Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System

8/13/2019 Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System

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People in prisons and jails often have complex and costlyhealth care needs, and states and local governmentscurrently pay almost the entirety of these individualshealth care costs. In addition, it is estimated that as many

as 701

to 902

percent of the approximately 10 million3

individuals released from prison or jail each year areuninsured. Lack of health insurance is associated withincreased morbidity and mortality,4and the high rate ofuninsurance among individuals involved with the criminal

justice system is compounded by rates of mental illness,substance use disorders, infectious disease, and chronichealth conditions that are as much as seven timeshigher than rates in the general population.5

When an individual returns to the community

after incarceration, disruptions in the continuity ofmedical care have been shown to increase rates ofreincarceration and lead to poorer and more costlyhealth outcomes.6Research shows that the first fewweeks after release from incarceration are the mostcritical in terms of connecting people to treatment.Reentry into the community is a vulnerable time, markedby difficulties adjusting, increased drug use, and a 12-fold increase in the risk of death in the first two weeksafter release.7For many, the failure to provide a link tohealthcare coverage and services upon release results

in needless, potentially months-long gaps in theiraccess to health care. If they access care at all, theseindividuals often rely upon hospital emergency roomservices, shifting much of the cost burden to hospitalsand state, county, and city agencies.8

This failure to link individuals involved with thecriminal justice system to health coverage and

services upon release from incarceration is especiallycostly to state and local governments. Total state andlocal spending on uncompensated health care for theuninsured reached $17.2 billion in 2008.9 Individuals

involved with the criminal justice system, who makeup as much as one-third of the uninsured populationin the United States, can be expected to account fora significant portion of this spending.10Furthermore,elevated recidivism rates, which are associated with alack of access to health care for individuals with mentalillnesses or substance use disorders, contribute to theburden of state and local corrections spending.11

The appropriate use of federal Medicaid dollars to helppay for health care provided to this population can save

states and localities money, in addition to minimizinghealth and public safety concerns associated withreentry following incarceration. However, opportunitiesto maximize and maintain Medicaid enrollment foreligible individuals in this population, and especially tomake use of Medicaid to finance certain types of careprovided to those who are incarcerated, have beenlargely underutilized by states.

Historically, adults who do not have dependentchildren or do not meet disability criteria have not

been eligible for Medicaid, which has limited theextent to which the program has funded servicesfor people involved with the criminal justice system.Under the Affordable Care Act (ACA), a significantportion of the justice-involved population will gaineligibility for Medicaid coverage for the first time.Some will qualify for federally subsidized healthinsurance plans offered through the state health

Medicaid and Financing Health Carefor IndividualsInvolved with the Criminal Justice System

December 2013

POLICY BRIEF:OPPORTUNITIES FOR CRIMINAL JUSTICE SYSTEMS TO INCREASE MEDICA ID ENROLLMENT |1


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insurance marketplaces, but the majority will benewly eligible for Medicaid under the laws expansionof the Medicaid program. States that make full useof opportunities to enroll eligible individuals in theircriminal justice systems in Medicaid and appropriatelyleverage the program to finance eligible care canrealize considerable cost savings by diverting more

individuals to treatmentwhich is significantly lesscostly than incarcerationand by reducing reliance onstate-funded health care services for the uninsured.

There are also opportunities to achieve budget savingsfor certain health care services provided to thosewho are incarcerated. Although the Medicaid inmateexclusionwhich refers to language in the SocialSecurity Act barring the use of federal Medicaidfunding to pay for health care services for inmates ofa public institution12limits the ability of states andlocalities to draw on Medicaid funding for inmate healthcare, certain exceptions to this provision can generateimportant cost savings. Medicaid payment for servicesprovided in correctional settings is restricted by theinmate exclusion, but federal law does grant states theauthority to use Medicaid to finance inpatient healthcare services for incarcerated individuals when providedby a licensed medical facility in the community, i.e., onethat is not under the authority of the corrections agency.Only a few states have yet opted to take advantageof this opportunity. However, with the expansion ofMedicaid under the ACA, an opportunity exists forstates to better leverage Medicaid to help financeinmates inpatient medical care.

This paper will provide an overview of federalMedicaid law related to people involved with thecriminal justice system; discuss policy optionsavailable to improve continuity of coverage whileensuring federal funds are spent appropriately;provide state examples of best practices; and giverecommendations for state and local governments.

Federal Medicaid Rules on Coverage

of Criminal Justice Populations

A significant portion of states criminal justice populations,including prison and jail populations, are eligible for

Medicaid, and the numbers will increase significantlyin 2014 in those states participating in the Medicaidexpansion authorized by the ACA. Although federallaw restricts the use of Medicaid to finance health careprovided to beneficiaries while they are incarcerated, theability to finance qualifying inpatient medical care is animportant exception. In addition, Medicaid can serve as a

valuable source of coverage for health care services forindividuals who are mandated to treatment, on probationor parole, or who are returning to the community followingincarceration. States that effectively utilize Medicaid tofinance care provided to eligible justice-involved individualscan realize significant cost savings. Furthermore, criminal

justice systems that identify and enroll eligible individualsin Medicaid at all points of justice system involvement,including in jails and prisons, can greatly improve access toneeded health services for this population.

While there is a Constitutional requirement under theEighth Amendment to provide health care services toindividuals who are incarcerated, federal law prohibitsstates from using federal Medicaid funds to pay for careprovided to incarcerated individuals in most circumstances,even if they are eligible and enrolled in the program.17Specifically, section 1905 of the Social Security Actprohibits payments with respect to care or services forany individual who is an inmate of a public institution(except as a patient in a medical institution).18This provision,known as the inmate exclusion provision, pertains toall individuals involuntarily confined in state or federalprisons, jails, detention facilities, or other penal facilities.

The inmate exclusion provision applies only to the availabilityof federal financial participation, i.e. it does not restrict theability of states to utilize state dollars to pay for inmatehealth care services. In practice, the exclusion resultsin most health care provided in jails and prisons beingfinanced by the state or local corrections agency, ratherthan by the state Medicaid program. However, the inmateexclusion provision does not change whether an individualis eligiblefor Medicaid and does not require termination ofMedicaid enrollment during incarceration.19In fact, underfederal Medicaid law, an individual incarcerated in a publicinstitution may remain enrolled in Medicaid if the appropriateeligibility criteria are met. States have been encouragedby CMS to suspend rather than terminate an individualsMedicaid enrollment during incarceration, allowing



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Medicaid

Jointly financed and administered by states and thefederal government, Medicaid is the primary sourceof health care coverage for more than 50 millionlow-income parents, children, and pregnant women.Beginning in 2014, millions of additional individuals,

including many low-income, childless adults will gaineligibility for coverage for the first time as a resultof the passage of the ACA. State participation inthe expansion of Medicaid eligibility is optional, andeligibility criteria will continue to vary by state.

Each state has a distinct Medicaid program that operateswithin broad guidelines defined by federal law.13Statesdocument the design of their Medicaid programs andoutline the benefits that are available to Medicaidbeneficiaries and the amount, duration, and scope of

those benefits in their State Plans, which are submittedto and reviewed by the federal Centers for Medicare andMedicaid Services (CMS).14While there is considerablevariation in Medicaid programs and benefits amongstates, and sometimes even among various categoriesof enrollees within a state, the comprehensiveness ofMedicaid coverage generally compares favorably withcommercial health insurance. Through a combinationof low overhead costs and below average providerreimbursement rates, Medicaid is also typically more cost-effective than other sources of health care coverage.15This is particularly true in comparison with health carespending by corrections systems, which typically do nothave the same negotiating power and cannot obtainsimilarly favorable rates for health care services.

