There is growing momentum among states to develop innovative models to help people involved with the justice system receive health care services covered by Medicaid while they are incarcerated. By providing services before justice-involved individuals are released, including care management to plan for reentry, states are hoping they can improve health outcomes when individuals return to their communities.
Individuals leaving incarceration — mainly people of color — are particularly at risk for poor health outcomes. Justice-involved individuals have disproportionately higher rates of physical and behavioral health diagnoses and are at higher risk for injury and death as a result of overdose and suicide than are people who have never been incarcerated. Nearly two-thirds (64%) of individuals in jail and more than half (54%) of individuals in state prisons report a mental health concern. This contributes to a high risk of death following release, with one study showing that during the first two weeks after release from state prison, the risk of death was 12.7 times that of other state residents.
Many incarcerated people can qualify for Medicaid while they are in jail or prison. However, under federal law, inpatient hospital care is the only service that can be covered by Medicaid for individuals considered an “inmate of a public institution.” Many people leaving jail or prison — often lacking a connection to community-based providers or a care plan — experience gaps in care despite their high needs. Recognizing the need for intervention, Congress passed the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) in 2018, which directed the U.S. Department of Health and Human Services (HHS) to issue guidance on how states can design Section 1115 demonstrations (also known as 1115 waivers) to provide services to justice-involved individuals before release to support reentry. HHS and the Centers for Medicare and Medicaid Services (CMS) are working on guidance, which may be released to states soon.
Eleven states have already submitted Section 1115 demonstration requests and begun discussions about their waivers with CMS: Arizona, California, Kentucky, Massachusetts, Montana, New Jersey, New York, Oregon, Utah, Vermont, and Washington. The demonstration requests vary, but all are focused on supporting reentry into the community and improving health outcomes.
Key elements of the waivers submitted include:
- Eligible populations. Six states (Arizona, California, Massachusetts, New Jersey, New York, and Utah) are seeking to establish eligibility criteria that includes individuals with chronic conditions (e.g., diabetes), behavioral health needs, or both. Some states have proposed more limited eligibility criteria and focus on behavioral health needs, such as a mental illness (the definition of which varies by state), substance use disorder, or both. Oregon, Washington, and Vermont are seeking to cover all Medicaid-eligible individuals.1
- Scope of covered services provided pre-release. Kentucky is proposing to cover a bundle of services focused on substance use disorder, including therapy, peer support, and reentry service planning. Arizona, California, Montana, New Jersey, New York, and Washington seek to cover a targeted set of services that includes medications and care management focusing on planning for reentry. Montana, for example, proposes to provide care management and clinical consultation services, coverage of certain medications including long-acting injectables, and a 30-day supply of medication upon release. Massachusetts, Oregon,2 and Vermont seek to cover full Medicaid state plan benefits to eligible individuals.
- Duration of coverage during the prerelease period. Most states that have submitted waivers are seeking to provide services to inmates in the 30 days prior to release. California, New Jersey, Oregon, and Vermont have asked for a longer coverage period. Length of stay in jails in particular can be short or of unpredictable duration and numerous operational issues arise in secured settings. As a result, one of the biggest challenges facing states is having sufficient time to enroll individuals in Medicaid (if they are not already enrolled), screen for eligibility for prerelease services, and meaningfully engage with individuals to support reentry.
Once CMS establishes the parameters of 1115 waivers pursuant to the SUPPORT Act directive, states with pending requests may need to adjust demonstration features to align with CMS’s expectations. Getting the waiver approved is only the first step; operationalizing the provision of Medicaid services in a correctional setting is a considerable lift for Medicaid programs and for correctional facilities. Security protocols and priorities at facilities can be at odds with prerelease initiatives, which typically involve connecting people to specialty care and building trusting relationships to help support reentry. Success will depend on intensive planning and close working relationships across Medicaid agencies, correctional facilities, correctional health care providers, managed care plans, community health providers, formerly incarcerated individuals, and community-based organizations. States and CMS are hopeful that this new federal–state partnership will help ensure individuals get the health care and social support they need as they return to their communities.