope with health and mental health care needs to retain workplace talent, mentioned a recently completed informational kit for employers to provide to employees caring for family members with dementia or Alzheimer’s disease

[1] In 2016, there will be no state of the state addresses in Arkansas, Montana, Nevada, North Carolina, North Dakota and Texas. As of mid-February 2016, the governors of Minnesota, Ohio and Oregon have not announced the date of their addresses. The governor of Maine did not have an address but instead submitted a letter on 2/8/16 to the state legislature.

State Medicaid Expansion Plans: 2015 Recap and 2016 Possibilities

December 22, 2015/in Policy Alabama, Alaska, Arizona, Arkansas, Iowa, Kentucky, Louisiana, Michigan, Montana, Ohio, Pennsylvania, South Dakota, Utah, Wyoming Blogs Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by Anita Cardwell

As 2015 comes to a close, Medicaid expansion activity in states has not slowed down. Currently, 30 states and the District of Columbia have expanded Medicaid, and six of these states have chosen to pursue waivers to implement alternative versions of expansion. As the new year approaches, a number of additional states are considering options for expanding Medicaid—either as outlined by the ACA or through waivers—and other states are planning to propose modifications to their existing expansion models. The following selected state snapshots provide a summary of key highlights from 2015 Medicaid expansion activity and what to watch for in the coming year.
States to Watch in 2016
Alabama: In early 2015, Governor Bentley indicated that his office might consider an “Alabama-specific” version of Medicaid expansion, and his administration is in the process of examining options and continuing communication with federal officials. A governor-appointed task force recommended that state policymakers should find a way to provide health coverage to uninsured individuals, and the task force’s statement outlined the benefits of closing the state’s coverage gap. Whether there will be support from the state legislature is a question.
Kentucky: While former Governor Beshear implemented the Medicaid expansion as defined by the ACA, newly sworn in Governor Bevin has signaled interest in making changes. During his campaign Governor Bevin indicated that he would end the state’s Medicaid expansion if elected, yet more recently Bevin suggested that Kentucky may pursue a waiver to modify the current traditional expansion into a model similar to Indiana’s. A recent Kaiser Family Foundation poll found that approximately seven in 10 Kentucky residents would prefer to maintain Medicaid expansion as is rather than implement changes that would cover fewer individuals.
Louisiana: While Governor Jindal has remained staunchly against Medicaid expansion, incoming Governor-elect John Bel Edwards has expressed strong support for expansion. In June 2015, the legislature passed a bill containing a financing tool to cover the state’s costs for expansion through the pooling of hospital funds. Additionally, in December state legislators requested the Department of Health and Hospitals to update previous 2013 and 2014 reports on Medicaid expansion options by early January.
South Dakota: Previously Governor Daugaard sought approval for a partial expansion of Medicaid for individuals at or below the federal poverty line (FPL), but federal officials denied this request. In the fall of 2015, the state restarted discussions with federal administrators about expansion options. The state is seeking greater federal reimbursement for Medicaid services provided through Indian Health Services, which would increase funding in the state budget that could be made available to support state expansion costs. In his December budget address the governor indicated support for expanding Medicaid if costs can be covered by the general fund budget.
Utah: Earlier in 2015 it appeared that Utah was close to implementing expansion—in December 2014 Governor Herbert proposed an alternative expansion model, the Healthy Utah Plan, and while this did not gain full legislative approval, a resolution was passed directing state leaders to seek a compromise. However the revised Utah Access Plus proposal was rejected by state legislators in October. In December 2015, the governor’s office indicated that the executive branch does not intend to propose another Medicaid expansion plan and any next steps will be dependent on legislative action. State legislators may consider expansion in 2016, but there are some indications that the legislature may hold off until the presidential election is decided.
Wyoming: At the end of 2014, Governor Mead and the state’s Department of Health released a Medicaid expansion plan, which included premiums and co-payments that could be reduced through healthy behavior activities, as well as a work assistance program. Legislation aligned with the plan was introduced in 2015, but voted down. The governor just released a two-year budget request that includes Medicaid expansion, contending that federal expansion dollars will help the state address budget shortfalls. However some indications are that the majority of state legislators will remain opposed to implementing expansion.
States Seeking Expansion Modifications
A number of states that previously expanded Medicaid are seeking modifications that put requirements on enrollees similar to Indiana’s expansion model, such as premiums and additional cost sharing payments that can be reduced through participation in healthy behavior activities. Arizona is proposing cost sharing above federal thresholds, time limits on coverage, as well as work requirements. However CMS has not approved waivers seeking to include cost sharing above amounts permitted by federal law (one exception being approval for Indiana to charge cost sharing above federal limits for non-emergency use of the ER). CMS has also not approved time limits on coverage and has previously denied waiver requests to condition Medicaid eligibility on work requirements.