The costs of the Medicaid program are shared bystates and the federal government. The federalshare varies by state based on the states averagepersonal income compared to the national average.For most services, the federal government pays a statebetween a floor of 50 percent and about 74 percentof service costs, leaving the state responsible for theremainder. For newly eligible enrollees under the ACA,the federal share will be at least 90 percent from2014 forward. This federal share of Medicaid costs iscalled the Federal Medical Assistance Percentage, orFMAP. In addition, the states costs for administeringthe Medicaid program are generally matched dollarfor dollar by the federal government, with someadministrative activities matched at a higher rate.16

Medicaid to be billed for certain, limited types of healthcare services that are permitted to be reimbursed duringincarceration. An additional benefit of suspensionis that individuals can more easily access Medicaidservices following release, which can be critical to asuccessful transition during the reentry process.

However, states and localities often misinterpretthe exclusion to require the termination of Medicaidenrollment, and some states information technologysystems are simply unable to accommodate asuspension of Medicaid enrollment. As a result, thevast majority of states currently forgo the opportunityto utilize Medicaid as a funding source for inpatienthealthcare services. By enabling the suspension ofenrollment in Medicaid, states can make more effectiveuse of Medicaid and ensure that it is leveragedappropriately both during incarceration and upon

release to link people to appropriate services.

Allowable Uses of Medicaid for

Incarcerated Persons

The inmate exclusion provision expressly allowsthe use of federal Medicaid funding to finance care

provided to an eligible incarcerated individual whenthat individual is a patient in a medical institution.20The Department of Health and Human Serviceshas clarified that this allows federal funds to beused when the incarcerated individual is admittedas an inpatient in a hospital, nursing facility, juvenilepsychiatric facility, or intermediate care facility forat least 24 hours.21Because community-basedinpatient care can represent a sizeable portion of the


States Suspending MedicaidSuspension of Medicaid Benets upon Incarceration: At least 12

states have laws or administrative policies to suspend Medicaid

enrollment of inmates.

California Colorado Florida Iowa Maryland Minnesota New York North Carolina

Ohio Oregon Texas

Washington


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cost of care provided to individuals in prisons and jails,there is the potential for considerable cost savings toa state that is able to effectively use Medicaid fundingto finance some of these services. For example, NorthCarolina has reported that it saved $10 million in thefirst year of billing Medicaid for eligible inpatientservices, while California saved about $31 million by

doing so in FY 2013.22

To qualify for federal financial participation, the individualmust be admitted for at least 24 hours and the facilitymust be community-based and separate from thecorrections system.24Once the individual has beenadmitted in the appropriate inpatient setting for at least 24hours, all medically necessary Medicaid covered servicesprovided to that individual while admitted can be billed bythe provider to Medicaid. At least 14 statesArkansas,California, Colorado, Delaware, Louisiana, Michigan,Mississippi, Nebraska, New York,25North Carolina,26Oklahoma, Pennsylvania, Vermont,27and Washingtoncurrently bill Medicaid for at least some eligible inpatienthealth services provided to incarcerated individuals, andadditional states are exploring this option.28

The potential savings available to state budgets arespurring efforts by additional states to bill Medicaidfor allowable inpatient medical services, as well as toexpand the scope of this practice in states alreadydoing so in a limited fashion. For example, in a studyof prison expenditures on health care services in NewYork between April 2008 and March 2010, it was found

that the New York Department of Corrections andCommunity Supervision contracted with community-based healthcare providers for certain emergency,inpatient, and outpatient services for its incarceratedpopulation, at a cost of approximately $230 million.Approximately $89 million of this money, or 38 percentof the costs for community-based care over the two-

year period, was for inpatient services that werepotentially reimbursable by Medicaid. To date, New Yorkhas implemented policies to seek federal Medicaidreimbursement retroactively for its jail population inlimited instances, and it is currently making policychanges to allow the state to draw on federal funds in allallowable circumstances.29New Yorks efforts, as well asrecent efforts to bill Medicaid for inmate inpatient carein North Carolina and Colorado, are discussed in moredetail later in this report.

While underutilized, this opportunity to use Medicaidto finance inpatient care for individuals in prisons and

jails has long existed. However, the ACAs Medicaidexpansion and enhanced federal funding will likelymake this practice much more attractive to statesthat choose to expand their Medicaid programbeginning in 2014. The resulting increase in thenumber of eligible inmates and the higher federalmatching rate in those states will likely incentivizethe implementation of policy changes to make useof federal Medicaid funding for their incarceratedpopulations inpatient medical care.


Understanding Medicaid Enrollment, Suspension, and Termination

Medicaid terminationThis term refers to the removal of an individual from the Medicaid rolls as a result ofincarceration, without regard to whether or not an individual remains eligible for the program. If terminated,an individual would need to submit a new application for the Medicaid program. Depending upon the type ofapplication, a new eligibility determination may take as long as 45 to 90 days under federal guidelines.23

Medicaid suspensionThis option allows an incarcerated individual to remain on the Medicaid rolls in asuspended status, which reflects that the individual continues to meet eligibility criteria but that health careservices (apart from qualifying inpatient medical care) cannot be financed using federal Medicaid dollars.

Medicaid redeterminationFederal policy requires that an individuals eligibility for Medicaid beredetermined at least every 12 months. Federal rules also state that for those who are eligible based onModified Adjusted Gross Income (MAGI) criteria, eligibility may not be redetermined more frequently thanevery 12 months.


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million savings could be realized for the state in FY2013-2014 as a result of the ACAs expansion ofMedicaid eligibility to state inmates with income levelsup to 133 percent FPL.37

Opportunities to Maximize Medicaid

Enrollment

The major provisions of the ACA, including the majorcoverage expansion provisions and the enhanced FMAPfor newly-Medicaid eligible adults, take effect in January2014. In preparation for the enormous changes comingto the health care system, federal, state, and localgovernments have been redesigning eligibility systems,defining Medicaid benefits packages for the expansionpopulation, developing enrollment strategies, andimplementing countless other policy and practice reforms.As states consider how they can maximize the Medicaidprogram to enhance access to health care services forindividuals while reducing state and local spending, it maybe helpful to review states existing efforts to leverage theMedicaid program to provide health care to individualsinvolved with the criminal justice system.

State Approaches to Utilizing Medicaid for

Healthcare Services for People Involved with the

Criminal Justice SystemThis section details examples of best practicesand ongoing systems changes to bill Medicaidfor allowable services provided to incarceratedpopulations in three states: North Carolina, New York,and Colorado. These states were chosen for more in-depth analysis of their Medicaid policies due to theirrecent and ongoing efforts to implement effectivepractices related to Medicaid eligibility and enrollmentfor their incarcerated populations. Each of the states

profiled has chosen to implement a different set ofpolicy options to maximize Medicaid coverage forthis population, and they are at varying stages ofimplementation. Policy and programmatic issuesexplored include the use of Medicaid funds to bill forinpatient medical care for jail and prison inmates andsuspension versus termination of Medicaid statusupon incarceration.

Of the three states, only North Carolina has adoptedand widely implemented policies to bill Medicaid forcommunity-based, inpatient medical care provided tothose who are incarcerated. It also requires suspensionof enrollment under an August 2008 directive to countydirectors of social services,44however, it appears thatin practice, many counties may not be following this

directive,45potentially limiting the impact of recentpolicy changes by the state to bill Medicaid for eligibleservices provided to its incarcerated population. NewYork suspends Medicaid enrollment when an eligibleindividual is incarcerated, bills Medicaid retroactively forinpatient care in some circumstances, and is currentlyundertaking policy and practice changes to make fulluse of Medicaid for both its prison and jail populations.Finally, Colorado passed legislation to suspend, ratherthan terminate Medicaid enrollment for its incarceratedpopulation in 2008, and this legislation is still in theprocess of being implemented.

North Carolina

North Carolina has recently implemented policies tomake use of Medicaid for eligible services providedto Medicaid-enrolled individuals incarcerated in thestates jails and prisons. A state law was passed in2010 requiring the Departments of Corrections andHealth and Human Services to develop protocols for

utilizing Medicaid to pay for care provided to those in thestate that would be receiving Medicaid if not for theirincarceration.46Since February 2011, under the StatePlan, North Carolina has been requiring hospitals andother inpatient providers to bill Medicaid for servicesprovided to Medicaid-enrolled incarcerated individuals.By requiring these community-based health careproviders to bill Medicaid directly for services providedto incarcerated individualsas these providers do forall Medicaid beneficiaries they servethe correctionssystem can avoid certain administrative burdens and can

generate greater efficiencies and reduced costs.

