Editor’s Note: The importance of connecting justice-involved populations to health coverage and care is evident from the high levels of physical and behavioral health issues they experience. People in prisons have four times the rate of active tuberculosis found in the general population, nine to ten times the rate of human immunodeficiency virus (HIV) infection, three times the rate of serious mental illness and four times the rate of substance abuse disorders.
In a new policy guide, summarized below, Manatt Health and The Urban Institute provide a road map for state and local justice and healthcare officials and other stakeholders to improve health coverage and outcomes for justice-involved people, enhance public safety, reduce recidivism, and more efficiently use public resources. The guide provides a menu of options, including real-world examples, that states and localities may consider for meeting the challenge of connecting justice-involved populations to health coverage and coordinated systems of care. Click here to download a free copy of the full policy guide.
The Importance of Connecting Justice-Involved Populations to Health Coverage and Care
Although the Constitution requires states and localities to provide healthcare to people in prisons and jails, many still fail to receive needed care. When individuals are released from those institutions, they often face disruptions in medical care that contribute to recidivism, drug use, and poor and costly health outcomes. Further, there is a particular nexus between behavioral health and reoffending, with people returning from prison with mental health conditions and substance abuse problems reporting higher levels of criminal behavior.
There is emerging evidence that connecting justice-involved people to health coverage and care in the community can increase rates of behavioral health treatment, as well as levels of well-being and health for re-entering populations. If states and localities can facilitate such linkages, they will be in a stronger position to address substance abuse issues, chronic physical and mental illness, unemployment and employment stability, and homelessness that result in many individuals cycling in and out of justice settings or hospitals.
Opportunities and Challenges
The Medicaid program presents manifold opportunities to improve poor health outcomes for people re-entering the community. The rules surrounding when services rendered to justice-involved people may be reimbursed by Medicaid, however, are complex and vary from state to state. Key federal requirements and options include the following:
- Federal rules prohibit Medicaid from paying for medical services and prescription medications for people while they are incarcerated, except when inpatient or institutional services are provided in a community-based setting, such as if someone serving a jail term must be hospitalized outside the jail for care.
- People who meet Medicaid eligibility requirements may be determined eligible for Medicaid before, during and after their incarceration as long as the state does not use federal Medicaid dollars for their healthcare services while they are incarcerated.
- Medicaid enrollment can be suspended upon incarceration and reactivated upon release.
- Medicaid federal administrative funding is available to support the development and operation of eligibility and enrollment functions to serve the justice-involved population.
Strategies for Connecting Justice-Involved Populations to Health Coverage and Care
Strategies that states and localities may consider for connecting justice-involved populations to health coverage and care can be organized around three areas:
- Enrolling the justice-involved population in Medicaid;
- Fostering linkages to coordinated, comprehensive healthcare that meets the distinctive needs of the justice-involved population; and
- Identifying financing options for enrollment and delivery system initiatives for justice-involved populations.
These strategies can be adopted alone or in combination to meet the unique needs of a state or locality. Though the strategies focus on incarcerated or re-entry populations, many are applicable throughout the justice continuum, including from arrest through pretrial and community supervision through alternatives to incarceration. Some strategies require collaboration and regular communications between the state Medicaid agency, state and local criminal justice agencies, and perhaps local health agencies. They also may require state Medicaid agencies to seek federal administrative funding and identify a source of nonfederal matching dollars.
1. Enrolling the Justice-Involved Population in Medicaid
Strategies for enrolling the justice-involved population in Medicaid fall into three areas:
First, bolster the eligibility and enrollment workforce. These strategies seek to increase the capacity of state and local eligibility and enrollment workers to help justice-involved populations enroll in and retain coverage. They include:
- Leveraging existing enrollment staff—including community-based navigators, application assisters and eligibility workers—to conduct outreach and enrollment for justice-involved people
- Establishing a special populations enrollment unit (or expanding an existing unit) within the state’s Medicaid agency to address the unique challenges and systemic issues for justice-involved people, such as identity proofing and the need for highly expedited application processing to prevent interruptions in care
- Engaging existing justice agency medical, behavioral health, case management and social services vendors to conduct enrollment
- Training justice-involved peer assisters, so justice-involved people can connect with knowledgeable and credible peers to increase their engagement in the enrollment process and their motivation to access needed care in the community
Second, set enrollment priorities. These strategies prioritize where to target outreach and enrollment efforts, as well as where to use information technology (IT) systems to efficiently identify those in need of coverage and trigger enrollment activity. Strategies include:
- Identifying incarcerated people with serious physical and behavioral health issues who are not yet Medicaid beneficiaries and prioritizing them for enrollment
- Establishing IT processes for checking Medicaid status to enroll uninsured people, including automated IT mechanisms for corrections and state Medicaid agencies to communicate with each other about a person’s incarceration and Medicaid coverage status