Arizona: While Arizona is currently implementing the ACA’s traditional Medicaid expansion, Governor Ducey took office in January 2015 and is seeking a federal waiver to pursue the proposed AHCCCS CARE plan. The plan includes health savings accounts and would require enrollees to pay premiums and co-payments that could be reduced through healthy behavior activities. Similar to Indiana’s approved waiver, the waiver seeks to implement cost sharing above federal limits for non-emergency use of the ER and proposes to disenroll and impose a lock out period for individuals above 100 percent FPL for non-payment of required cost sharing. However, the state is also seeking to implement elements not seen in other waivers, such as requirements that enrollees must be working, attending school, a training program, or actively seeking employment; and limiting lifetime enrollment in the program for able-bodied adults to five years.
Arkansas: The Arkansas Health Care Independence Program, also know as the “Private Option”, was the first Medicaid expansion waiver approved under the ACA, which uses Medicaid funds as premium assistance to provide coverage for newly eligible adults through qualified health plans (QHPs). The state later sought, and was granted, a waiver amendment allowing the creation of health savings accounts, which enrollees pay into to cover co-payments. In early 2015 newly sworn in Republican Governor Hutchinson created a legislative task force to provide recommendations on the future of the state’s expansion model. In December the state announced plans to submit a waiver amendment to continue the program past its current end date of December 2016, which may include changes the task force is considering, such as enhanced cost sharing, a work referral program, and measures to promote employer-sponsored insurance. The governor also recently suggested adding an asset test and lifetime benefit limits to the Private Option, and in December the task force endorsed the governor’s plan to seek changes to the waiver.
Iowa: In 2014 the state expanded Medicaid through the Iowa Health and Wellness Plan, enrolling newly eligible adults with incomes above 100 percent FPL in exchange coverage using Medicaid funds as premium assistance, and providing Medicaid managed care plan coverage for lower-income and medically frail individuals. Both groups have income-based premiums that can be reduced if certain healthy behavior standards are met. However, in late 2014, one of the two participating QHPs withdrew from the exchange, and soon after, the other plan indicated it would no longer accept new Medicaid members. With a lack of QHP options, coverage through the premium assistance model became voluntary. Consequently in September 2015 Iowa submitted a waiver amendment to require all individuals eligible for the expansion to be enrolled in Medicaid managed care plans beginning in 2016.
Ohio: The state has implemented the traditional ACA Medicaid expansion, but the FY2016-FY2017 budget bill HB 64 proposed the Healthy Ohio program, which would require certain Medicaid recipients to contribute to state-run health savings accounts to cover care costs. Governor Kasich signed the budget bill into law in June. The plan to make changes to the existing expansion will require federal approval.
Other Notable State Updates from 2015
Alaska: Soon after taking office in December 2014, Governor Walker and the Department of Health and Social Services released a concept for expanding and reforming Medicaid through the Healthy Alaska Plan. The majority of state legislators were strongly opposed to expansion and legislation did not move forward despite two special sessions. In July 2015 the governor announced his plans to expand Medicaid using executive authority, even though the legislature restricted the executive branch’s authority to expand Medicaid (deemed unconstitutional by some legal analyses). In August the state legislature indicated that it plans to sue the governor for expanding without legislative approval. However the Alaska Supreme Court ruled that despite the ongoing lawsuit, expansion could move forward and individuals began enrolling in September.
Michigan: The state’s original Medicaid expansion waiver that was effective in April 2014, the Healthy Michigan Plan, requires all newly eligible adults to contribute to health savings accounts that are used for required co-payments. Individuals with incomes above 100 percent FPL also are required to make monthly premium contributions, which can be reduced through participation in certain healthy behavior activities. However state law authorizing the expansion required Michigan to submit a waiver amendment, which CMS approved last week (required to prevent the expansion from ending in April 2016). Under the waiver amendment’s special terms and conditions, in April 2018, non-medically frail beneficiaries with incomes above 100 percent FPL will choose to either move to a marketplace option or remain in the Medicaid delivery system. Premiums for both groups cannot exceed two percent of income, and failing to make contributions is not a condition of eligibility for those who must pay premiums. Total cost sharing must follow federal Medicaid rules (the waiver amendment had proposed total cost sharing up to seven percent of income). Individuals who stay in the Medicaid delivery system will be required to engage in certain healthy behaviors that can reduce cost sharing. The state will revise its health behavior protocols in 2017.
Montana: Governor Bullock’s FY2016-17 budget included expansion through the Healthy Montana Plan. While the legislature did not pass the governor’s plan as proposed in legislation, it did pass the HELP Act, which was signed by the governor in April 2015. In September the state submitted a waiver to implement the HELP program, which includes co-payments and premiums, with disenrollment for individuals above poverty for nonpayment after a grace period (re-enrollment can occur relatively soon after certain conditions are met). CMS approved the waiver in November, and coverage for enrollees will be effective in January 2016.
Pennsylvania: When Governor Wolf took office in January 2015, the state had just expanded Medicaid through a waiver for the Healthy PA plan implemented under the previous administration. The plan had included some of the same elements found in other expansion waivers, such as premiums that could be reduced through participation in healthy behavior activities and cost sharing. As promised during his campaign, Governor Wolf transitioned Pennsylvania’s waiver to a traditional Medicaid expansion program, HealthChoices, with coverage effective in September.