A report in 2010 by North Carolinas State Auditor foundthat during the two-year period from 2008 to 2009,the state Department of Corrections paid about $159.8million for health care, about $26.5 million of which wasfor inpatient medical care that was provided to likelyMedicaid-eligible incarcerated individuals. The report



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Special benefits considerations for the Medicaid expansion population

All newly-eligible Medicaid beneficiaries will be enrolled in an alternative benefits plan (also known asa benchmark plan), which may be based on certain private health insurance plans or be any coverageapproved by the Secretary of HHS, including a states traditional coverage under the State Plan. 38Inaddition, coverage must include the ACAs ten categories of Essential Health Benefits (EHBs).39Amongthe mandatory EHB coverage categories for Medicaid alternative benefit plans is coverage of servicesfor mental health and substance use disorders, which must be covered at parity with medical/surgicalbenefits.40The inclusion of substance use disorder treatment services as an EHB to be provided at parityis especially significant, as there has been wide variation in coverage of substance use disorder servicesacross state Medicaid programs, if these services have been covered at all.41Given that the justice-involvedpopulation is estimated to make up a significant proportion of the newly eligible and taking into accountthe higher than average prevalence of substance use and mental health disorders in this population, therequirement that plans covering the expansion population include these benefits represents a significantopportunity to improve access to mental health and substance use disorder services.

These protections are important to ensure that newly eligible adults, including those with involvement inthe criminal justice system, receive adequate coverage. However, states will continue to have significantdiscretion in outlining the services covered within these mandatory benefit categories, and some statesmay use the flexibility available to them to offer the expansion population a package of benefits thatis potentially less robust that what Medicaid traditionally covers. To protect the coverage of vulnerablepopulations, the ACA specifies that certain categories of individuals, including the medically frail, areexempt from mandatory enrollment in the alternative benefit plan.42Those who qualify as medically frailinclude individuals with a wide range of disabilities and limitations, including individuals with chronicsubstance use disorders and adults with serious mental illness.43These individuals will want to evaluateboth the alternative benefit plan and traditional Medicaid to determine which set of benefits best meetstheir needs.

estimated that by using Medicaid to pay for hospitaland other inpatient care for its eligible prison and jailpopulation, North Carolina could have realized a two-year savings of $23 million. According to the auditor,this approximately 87-percent savings on inpatient carefor Medicaid-eligible individuals would have resultedboth from the ability to bill Medicaid for eligible servicesthereby drawing down federal funding, as well as from thelower provider rates negotiated by Medicaid as compared

to the prices paid by the Department of Corrections.47

The State Auditors report also noted that the Medicaidexpansion under the ACA would result in considerableadditional savings for the state, should it choose toparticipate in the Medicaid expansion. While the reportdid not attempt to quantify the potential savings to thestate under the ACA, if North Carolina expands Medicaideligibility to nearly everyone in the state at or below 133

percent FPL, state spending on health care services forjustice-involved individuals would fall significantly.48

New York

New York is one of the few states that suspendsMedicaid enrollment when someone is incarcerated, andit is the only state to suspend Medicaid indefinitely, ratherthan only until a new eligibility determination is required.49

It is also one of only a handful of states to have providedMedicaid coverage to childless adults up to 100 percentFPL prior to the passage of the ACA in 2010. Thesepolicies put New York in a unique position to utilizeMedicaid to pay for care provided to its incarceratedpopulation; however the state is just recently beginningto undertake an effort to maximize Medicaid enrollmentand reimbursement policies for care provided to peopleinvolved with the criminal justice system.


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New York removed restrictions in state law thatprohibited claiming federal Medicaid funds for careprovided to incarcerated individuals beginning in 2001,and it started suspending rather than terminatingMedicaid enrollment for incarcerated individuals in2008.50However, state practices have resulted in thereceipt of just a portion of potentially available federal

Medicaid funds for qualifying services provided toincarcerated individuals. Under current New York policy,reimbursement from the federal government is onlysought for services provided to individuals incarceratedin local jails. Moreover, reimbursement for care providedto individuals in local jails is only sought in limitedsituations compared to the broader range of eligiblesituations that federal law permits.51As a result, thestate is only receiving a small portion of the federalreimbursement that might be available.

Still, to date, local governments in New York havereceived more than $4.5 million in reimbursement fromthe federal government for inpatient medical servicesprovided to Medicaid eligible inmates.52To claim thisreimbursement, the state submits claims to the federalgovernment on behalf of the local jurisdiction for theamount that would have been billed by the inpatienttreatment facility. The local jurisdiction then receivesreimbursement for the federal share of the Medicaidcosts. The local jurisdiction remains responsible forwhat the states share of costs would have been, aswell as any difference between Medicaid rates and therate paid by the jail for those inpatient services.53

New Yorks approach is more administrativelycomplicated than approaches in which statesrequire the treating medical facility to bill Medicaiddirectly, and it fails to capture available federalfunds that could be used to reimburse providersfor allowable inpatient medical services provided tostate prisoners. New York is working to change itspolicy to allow the state to access federal Medicaidfunds for care provided to its incarcerated populationin all allowable circumstances, i.e., for inmates ofboth jails and prisons, as well as to require healthcare providers to bill Medicaid directly rather thansubmitting for retroactive reimbursement.54Accordingto a December 2012 report by the Office of theState Comptroller, New York could save $20 millionannually if it used Medicaid to finance allowable

inpatient services provided to all eligible incarceratedindividuals. 55

New Yorks practice of suspending Medicaid enrollmentindefinitely when an individual is incarcerated, whichrelies on a state law providing that time incarceratedshall not count toward the required redetermination

period,56as well as its status as a Medicaid expansionstate, makes it strongly positioned to access federalMedicaid funding for its incarcerated population and maypotentially make it a model for other states to follow.

Colorado

In 2008, the Colorado state legislature passed a law torequire that persons who are eligible for Medicaid justprior to their confinement in a jail, juvenile commitmentfacility, Department of Corrections facility, or Department ofHuman Services facility shall have their Medicaid benefitssuspended, rather than terminated, during the period oftheir confinement.57This legislation is in the process ofbeing implemented, and in the years since the passageof the state law a detailed correspondence between thestate and the federal Department of Health and HumanServices has developed that may be useful for other statesconsidering similar policy changes (see appendix).58Forexample, the correspondence clarifies that:

As long as the individual continues to be eligiblefor Medicaid and is residing as an inpatient in amedical facility, federal policy and regulations donot place a time limit on federal Medicaid fundingavailability for those individuals under the exceptionto the inmate exclusion provision;59

If the correctional authority limits an individualsability to leave a correctional facility on a permanentbasis, such as a requirement that the individualreturn to the facility at night, that would be consideredincarceration under the federal standard;60

The state would not have to amend its Medicaid StatePlan in order to establish suspension of Medicaidfor incarcerated individuals, and would therefore notneed approval from the federal Centers for Medicare& Medicaid Services (CMS) to institute the change.61

The Colorado Department of Health Care Policyand Financing continues to communicate with CMS



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and other states as it moves forward to implementMedicaid suspension policies for those in its pr isonand jail system. Colorados ongoing clarificationson the appropriate use of federal Medicaid funds tofinance inpatient medical care for eligible, incarceratedindividuals have been critical to the states efforts toutilize Medicaid funding and can serve as a valuable

source of information for other states.

Opportunities and Recommendations

for State Policymakers

While opportunities to make more effective use ofMedicaid have always been available, with the passage ofthe Affordable Care Act and the expansion of Medicaid,states have an important opportunity to reevaluate whethertheir use of Medicaid to finance care for eligible, justice-involved populations is making efficient use of state andfederal resources. Below are recommendations for statesto consider implementing in order to better meet the healthneeds of incarcerated and reentering individuals.