Third, improve suspension and renewal processes. Strategies in this category explore suspension and reclassification—alternatives to terminating Medicaid coverage for incarcerated individuals. Encouraged by the Centers for Medicare & Medicaid Services (CMS), improvements in suspension and reclassification are intended to ensure coverage is activated at the time of release and reserve Medicaid enrollment resources for people without prior coverage. Strategies to consider include:
- Establishing a process for state Medicaid agencies to suspend or reclassify Medicaid coverage status when a person becomes incarcerated and reinstate the enrollee’s full-benefit coverage upon release
- Renewing eligibility for incarcerated beneficiaries using available federal and state data
2. Fostering Links to Coordinated, Comprehensive Systems of Care
Although healthcare coverage is an important first step, it is not sufficient to ensure people receive the healthcare services they need. It is critical to have strategies in place that connect newly insured people to crucial healthcare services as they transition to the community. Strategies in this category fall into three areas:
First, enhance links to existing services and systems of care. These strategies focus on using the existing healthcare infrastructure to improve care for justice-involved people, focusing on encouraging health plans and providers to engage with people before they return to the community (known as “in-reach”). Strategies include:
- Amending state Medicaid agencies’ contracts with Medicaid managed care organizations (MCOs) to support care coordination activities as enrolled people transition from jail or prison back to the community
- Assigning justice-involved people to an MCO before their release, increasing the effectiveness of in-reach in a Medicaid managed care environment
- Establishing routine and robust care transition processes as part of discharge planning, including a short summary of prescriptions, clinical summaries and treatment information that would be conveyed to community providers, if the re-entering person consents
Second, expand or create new coordinated, comprehensive systems of care. Strategies in this category focus on opportunities to increase coordination across agencies, health plans and providers and to promote comprehensive systems of coverage and care that address the specific health needs of justice-involved people. They include:
- Establishing health homes or health homes-like initiatives—integrated, team-based clinical approaches through which providers coordinate care for people with serious or multiple chronic conditions
- Creating a peer support program to assist people as they transition from jail back to the community
Third, increase access to critical Medicaid benefits. In this set of strategies, we look at opportunities to increase access to crucial medical benefits, such as medication and temporary respite, for people currently or formerly incarcerated. Strategies to consider include:
- Providing people being discharged with a 30-day supply of medication at release or a prescription to fill at a community-based pharmacy that accepts Medicaid reimbursement
- Requiring MCOs to provide Medicaid-allowable services for people returning to the community from incarceration, within specific timelines
3. Identifying Financing Strategies to Support Enrollment and Care
Our final set of strategies focuses on options for accessing Medicaid financing to support enrollment and care coordination for justice-involved populations in three categories:
First, fund enrollment assistance. The strategies in this category seek to leverage federal and state funding to support enrolling incarcerated people into Medicaid before they re-enter the community. Enrollment can involve either assisting uninsured incarcerated people in completing Medicaid applications or ensuring that, as soon as possible after release, standard coverage reactivates. Strategies include:
- Using Medicaid Administrative Claiming (MAC) to support prerelease enrollment efforts by public employees
- Partnering with MCOs or leveraging their capitation rates to fund re-enrollment
- Using the Federal Medical Assistance Percentage (FMAP) to support carve-out behavioral health plans or systems to enroll incarcerated people with mental health or substance use disorders
- Leveraging Medicaid or private grant funding sources for community-based organizations to support enrollment efforts in jails and prisons
Second, fund IT development. This section explores how state and local officials might claim 90% of federal Medicaid funding to support IT development that links the justice-involved population with a state Medicaid agency’s eligibility and enrollment system. Information technology links between previously disparate electronic systems serving Medicaid and justice agencies could streamline Medicaid enrollment and renewal processes for eligible, justice-involved, low-income youth and adults. Strategies include leveraging 90% MAC matching funds to help build an electronic interface between justice and Medicaid IT systems that supports Medicaid enrollment, eligibility status, adjustment and renewal.
Third, fund transition services. The strategies in this category suggest how state and local officials could tap federal funding for services that help incarcerated people transition toward receiving necessary care after community re-entry. Their objective is to facilitate the receipt of essential health services when justice-involved people return to their communities. Strategies include:
- Providing needed prescription drugs at discharge by giving departing people bottles of medicine; administering long-acting doses; or, when seeking Medicaid coverage for the medication, dispensing prescription drugs after people are free to leave but are briefly remaining on-site to obtain their medicine, so they are no longer considered incarcerated under Medicaid law
- Pursuing using administrative claiming for case management activities to fund transitional services that facilitate post-release care
Organizing for Action
Many of the policies above require collaboration and regular communication between the state Medicaid agency, state and local criminal justice agencies, and perhaps local health agencies. Each participating agency should consider designating a coordinator or contact person for interfacing with other agencies and quickly resolving problems. To monitor the target population and the success of selected initiatives, jurisdictions could also identify and attempt to collect performance measures when implementing the strategies. Finally, the strategies also may require state Medicaid agencies to seek federal administrative funding and identify the source of nonfederal matching dollars.