Illinois: State Strategies to Enroll Justice-Involved Individuals in Health Coverage

December 17, 2015/in Policy Illinois Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Coverage and Access, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration /by NASHP

Policy and Process Changes
State Legislation
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.
Application Process Changes
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 enrollment guide
Post-Release Outreach
Parole office
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.
Mailings and calls
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.
Beyond Eligibility and Enrollment Strategies
Health Literacy Materials
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).
Cross-Agency Coordination and Partnerships
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.
Looking Forward: Future Issues to Address
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.

Wisconsin: State Strategies to Enroll Justice-Involved Individuals in Health Coverage

December 17, 2015/in Policy Wisconsin Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Coverage and Access, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration /by NASHP

Policy and Process Changes
Memorandums of Understanding (MOUs) between state agencies
In 2004, the Department of Health Services (DHS) and the DOC in Wisconsin established their first MOU 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.
Eligibility Determination Changes
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 20^th 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.
Application Process Changes
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 20^th 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.
Enrollment as Part of Pre-Release Planning
Medicaid Enrollment Education/Training for Incarcerated Individuals
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
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.
Health Literacy Materials
The DOC developed and distributed informational pamphlets [add link to WI – 3] 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
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.
Cross-Agency Coordination and Partnerships
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.
Looking Forward: Future Issues to Address
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.

Rhode Island: State Strategies to Enroll Justice-Involved Individuals in Health Coverage

December 17, 2015/in Policy Rhode Island Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Coverage and Access, Medicaid Expansion, Physical and Behavioral Health Integration /by NASHP

Policy and Process Changes
Contract Modifications
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.
Application Process Changes
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.
Enrollment as Part of Pre-Release Planning
Medicaid Enrollment Education/Training for Incarcerated Individuals
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.
Application Assistance
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.
Post-Release Outreach
Parole office
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.
Beyond Eligibility and Enrollment Strategies
Health Literacy Materials
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.
Access to Care
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.
Cross-Agency Coordination and Partnerships
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.
Looking Forward: Future Issues to Address
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.

Dental Benefits and Health Insurance Marketplaces: An Update on Policy Considerations

December 1, 2015/in Policy Reports Child Oral Health, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Expansion, Oral Health, State Insurance Marketplaces /by NASHP and Najeia Mention

The Affordable Care Act (ACA) includes pediatric dental services as one of ten Essential Health Benefits that health plans in the small group and individual markets must cover. Adult dental services are not required, but are being offered by marketplace plans as well. However, the way that the ACA structures dental coverage has created a number of implementation challenges relating to affordability, benefit design, and consumer experience.
In 2014, the National Academy for State Health Policy (NASHP) examined these issues in a comprehensive report. In early 2015, NASHP convened a follow-up call with marketplace and dental leaders to discuss progress on addressing these issues.
This brief provides an update of current activity across the marketplaces. Key issues addressed include:

Impact of decisions to offer pediatric dental coverage through medical plans or stand-alone dental products on affordability and implementation of marketplace systems;
State interest in offering optional adult dental coverage;
Enhancing data and reporting on access to and purchase of dental coverage;
Improving outreach, enrollment, and dental plan quality;
Impact of future state and federal decisions about coverage programs on dental coverage through marketplaces, including decisions about federal funding for the Children’s Health Insurance Program (CHIP).