1. Discontinue automatic Medicaid terminations

The federal government has repeatedly encouragedstates to ensure that incarcerated individuals eligible forMedicaid are returned to the Medicaid rolls upon release,so that coverage is immediately available.62However, justa few states have implemented this recommendation. Itappears that only New York suspends Medicaid enrollmentindefinitely, allowing individuals who are incarcerated forlonger periods or those who are incarcerated during theirannual redetermination date to remain enrolled. Otherstates, including California,63Florida,64Iowa,65Maryland,Minnesota, North Carolina,66Ohio,67Oregon,68Texas, andWashington, do not automatically terminate Medicaid butsuspend it for a certain period of time, typically until theenrollees scheduled eligibility redetermination period.69Additional states have policies in place to enroll eligibleindividuals in Medicaid as part of discharge planning.70States that suspend Medicaid can more easily ensure thatenrollment is reinstated when incarcerated individuals arereleased and that formerly incarcerated individuals canimmediately access health care without gaps in coverage.An indefinite suspension approach as exemplified by NewYork would likely enable states to make the most effective

use of federal funding, as there would be no lapses inMedicaid enrollment for incarcerated individuals thatcontinue to meet eligibility criteria. Policy options include:

End the automatic termination of Medicaid forindividuals when they are incarcerated byindefinitely suspending Medicaid enrollment and

facilitating reactivation when needed.

or

Suspend Medicaid up to the enrollees annualeligibility redetermination date, minimizingdisruptions in Medicaid enrollment for thoseincarcerated for short periods of time. Combinedwith discharge planning that includes Medicaideligibility screenings, states could use this morelimited approach to reenroll eligible individualswhen they are released. However, this limitedapproach may continue to result in disruptions inenrollment that would likely make it more difficultfor states to draw down available federal fundingfor care provided to incarcerated individuals.

Upgrade claims systems and other computersystems to track suspended enrollment. States arecurrently upgrading their Medicaid systems toprepare for the implementation of the ACA, withenhanced federal funding for certain administrativeactivities.71This may provide states that havepreviously chosen not to implement Medicaidsuspension policies due to difficulties upgradingeligibility and claims systems with an opportunity torevisit their disenrollment policies.

Regardless of Medicaid suspension or terminationpolicies, ensure that all individuals released fromincarceration who are eligible for Medicaid areenrolled and eligible to receive health care servicesupon release.

2. Make effective use of federal Medicaid funding forinpatient services

Federal officials have repeatedly informed states thatthe Medicaid inmate exclusion provision does notapply to inpatient medical services provided in certainfacilities under federal law. States that have designedtheir Medicaid eligibility and enrollment systems in a way



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that makes use of federal funding for these services, orstudied potential savings associated with doing so, haveshown that considerable reductions in state and localspending can be achieved by using federal funding tohelp finance these services. In addition, these analyseshave also frequently demonstrated that additional savingscan be captured as a result of the more favorable provider

rates negotiated by Medicaid, as compared with the ratespaid by the local or state corrections agency. As manymore incarcerated individuals become Medicaid eligiblein 2014 at the enhanced federal matching rate, statesprepared to use Medicaid to finance inpatient care willsee substantial savings.

States should ensure that processes are in placeto determine an inmates Medicaid eligibility andenrollment status at entry into the criminal justicesystem.

States should implement policies to requirecommunity-based hospitals, nursing homes,

juvenile psychiatric facilities, and intermediate carefacilities to bill Medicaid for eligible inpatientservices provided to incarcerated individuals.

3. Screen individuals involved with the criminal justice

system for Medicaid eligibility at every opportunity

While much of the discussion in this report focuseson untapped opportunities to leverage Medicaid forincarcerated populations, states can ensure greateraccess to health coverage and services and achieveefficiencies in state and local spending by ensuring thatall individuals involved in the criminal justice systemare screened for Medicaid eligibility. The ACA requiresthe use of a single, streamlined application to evaluateeligibility for both Medicaid and federally subsidizedhealth coverage offered by the health insuranceMarketplace, meaning that the submission of a singleapplication will be sufficient to ensure that an individualseligibility for enrollment in either type of health carecoverage is considered. In addition, the Medicaidalternative benefits package required by the ACA,including coverage of mental health and substance usedisorder services, provides new opportunities to expandappropriate diversion to treatment and to ensure accessto necessary health care services upon release for

people involved with the criminal justice system.As discussed earlier, opportunities to utilize Medicaidto fund health care services for incarcerated individualsare limited by the inmate exclusion, but are still quitefinancially significant. To ensure that these opportunitiesare fully captured, states should screen individualsinvolved with the criminal justice system for Medicaid

eligibility at every opportunity, including duringincarceration. Contrary to common perceptions amongindividuals charged with reentry planning, there is nofederal prohibition against screening individuals forMedicaid eligibility during incarceration. In fact, federallaw requires that Medicaid applicants be allowed to haveindividuals accompany, assist, and represent them in theapplication or eligibility redetermination processes if theychoose.72HHS has clarified that corrections departmentemployees and others working on behalf of incarceratedindividuals are not precluded from serving as anauthorized representative of incarcerated individuals forpurposes of submitting an application on such individualsbehalf.73States could implement policies to screeneveryone for Medicaid eligibility in all of their prisonsand jails, and immediately suspend coverage when anincarcerated individual is found eligible.

Administrative costs incurred by states for staffing,training, and performing Medicaid eligibility determinationsare split evenly by the states and the federal government,and a federal administrative matching rate of 90percent is temporarily available to states for the costs ofupgrading eligibility and enrollment systems to preparefor the coverage expansions under the ACA.74Bymaximizing enrollment of its incarcerated population, astate could also maximize the use of available federalMedicaid funds and ensure that all eligible individualsleaving prisons and jails are enrolled in Medicaid andable to access services. HHS has made clear thatcorrections department employees and others workingon behalf of individuals incarcerated in prisons and

jails may serve as authorized representatives for thepurposes of submitting an application for Medicaidcoverage, and that these administrative activities arelikely eligible for federal matching funds.

To ensure that the state budget efficiencies andexpanded Medicaid coverage are achieved:



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States should implement policies to screen allindividuals in their prisons and jails for Medicaideligibility, and suspend enrollment for those foundeligible. By maximizing their incarcerated populationsMedicaid coverage, states can make full use ofMedicaid to finance inpatient health care for thispopulation and ensure that all eligible individuals beingreleased from prison or jail have Medicaid coverage.

States should develop strategies to screen and enrollMedicaid-eligible individuals at all points of justice-system involvement and maximize the use of federaladministrative matching funds to support enrollmentstaff and processes. A large percentage of those whoare on probation, parole, or at other points in the criminal

justice system may be eligible for Medicaid, and statesshould work to ensure that those who are eligible areenrolled and able to access needed health services.

Given the significant overlap in justice-involved andMedicaid-eligible populations, criminal justice andMedicaid agencies should work closely to identify andaddress enrollment challenges and coverage issuesunique to the criminal justice population.

4. Ensure that Medicaid coverage for the newly eligibleoffers an adequate scope of services

Finally, increased enrollment in Medicaid will be of limitedvalue in enhancing coverage and access to health care

services for people involved with the criminal justicesystem who are living in the community, if the Medicaidalternative benefit plans covering the newly eligiblepopulation do not include an adequate scope of services.The high rates of chronic and communicable diseasein the justice-involved population point to a compellingneed for access to comprehensive coverage, especiallywith regard to mental health and substance use disorderservices. While the ACA requires that coverage for allten categories of essential health benefits be included inthese plans, including the provision of mental health and

substance use disorder coverage at parity, it does notaddress scope of services. To ensure that individuals canaccess necessary health care services:

Criminal justice and Medicaid agencies shouldwork as a team to ensure that the scope of servicesincluded in the states Medicaid alternative benefitplan are adequate to meet the needs of the justice-involved population. Essential services include, but

are not necessarily limited to: integrated treatmentfor co-occurring mental and addictive disorders,cognitive behavioral interventions to addressfactors associated with illegal activity, and intensivecase management.

ConclusionThe Affordable Care Act has provided a new focuson enrolling those who are eligible for health carecoverage but who remain uninsured, as well as thosewho will gain coverage for the first time under the law.These system changes are ongoing and will take yearsto fully implement, however criminal justice systems,health departments, and state and local officials cannow identify and review existing and new opportunitiesto utilize Medicaid to meet the health needs of people

involved with the criminal justice system.

The expansion of Medicaid under the ACA provides anopportunity for states to review their health coveragepolicies for their criminal justice populations. HHS hasmade clear that states can and should ensure thatMedicaid enrollment is suspended while an eligibleindividual is incarcerated and that they should implementpolicies to immediately return an eligible individual to theMedicaid rolls at release. In addition, federal law givesstates flexibility to use Medicaid for certain inpatient

medical services provided to their Medicaid eligibleincarcerated populations. This flexibility is underutilizedand states that suspend, rather than terminate, andreinstate Medicaid eligibility when an incarceratedindividual receives community-based inpatient carecould see considerable cost-savings.

Many more people who are involved with the criminaljustice system will soon be eligible for Medicaid atan enhanced federal match, and states have anunprecedented opportunity to improve health outcomes,

maintain continuity of care, and reduce their healthcare costs for the criminal justice population byimplementing policies to maximize Medicaid coverage andreimbursements. To effectively meet these challenges,policymakers from criminal justice and Medicaid agenciesshould regularly communicate and partner to improverelevant systems, processes, and policies affecting theirMedicaid-eligible criminal justice population.



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Resources

The following resources may be helpful to state officialsworking to implement changes in Medicaid eligibility andenrollment policies for criminal justice populations.

Implications of The Affordable Care Act on PeopleInvolved with the Criminal Justice System(2013)A brief providing an overview of the implications of theACA for adults involved with the criminal justice system,as well as information about how professionals in thecriminal justice field can help this population access theservices now available to them.

County Jails and the Affordable Care Act: Enrolling

Eligible Individuals in Health Coverage(March 2012)A report by the National Association of Counties

detailing issues and challenges local jails and humanservices agencies may face determining eligibility andenrolling those in county jails into health coveragegained under the Affordable Care Act.

How Will the Medicaid Expansion for Adults Impact

Eligibility and Coverage?(July 2012)An issue brief prepared by the Kaiser Family Foundationthat provides an overview of Medicaid eligibility for adultsand implications of the ACA for adult Medicaid coverage.

Frequently Asked Questions: Implications of theFederal Health Legislation on Justice-Involved

Populations(2011)A set of FAQs from the Council of State GovernmentsJustice Center detailing the impact of health coverageand other provisions in the ACA for those in criminal

justice system.

Medicaid Expansion and the Local Criminal

Justice System(2011)An article published in American Jails describing

the implications of the Medicaid expansion for localcorrectional systems.

Facilitating Medicaid Enrollment for People with

Serious Mental Illnesses Leaving Jail or Prison:

Key Questions for Policymakers Committed to

Improving Health and Safety(2011)A brief providing elected officials and correctionsand mental health directors with guidance related to

enrolling eligible individuals with serious mental illness inMedicaid and other programs.

Establishing and Maintaining Medicaid Eligibility

upon Release from Public Institutions(2010)A report by the Substance Abuse and Mental HealthServices Administration discussing opportunities and

challenges for increasing Medicaid coverage amongthose being released from correctional institutions andother public institutions.

Policy Basics: Introduction to Medicaid(2008)A short report by the Center on Budget and PolicyPriorities providing an overview of Medicaid eligibility,benefits, and financing.

Endnotes1Kamala Mallik-Kane and Christy A. Visher, Health and Prisoner Reentry:How Physical, Mental, and Substance Abuse Conditions Shape the Processof Reintegration(Washington: Urban Institute, 2008).2 Emily Wang, et al., Discharge Planning and Continuity of Health Care:Findings from the San Francisco County Jail, American Journal of PublicHealth98, no. 12 (2008): 2182-2184.3E. Ann Carson and William J. Sabol, Prisoners in 2011(Washington:Bureau of Justice Statistics, U.S. Department of Justice, 2012); Todd D.Minton, Jail Inmates at Midyear 2011Statistical Tables(Washington: Bureauof Justice Statistics, U.S. Department of Justice, 2012).4Min Rex Cheung, Lack of Health Insurance Increases All Cause and AllCancer Mortality in Adults: An Analysis of National Health and NutritionExamination Survey (NHANES III) Data, Asian Pacific Journal of CancerPrevention14, no. 4 (2013): 2259-2263.5National Institute of Corrections, Solicitation for a Cooperative

AgreementEvaluating Early Access to Medicaid as a Reentry Strategy,Federal Register76, no . 129 (2011): 39438-39443.6Mary Sheu, et al. , Continuity of Medical Care and Risk of Incarcerationin HIV-Positive and High-Risk HIV-Negative Women, Journal of WomensHealth 11 no. 8 (2002): 743-750; Carol E. Adair, et al, Continuity ofCare and Health Outcomes Among Persons with Severe Mental Illness,Psychiatric Services56, no. 9 (2005): 1061-1069; Richard R. Van Dorn, etal., Effects of Outpatient Treatment on Risk of Arrest of Adults with SeriousMental Illness and Associated Costs, Psychiatric Services64, no. 9 (2013):856-862; Faye S. Taxman, Reducing Recidivism through a SeamlessSystem of Care, (paper presented at Office of National Drug Control PolicyTreatment and Criminal Justice System Conference, February 20, 1998),available at ncjrs.gov/ondcppubs/treat/consensus/taxman.pdf.7Ingrid A. Binswanger, et al., Release from PrisonA High Risk of Death forFormer Inmates, New England Journal of Medicine356, no. 2 (2007): 157165.

8Nicholas Freudenberg, et al., Comparison of Health and SocialCharacteristics of People Leaving New York City Jails by Age, Gender, andRace/Ethnicity: Implications for Public Health Interventions, Public HealthReports 122, no. 6 (2007):733-743; Emily Wang, Yongfei Wang, and HarlanKrumholz,A High Risk of Hospitalization Following Release from CorrectionalFacilities in Medicare Beneficiaries: A Retrospective Matched Cohort Study,2002 to 2010, JAMA Internal Medicine173, no. 17 (2013): 1621-1628.9Allison Hamblin, et al., Medicaid and Criminal Justice: The Need for Cross-System Collaboration Post Health Care Reform (Oakland: CommunityOriented Correctional Health Services, January 2011).10Jack Hadley, et al., Covering the Uninsured in 2008: Current Costs, Sourcesof Payment, and Incremental Costs, Health Affairs27, no 5 (2008): 399-415.

http://csgjusticecenter.org/mental-health/publications/implications-of-the-affordable-care-act-on-people-involved-with-the-criminal-justice-system/http://csgjusticecenter.org/mental-health/publications/implications-of-the-affordable-care-act-on-people-involved-with-the-criminal-justice-system/http://www.naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://www.naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8338.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8338.pdfhttp://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://www.cochs.org/files/medicaid_expansion/2011_ND_Medicaid%20Expansion_DuBose.pdfhttp://www.cochs.org/files/medicaid_expansion/2011_ND_Medicaid%20Expansion_DuBose.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://store.samhsa.gov/shin/content/SMA10-4545/SMA10-4545.pdfhttp://store.samhsa.gov/shin/content/SMA10-4545/SMA10-4545.pdfhttp://www.cbpp.org/files/policybasics-medicaid.pdfhttps://www.ncjrs.gov/ondcppubs/treat/consensus/taxman.pdfhttps://www.ncjrs.gov/ondcppubs/treat/consensus/taxman.pdfhttp://www.cbpp.org/files/policybasics-medicaid.pdfhttp://store.samhsa.gov/shin/content/SMA10-4545/SMA10-4545.pdfhttp://store.samhsa.gov/shin/content/SMA10-4545/SMA10-4545.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://csgjusticecenter.org/documents/0000/1141/Key_Questions_final.pdfhttp://www.cochs.org/files/medicaid_expansion/2011_ND_Medicaid%20Expansion_DuBose.pdfhttp://www.cochs.org/files/medicaid_expansion/2011_ND_Medicaid%20Expansion_DuBose.pdfhttp://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://csgjusticecenter.org/cp/publications/frequently-asked-questions-implications-of-health-reform-on-justice-involved-populations/http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8338.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8338.pdfhttp://www.naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://www.naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://csgjusticecenter.org/mental-health/publications/implications-of-the-affordable-care-act-on-people-involved-with-the-criminal-justice-system/http://csgjusticecenter.org/mental-health/publications/implications-of-the-affordable-care-act-on-people-involved-with-the-criminal-justice-system/