Read full brief here

Corrections and Medicaid Partnerships: Strategies to Enroll Justice-Involved Populations

November 17, 2015/in Policy Colorado, New Mexico, Wisconsin Webinars Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration /by NASHP Staff

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

November 16, 2015/in Policy Toolkits Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement /by Anita Cardwell, Chiara Corso and Sarabeth Zemel

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:

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]
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.

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.

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 20^th 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 20^th 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.

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:

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.

*Health Reform*
Medicaid Expansion and Criminal Justice Costs: Pre-Expansion Studies and Emerging Practices Point Toward Opportunities for States	State Health Reform Assistance Network	November 2015
State Medicaid Eligibility Policies for Individuals Moving Into and Out of Incarceration	The Henry J. Kaiser Family Foundation – The Kaiser Commission on Medicaid and the Uninsured	August 2015
Helping the Justice-Involved Population Enroll in Affordable Care Act Coverage	Families USA	May 2015
Consumer Rights Come to Jail: How the Affordable Care Act Changes the Rights of Individuals Pending Disposition	Community Oriented Correctional Health Services (COCHS)	March 15
Opportunities for Enrolling Justice-Involved Individuals in Medicaid	StateRefor(u)m	January 2015
Mapping the Criminal Justice System to Connect Justice-Involved Individuals with Treatment and Health Care under the Affordable Care Act	National Institute of Corrections, U.S. Department of Justice	June 14
The ACA Opens The Door For Two Vulnerable Populations	Health Affairs	March 2014
What The Affordable Care Act Means for People with Jail Stays	Health Affairs	March 2014
Medicaid Expansion: Considerations For States Regarding Newly Eligible Jail-Involved Individuals	Health Affairs	March 2014
How Health Care Reform Can Transform the Health of Criminal Justice-Involved Individuals	Health Affairs	March 2014
Medicaid Expansion and Jail‐Involved Individuals: Opportunities to Promote Coverage, Improve Health, and Reduce Recidivism	Center for Health Care Strategies (CHCS)	March 2014
Implications of The Affordable Care Act on People Involved with the Criminal Justice System	The Council of State Governments (CSG) Justice Center	February 2013
The Affordable Care Act and Criminal Justice: Intersections and Implications	Bureau of Justice Assistance, U.S. Department of Justice	July 2012
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
Medicaid and Criminal Justice: The Need for Cross-System Collaboration Post Health Care Reform	Community Oriented Correctional Health Services (COCHS)	January 2011

*Health Coverage and Access*
Health Insurance for People Involved in the Justice System: Outreach and Enrollment Strategies	Families USA	October 2015
State Medicaid Eligibility Policies for Individuals Moving Into and Out of Incarceration	The Henry J. Kaiser Family Foundation – The Kaiser Commission on Medicaid and the Uninsured	August 2015
Consumer Rights Come to Jail: How the Affordable Care Act Changes the Rights of Individuals Pending Disposition	Community Oriented Correctional Health Services (COCHS)	March 2015
State Profiles of Health Care Information for The Criminal Justice System	Legal Action Center (LAC)	January 2015
State and Local Initiatives to Enroll Individuals in Medicaid in Criminal Justice Settings	Johns Hopkins Bloomberg School of Public Health – Center for Mental Health and Addiction Policy Research	January 2015
Strengthening the Connection between Medicaid Eligibility and Access to Services for the Jail-Involved Population	The Center for Health Care Strategies (CHCS)	December 2014
Promoting Health Access to Keep People with Mental Illness Out of Jail	Center for Health Care Strategies (CHCS)	December 2014
Medicaid: Information on Inmate Eligibility and Federal Costs for Allowable Services	The U.S. Government Accountability Office (GAO)	September 2014
Health Coverage and Care for the Adult Criminal Justice-Involved Population	The Henry J. Kaiser Family Foundation – The Kaiser Commission on Medicaid and the Uninsured	September 2014
Prison Inmates’ Prerelease Application for Medicaid: Take-up Rates in Oregon	The Urban Institute	August 2014
Medicaid Expansion: Considerations For States Regarding Newly Eligible Jail-Involved Individuals	Health Affairs	March 2014
Integrating Correctional And Community Health Care For Formerly Incarcerated People Who Are Eligible for Medicaid	Health Affairs	March 2014
Medicaid Expansion and Jail‐Involved Individuals: Opportunities to Promote Coverage, Improve Health, and Reduce Recidivism	Center for Health Care Strategies (CHCS)	March 2014
Facilitating Access to Health Coverage for Juvenile Justice-Involved Youth	National Academy for State Health Policy (NASHP)	March 2014
Preparing for Medicaid Expansion: Ensuring Health Care Access for Individuals with Criminal Justice Involvement	Community Oriented Correctional Health Services (COCHS); The Center for Health Care Strategies (CHCS)	September 2013
Medicaid and Criminal Justice: The Need for Cross-System Collaboration Post Health Care Reform	Community Oriented Correctional Health Services (COCHS)	January 2011
Ten Ways Corrections Systems Can Help Link Returning Offenders to Health Insurance	Centers for Medicare and Medicaid Services (CMS)	2013
Advocacy Toolkit: Restoring Medicaid Upon Release from Prison	Legal Action Center (LAC)	Not specified
Health Coverage Enrollment for Justice-Involved Individuals	National Association of Counties (NACO)	Not specified

*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

*Health Outcomes and Recidivism*
Predictive Analytics in Health Care and Criminal Justice:	Community Oriented Correctional Health Services (COCHS)	June 2015
Promoting Health Access to Keep People with Mental Illness Out of Jail	Center for Health Care Strategies (CHCS)	December 2014
How Health Care Reform Can Transform the Health of Criminal Justice-Involved Individuals	Health Affairs	March 2014
Integrating Correctional And Community Health Care For Formerly Incarcerated People Who Are Eligible for Medicaid	Health Affairs	March 2014
Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice	Health Affairs	March 2014
Medicaid Expansion and Jail‐Involved Individuals: Opportunities to Promote Coverage, Improve Health, and Reduce Recidivism	Center for Health Care Strategies (CHCS)	March 2014
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 PDF

Where

	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.

The Healthier Washington Initiative Promotes Accountable Communities of Health Statewide

November 13, 2015/in Policy Washington Blogs Accountable Health, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health Equity, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Social Determinants of Health /by Taylor Kniffin

At a recent NASHP preconference, Improving Health, Lowering Costs: Translating Population Health into Effective State Policy, we heard from Washington State about the innovative work currently underway as part of its Healthier Washington initiative. This panel featured MaryAnne Lindeblad from the Washington Health Care Authority (HCA) and two local perspectives: Patty Hayes, Director of Public Health in Seattle & King County, and Barry Kling from the Chelan-Douglas Health District. They discussedAccountable Communities of Health (ACH), regions that bring together public and private entities to improve health and health systems, improve population health, and drive physical and behavioral health integration.
Nine regional ACHs will bring together health care providers, social service organizations, health plans, hospitals, county governments, tribes, and others. They are being phased in throughout the state based on community readiness determined by aligned policies, designated regional borders, and Medicaid procurement. Performance measures, metrics, and expectations are intended to be developed in partnership with the state. ACHs will be governed through public-private partnerships, tailored to fit the community in question, and will receive funds through the state that can then be distributed to the various partners carrying out transformation projects within each region. Potential responsibilities of ACHs include partner procurement; the development of a regional health assessment or health improvement plan; the assumption of accountability for results; acting as a forum to decide on payment models, performance measures, and investments; workforce development; and using data to address community health needs.
Even before the start of the Healthier Washington initiative, King County’s Transformation Plan was already well underway. This five-year, equity-driven Transformation Plan aims to shift the focus from a costly, crisis-oriented health response to prevention, embrace recovery, and eliminate disparities to significantly increase the health and well-being of the community by 2020. It incorporates several initiatives within King County, including Communities of Opportunity, Behavioral Health Integration, and the Familiar Faces Initiative. When the Healthier Washington initiative selected King County to be one of the many ACHs, those in King County viewed this as an opportunity to carry forward the momentum that was already underway in that area.
Chelan-Douglas Health District, a rural, politically conservative community, faces similar struggles of other rural areas—among them a stressed health care system and workforce shortages. As of early 2014, Chelan-Douglas became part of the North Central ACH. Several skeptical partners challenged this involvement in the Healthier Washington initiative, but ultimately agreed to participate in order “to be at the table [rather] than on the menu.” For this district, participation as an ACH means new organizational structures and new financial arrangements, along with some skepticism about participating in a new state program.
As the Healthier Washington initiative continues to move forward, the State will need to balance the various needs of the many ACHs and think about how such structures either support or inhibit local change. Specific questions to consider as this initiative moves forward are whether the HCA will take into account the special circumstances of rural health care and how savings will be invested into population health improvement strategies. Ultimately, it plans to leverage resources and opportunities to transform healthcare in Washington.
How is your state supporting local innovation through state level initiatives to improve population health and address social determinants? Let us know by starting a discussion on State Refor(u)m.

Sign Up for Our Weekly Newsletter

This form needs Javascript to display, which your browser doesn't support. Sign up here instead