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11Pew Center on the States, State of Recidivism: The Revolving Door ofAmericas Prisons(Washington: Pew Center on the States, The CharitableTrusts, 2011).121905, Social Security Act.13The Supreme Court Decision on the constitutionality of the ACAeffectively rendered states participation in the laws Medicaid expansionoptional, rather than mandatory. As of July 2013, 28 states were reported tobe moving toward expansion. See Beyond the Pledges: Where the StatesStand on Medicaid, available at advisory.com/Daily-Briefing/Resources/

Primers/MedicaidMap.14For a general overview of the Medicaid program, see Kaiser FamilyFoundation,Medicaid Resource Book, 2003 , available at kff.org/medicaid/2236-index.cfm.15 Families USA, Cutting Medicaid Ineffective and Harmful, (Washington:Families USA, September 2012), available at familiesusa2.org/assets/pdfs/medicaid/Cutting-Medicaid-Ineffective-and-Harmful.pdf.16 For more information, see: Kaiser Family Foundation, Medicaid Financing:An Overview of the Federal Medicaid Matching Rate (FMAP) (Washington:Kaiser Family Foundation, September 2012), available at kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal.17 Estelle v. Gamble, 429 U.S. 97 (1976).18 1905(a)(A), Social Security Act.19Robert A . Streimer to All Associate Regional Administrators, Divisionfor Medicaid State Operations, Clarification of Medicaid coverage Policyfor Inmates of a Public Institution (Washington: Health Care Financing

Administration, U.S. Department of Health and Human Services, December12, 1997).201905(a)(A), Social Security Act.21Streimer, Clarification of Medicaid Coverage Policy for Inmates of aPublic Institution.22Christine Vestal, States Missing Out on Millions in Medicaid forPrisoners, Stateline: The Daily News Service of the Pew Charitable Trusts,June 25, 2013, available at pewstates.org/projects/stateline/headlines/states-missing-out-on-millions-in-medicaid-for-prisoners-85899485969.23U.S. Code of Federal Regulations, Title 42, Public Health, Section435.911 [42 CFR 435.911] states that Medicaid eligibility determinationsmay not exceed 90 days for Medicaid applications made on the basis ofdisability and 45 days for all other applications.24Richard C. Allen to Joan Henneberry (Washington: Centers forMedicare & Medicaid Services, U.S. Department of Health and Human

Services, August 16, 2010), available at colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485.25New York State Office of the State Comptroller, Payments for InmateHealth Care Services: Department of Corrections and CommunitySupervision(Albany: Division of State Government Accountability, December2012), available at osc.state.ny.us/audits/allaudits/093013/10s41.pdf .26Beth A. Wood, Performance Audit: Department of Correction InmateMedicaid Eligibility, August 2010(Raleigh: Office of the State Auditor, Stateof North Carolina, August 2010), available at ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdf .27Correction: Pew Report on Medicaid and Inmate Health Care WasInaccurate; Aug 16 Story Updated, Vermont Digger, August 29, 2013,available at vtdigger.org/2013/08/29/correction-pew-report-on-medicaid-and-inmate-health-care-was-inaccurate-aug-16-story-updated.28Vestal, States Missing Out on Millions in Medicaid for Prisoners.29

New York State Office of the State Comptroller, Payments for Inmate HealthCare Services: Department of Corrections and Community Supervision .30U.S. Congressional Budget Office, H.R. 4872, Reconciliation Act of 2010(Final Health Care Legislation)(Washington: U.S. Congressional BudgetOffice, March 20, 2010), available at cbo.gov/publication/21351.31Genevieve M. Kenney, et al., Opting in to the Medicaid Expansion underthe ACA: Who are the Uninsured Adults Who Could Gain Health InsuranceCoverage? (Washington: Urban Institute, 2012), available at urban.org/UploadedPDF/412630-opting-in-medicaid.pdf .32National Institute of Corrections, Solicitation for a CooperativeAgreement - Evaluating Early Access to Medicaid as a Reentry Strategy (76FR 39438), (Washington: Federal Register, July 6, 2011).

33Genevieve M. Kenney, et al., Variation in Medicaid Eligibility andParticipation among Adults: Implications for the Affordable Care Act , Inquiry49 (2012): 231-253.341905(y)(1) of the Social Security Act designates the FMAP rate for thenewly eligible adults at 100 percent for years 2014-2016, 95 percent in2017, 94 percent in 2018, 92 percent in 2019, and 90 percent in 2020 andthereafter.351905(z), Social Security Act .36CMS has not yet identified which states qualify as expansion states.

A recent report by the Congressional Research Service speculatedthat 11 states and D.C. would qualify as expansion states, includingArizona, Delaware, Hawaii, Maine, Massachusetts, Minnesota, NewYork, Pennsylvania, Vermont, Washington, Wisconsin, and the Districtof Columbia. Alison Mitchell and Evelyne P. Baumrucker, MedicaidsFederal Medical Assistance Percentage (FMAP), FY2014(Washington:Congressional Research Service, January 30, 2013), available at fas.org/sgp/crs/misc/R42941.pdf.37Kaiser Family Foundation, Medicaid and the Uninsured, GovernorsBudgets for FY 2013 - What is Proposed for Medicaid?(Washington: KaiserCommission on Medicaid and the Uninsured, Kaiser Family Foundation,March 2012), available atkaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdf.381937 of the Patient Protection and Affordable Care Act outlines fivealternative benefit or benchmark plan options, including: 1) the standardBlue Cross/Blue Shield Preferred Provider Option offered through the

Federal Employees Health Benefit program, 2) state employee coveragethat is offered and generally available to state employees, 3) the commercialHMO with the largest insured, commercial, non-Medicaid enrollment inthe state, 4) benchmark-equivalent coverage that is provided when theaggregate actuarial value of the benefit package is at least actuariallyequivalent to the coverage provided by one of the benefit packagesdescribed above, or 5) a coverage option approved by the Secretary ofHealth and Human Serv ices, known as Secretary-approved coverage.440.330, Public Heath, Title 42, Code of Federal Regulations (42 CFR440.330) gives states the flexibility to use the Secretary-approved option toextend comprehensive Medicaid coverage to the newly-eligible expansionpopulation.391302(b) of the Patient Protection and Affordable Care Act outlinesten categories of Essential Health Benefits, including: ambulatory patientservices; emergency services; hospitalization; maternity and newborn care;

mental health and substance use disorder services, including behavioralhealth treatment; prescription drugs; rehabilitative and habilitative servicesand devices; laboratory services; preventive and wellness services and chronicdisease management; and pediatric services, including oral and vision care.402001(c)(6) of the Patient Protection and Affordable Care Act requiresthat mental health and substance abuse benefits meet the requirements ofthe Mental Health Parity and Addiction Equity Act of 2008.41Allison C. Colker, Treatment of Alcohol and Other Substance UseDisorders: What Legislators Need to Know (paper presented at NationalConference of State Legislatures, Washington, January 2004).422001 of the Patient Protection and Affordable Care Act. As defined in1937(2)(A) of the Social Security Act, those exempt from enrollment ina Medicaid alternative plan include individuals in the following categories:those who are blind or disabled, terminally ill hospice patients, eligibility due toinstitutionalization, medically frail and special needs individuals, and children

in foster care receiving welfare services and children receiving foster care oradoption assistance.43440.315(f), Public Health, Title 42, Code of Federal Regulations [42CFR 440.315(f)] defines medically frail individuals as children with seriousemotional disturbances, individuals with disabling mental disorders,individuals with serious and complex medical conditions, individuals withphysical and/or mental disabilities that significantly prevent them fromperforming one or more activities of daily living, adults with serious mentalillness, individuals with a disability determination based on Social Securitycriteria, and individuals with a chronic substance use disorder.44William W. Lawrence, Jr., to County Directors of Social Serv ices, DMAAdministrative Letter No: 09-08, Medicaid Suspension (Raleigh: North Carolina

http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMaphttp://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMaphttp://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMaphttp://kff.org/medicaid/2236-index.cfm.http://kff.org/medicaid/2236-index.cfm.http://familiesusa2.org/assets/pdfs/medicaid/Cutting-Medicaid-Ineffective-and-Harmful.pdfhttp://familiesusa2.org/assets/pdfs/medicaid/Cutting-Medicaid-Ineffective-and-Harmful.pdfhttp://kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/http://kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/http://kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/http://www.pewstates.org/projects/stateline/headlines/states-missing-out-on-millions-in-medicaid-for-prisoners-85899485969http://www.pewstates.org/projects/stateline/headlines/states-missing-out-on-millions-in-medicaid-for-prisoners-85899485969http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://osc.state.ny.us/audits/allaudits/093013/10s41.pdfhttp://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdfhttp://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdfhttp://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdfhttp://vtdigger.org/2013/08/29/correction-pew-report-on-medicaid-and-inmate-health-care-was-inaccurate-aug-16-story-updated/http://vtdigger.org/2013/08/29/correction-pew-report-on-medicaid-and-inmate-health-care-was-inaccurate-aug-16-story-updated/http://cbo.gov/publication/21351http://cbo.gov/publication/21351http://urban.org/UploadedPDF/412630-opting-in-medicaid.pdfhttp://urban.org/UploadedPDF/412630-opting-in-medicaid.pdfhttp://www.fas.org/sgp/crs/misc/R42941.pdfhttp://www.fas.org/sgp/crs/misc/R42941.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://kaiserfamilyfoundation.files.wordpress.com/2013/01/8294.pdfhttp://www.fas.org/sgp/crs/misc/R42941.pdfhttp://www.fas.org/sgp/crs/misc/R42941.pdfhttp://urban.org/UploadedPDF/412630-opting-in-medicaid.pdfhttp://urban.org/UploadedPDF/412630-opting-in-medicaid.pdfhttp://cbo.gov/publication/21351http://vtdigger.org/2013/08/29/correction-pew-report-on-medicaid-and-inmate-health-care-was-inaccurate-aug-16-story-updated/http://vtdigger.org/2013/08/29/correction-pew-report-on-medicaid-and-inmate-health-care-was-inaccurate-aug-16-story-updated/http://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdfhttp://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdfhttp://osc.state.ny.us/audits/allaudits/093013/10s41.pdfhttp://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://www.pewstates.org/projects/stateline/headlines/states-missing-out-on-millions-in-medicaid-for-prisoners-85899485969http://www.pewstates.org/projects/stateline/headlines/states-missing-out-on-millions-in-medicaid-for-prisoners-85899485969http://kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/http://kff.org/health-reform/issue-brief/medicaid-financing-an-overview-of-the-federal/http://familiesusa2.org/assets/pdfs/medicaid/Cutting-Medicaid-Ineffective-and-Harmful.pdfhttp://familiesusa2.org/assets/pdfs/medicaid/Cutting-Medicaid-Ineffective-and-Harmful.pdfhttp://kff.org/medicaid/2236-index.cfm.http://kff.org/medicaid/2236-index.cfm.http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMaphttp://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMap


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Department of Health and Human Services, August 27, 2008) available at info.dhhs.state.nc.us/olm/manuals/dma/abd/adm/MA_AL09-08.htm.45Wood, Performance Audit: Department of Correction Inmate MedicaidEligibility, August 2010.4619.8, North Carolina Session Law 2010-31, An Act to Modify theCurrent Operations and Capitol Improvements Appropriations Act of 2009and for Other Purposes.47Wood, Performance Audit: Department of Correction Inmate MedicaidEligibility, August 2010.48On February 12, 2013, North Carolina Governor Pat McCrory announcedthat the state would not par ticipate in the ACAs Medicaid expansion. TheU.S. Department of Health and Human Ser vices has said that there is nodeadline for states to expand Medicaid, and a state can opt-in at any time.49Substance Abuse and Mental Health Ser vices Administration,Establishing and Maintaining Medicaid Eligibility upon Release from PublicInstitutions(SMA) 10-4545(Washington: U.S. Department of Health andHuman Services, 2010); New York State Department of Health, Ma intainingMedicaid Eligibility for Incarcerated Individuals, Medicaid Reference Guide(New York State Department of Health, updated January 2012), 545-546, available at health.ny.gov/health_care/medicaid/reference/mrg/january2012/pages545-546.pdf; New York State Department of Health,Administrative Directive to Commissioners of Social Services: MaintainingMedicaid Eligibility for Incarcerated Individuals, (Albany: New York StateDepartment of Health, April 21, 2008), available at health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdf.50Kathryn Kuhmerker to Local District Commissioners, RetroactiveFederal Financial Participation (FFP) Reimbursement for InpatientMedical Costs for Involuntarily Confined Individuals (Albany: Departmentof Health, State of New York, May 3, 2001) available at wnylc.net/pb/docs/01OMMLCM4.PDF.51Bett y Rice to Local District Commissioners, Medicaid Directors,Temporary Assistance Directors, and CNS Coordinators, RevenueReimbursement Project: Retroactive FFP Claiming of Certain InpatientMedical Claims for Inmates of Correctional Facilities (Albany: Office ofMedicaid Management, February 15, 2005), available at health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdf.This memodirects that local jurisdictions in New York only seek reimbursement if theincarcerated patient was enrolled in Medicaid at the time of incarceration,if a Medicaid application was previously submitted and denied due to theindividuals incarcerated status, or if the inpatient services were provided

to an otherwise eligible individual in the three months prior to the date inwhich the local jurisdiction submitted the reimbursement forms to the state(435.91, Public Health, Title 42, Code of Federal Regulations [42 CFR435.914] states that Medicaid coverage may start retroactively for up tothree months prior to the month of application).52New York State Office of the State Comptroller, Payments for InmateHealth Care Services: Department of Corrections and CommunitySupervision.53Rice, Revenue Reimbursement Project: Retroactive FFP Claiming ofCertain Inpatient Medical Claims for Inmates of Correctional Facilities.54Jason A . Helgerson, 13ADM-02: Medicaid Payment of Inpatient HospitalClaims for Incarcerated Individuals and Individuals Age 21-64 Who AreAdmitted to a Psychiatric Center (Albany: New York State Departmentof Health, July 9, 2013), available at health.ny.gov/health_care/medicaid/publications/adm/13adm2.htm .55

New York State Office of the State Comptroller, Payments for InmateHealth Care Services: Department of Corrections and Community Supervision .56 3661(a), New York State Social Services Law provides that:Notwithstanding any other provision of law, in the event that a person whois an inmate of a state or local correctional facility, as defined in sectiontwo of the correction law, was in receipt of medical assistance pursuant tothis title immediately prior to being admitted to such facility, such personshall remain eligible for medical assistance while an inmate, except thatno medical assistance shall be furnished pursuant to this title for any care,services, or supplies provided during such time as the person is an inmate;provided, however, that nothing herein shall be deemed as preventing theprovision of medical assistance for inpatient hospital services furnished to

an inmate at a hospital outside of the premises of such correctional facility,to the extent that federal financial participation is available for the costs ofsuch services. Upon release from such facility, such person shall continueto be eligible for receipt of medical assistance furnished pursuant to thistitle until such time as the person is determined to no longer be eligiblefor receipt of such assistance. To the extent permitted by federal law, thetime during which such person is an inmate shall not be included in anycalculation of when the person must recertify his or her eligibility for medicalassistance in accordance with this ar ticle.57An Act Concerning Suspension of Medicaid Benefits for PersonsConfined Pursuant to a Court Order and Making an Appropriation Therefor,Senate Bill 08-006, Colorado State Legislature, 2008.58The letters between state representatives and HHS are available on thewebsite of the Colorado Department of Health Care Policy and Financing,available at colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485.59Richard C. Allen to Joan Henneberry, Question 1.60Ibid., Question 2.61Ibid., Question 9.62Donna E. Shalala to Honorable Charles L. Rangel (Washington:Department of Health and Human Services, April 6, 2000); Tommy G.Thompson to Honorable Charles L. Rangel (Washington: Department ofHealth and Human Services, October 1, 2001).634011.11, California Penal Code, California Statutes.64409.9025, Eligibility While an Inmate, Title 30, Social Welfare, FloridaStatutes.65249A.38, Inmates of Public InstitutionsSuspension or Termination ofMedical Assistance, Iowa Statutes.66Lawrence, DMA Administrative Letter No: 09-08, MedicaidSuspension.67Ohio Department of Rehabilitation and Correction, Reinstatement ofMedicaid for Public Institution Recipients: 07-ORD-14 (Columbus: OhioDepartment of Rehabilitation and Correction, November 10, 2009) availableat drc.ohio.gov/web/drc_policies/documents/07-ORD-14.pdf .68411.439, Suspension of Medical Assistances of Persons with SeriousMental Illness Under Certa in Circumstances, Volume 10, Oregon RevisedStatutes.69Substance Abuse and Mental Health Serv ices Administration,Establishing and Maintaining Medicaid Eligibility upon Release from PublicInstitutions- (SMA) 10-4545.70National Association of Counties, County Jails and the Affordable Care

Act: Enrolling Eligible Individuals in Health Coverage (Washington: NationalAssociation of Counties, March 2012), available at naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdf.71Centers for Medicare & Medicaid Services, Medicaid P rogram: FederalFunding for Eligibility Determination and Enrollment Activities (76 FR21949) (Washington: Federal Register, Apr il 19, 2011).72435.908, Assistance with Application, Public Health, Title 42, Code ofFederal Regulations [42 CFR 435.908].73Centers for Medicare & Medicaid Ser vices, Medicaid Program:Eligibility Changes Under the Affordable Care Act of 2010 (77 FR 17143)(Washington: Federal Register, March 23, 2012).74Centers for Medicare & Medicaid Services, Medicaid P rogram: FederalFunding for Eligibility Determination and Enrollment Activities (76 FR21949).
http://info.dhhs.state.nc.us/olm/manuals/dma/abd/adm/MA_AL09-08.htmhttp://info.dhhs.state.nc.us/olm/manuals/dma/abd/adm/MA_AL09-08.htmhttp://www.health.ny.gov/health_care/medicaid/reference/mrg/january2012/pages545-546.pdfhttp://www.health.ny.gov/health_care/medicaid/reference/mrg/january2012/pages545-546.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdfhttp://wnylc.net/pb/docs/01OMMLCM4.PDFhttp://wnylc.net/pb/docs/01OMMLCM4.PDFhttp://wnylc.net/pb/docs/01OMMLCM4.PDFhttp://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/adm/13adm2.htmhttp://www.health.ny.gov/health_care/medicaid/publications/adm/13adm2.htmhttp://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://drc.ohio.gov/web/drc_policies/documents/07-ORD-14.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://naco.org/programs/csd/Documents/Health%20Reform%20Implementation/County-Jails-HealthCare_WebVersion.pdfhttp://drc.ohio.gov/web/drc_policies/documents/07-ORD-14.pdfhttp://www.colorado.gov/cs/Satellite/HCPF/HCPF/1247146939485http://www.health.ny.gov/health_care/medicaid/publications/adm/13adm2.htmhttp://www.health.ny.gov/health_care/medicaid/publications/adm/13adm2.htmhttp://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma008.pdfhttp://wnylc.net/pb/docs/01OMMLCM4.PDFhttp://wnylc.net/pb/docs/01OMMLCM4.PDFhttp://www.health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdfhttp://www.health.ny.gov/health_care/medicaid/publications/docs/adm/08adm-3.pdfhttp://www.health.ny.gov/health_care/medicaid/reference/mrg/january2012/pages545-546.pdfhttp://www.health.ny.gov/health_care/medicaid/reference/mrg/january2012/pages545-546.pdfhttp://info.dhhs.state.nc.us/olm/manuals/dma/abd/adm/MA_AL09-08.htmhttp://info.dhhs.state.nc.us/olm/manuals/dma/abd/adm/MA_AL09-08.htm


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Appendix

1. Letter on Clarification of Medicaid CoveragePolicy for Inmates of a Public Institution. HealthCare Financing Administration [now calledthe Centers for Medicare & Medicaid Services],

Washington, DC, December 1997.

2. Letter on Medicaid Eligibility of Inmates in the NewYork City Jail System. Secretary of Health andHuman Services, Washington, DC, April 2000.

3. Letter on Medicaid Eligibility of Inmates uponRelease from Prison. Secretary of Health andHuman Services, Washington, DC, October 2001.

4. Letter on Suspension of Medicaid Eligibility

for Incarcerated Persons. Centers for Medicare &Medicaid Services, Washington, DC, December2008.

5. Letter on Federal Medicaid Policy for MedicaidEligible Individuals that Become Incarceratedand Subsequently Need Medical Care. Centersfor Medicare & Medicaid Services, Washington,DC, August 2010.



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Acknowledgments

The Council of State Governments Justice Centerthanks the Legal Action Center for their work indeveloping this policy brief. Contributors to this reportinclude Dan Belnap, Senior Health Policy Analyst,

Legal Action Center; Gabrielle de la Gueronniere,Director for National Policy, Legal Action Center;and Paul Samuels, Director/President, Legal ActionCenter.

Bureau of Justice AssistanceU.S. Department of Justice

The Legal Action Center (LAC) is the only nonprofit law and policy organization in the United States whose mission is to advocate for sound

substance use, criminal justice, and HIV/AIDS public policies and to fight discrimination against and protect the privacy of people with these

backgrounds. Since 1973, LAC has worked to improve our nations public policies to promote drug and alcohol prevention, treatment and recovery,

and smarter criminal justice and HIV policies. LAC is committed to helping people reclaim their lives, maintain their dignity, and participate fully in

society as productive, responsible citizens.

This project was supported by Grant No. 2010-MU-BX-K084 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a

component of the Office of Justice Programs within the United States Department of Justice. Points of view or opinions in this document are those

of the author and do not represent the official position or policies of the United States Department of Justice. The Bureau of Justice Assistance

reserves the right to reproduce, publish, translate, or otherwise use and to authorize others to publish and use all or any part of the copyrighted

material contained in this publication.

The Council of State Governments Justice Center is a national nonprofit organization that serves policymakers at the local, state, and federal levels

from all branches of government. It provides practical , nonpartisan advice and evidence-based, consensus-driven strategies to increase public safety

and strengthen communities.

Suggested citation: Council of State Governments Justice Center, Policy Brief: Opportunities for Criminal Justice Systems to Increase Medicaid

Enrollment, Improve Outcomes, and Maximize State and Local Budget Savings (New York: Council of State Governments Justice Center, 2013).

2013 by the Council of State Governments Justice Center.
http://www.ojp.usdoj.gov/BJAhttp://www.ojp.usdoj.gov/BJAhttp://csgjusticecenter.org/http://www.ojp.usdoj.gov/BJAhttp://www.lac.org/

Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System

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