In January 2023, California became the first state in the nation to be approved to provide a set of pre-release healthcare services and improve access to care for people returning home from jails and prisons. Many other states are now developing Medicaid re-entry waiver proposals following guidance from the Centers for Medicare and Medicaid Services.
With approval from CMS, Washington state will offer some Medicaid coverage to youth and adults in correctional facilities up to 90 days before they are released, starting July 1, 2025.
Six states—Illinois, Kentucky, Massachusetts, Rhode Island, Utah, and West Virginia—have pending Medicaid re-entry demonstration waivers. Several other states, including Arizona, Montana, New Hampshire, New Jersey, New Mexico, New York, Oregon, and Vermont, are reported to be developing waiver proposals.
During a Nov. 14 event hosted by KFF, Jennifer Strohecker, Pharm.D., the Medicaid director in Utah, spoke about the efforts in her state. “Like many other states, Utah is very invested in justice-involved re-entry initiatives. As we've now had further guidance from CMS, we are really excited about the opportunities this allows for improvements in that connection of care and continuity of care through pre-release services,” she said.
“With the rate of mental illness in Utah jails being six times higher than the general public, substantial gaps in care is what we're noticing. Incarcerated individuals who may have a substance use disorder, who have untreated mental illness are moving through the system and having gaps,” Strohecker added. “They’re not receiving that level of care we want. We are working with our prisons and our jails to really stand up the infrastructure for this in anticipation that these conversations with CMS will be moving towards approval of this essential service soon. This is certainly a high-priority item for us.”
In June 2022 Jami Snyder, who then oversaw Arizona’s Medicaid and CHIP program, said “We want to be able to reimburse for services when an individual is preparing to leave a correctional setting. We want to be able to reimburse for those care coordination and case management services, so we can get individuals connected to care quickly when they leave that correctional environment through a variety of providers, including our justice clinic sites.”
The farthest along on this path is California, which has taken several steps in establishing its Justice-Involved initiative.
The state is taking steps to address poor health outcomes in this population by establishing pre-release Medi-Cal enrollment strategies to ensure individuals have continuity of coverage upon their release, as well as access to key services to help them successfully return to their communities.
The Justice-Involved Initiative allows eligible Californians who are incarcerated to enroll in Medi-Cal and receive a targeted set of services in the 90 days before their release. This initiative aims to ensure continuity of healthcare coverage and services between the time they are incarcerated and when they are released. It also provides people who are re-entering the community with the prescribed medications and durable medical equipment they need, and access to programs and services to support this transition.
Several initiatives that focus efforts on ensuring Medi-Cal enrollment and benefits upon release from correctional facilities include the following:
• Since 2015, state prisons have been required to use a standardized process for gathering and processing pre-release applications to ensure that JI individuals are enrolled in Medi-Cal before their return to the community.
• From 2016 to 2021, 17 counties offered whole-person care (WPC) pilots dedicated to serving individuals reentering the community post-incarceration and have designed programs to directly engage local jails and/or probation departments. These programs have transitioned to become Enhanced Care Management (ECM)/Community Supports programs in CalAIM.
• Since January 1, 2023, all counties are mandated to implement pre-release Medi- Cal application processes in county jails and youth correctional facilities.
• Since January 1, 2023, and as authorized by SB 184, Medi-Cal benefits for juveniles and adults may be kept in suspended status until the individual is no longer an inmate of a public institution.
• A 2021 state law (AB 133) requires correctional services to implement a process to facilitate referrals to county specialty mental health services (SMHS), Drug Medi-Cal (DMC), the Drug Medi-Cal Organized Delivery System (DMC-ODS), and/or Medi-Cal MCPs for incarcerated individuals who received behavioral health services while incarcerated, to allow for the continuation of behavioral health treatment. These referrals are called behavioral health linkages.
• Managed care plans are required to offer intensive, community-based care management for individuals transitioning to the community through the statewide ECM and Community Supports benefit. All individuals who are eligible for pre-release Medi-Cal services and enrolled in managed care will also be eligible to receive ECM upon release to the community.
CMS is requiring state Medicaid programs to assess whether these interventions are having positive impacts on health outcomes and costs.
For instance, in its letter approving Washington state’s waiver, CMS said that “by allowing early interventions to occur in the full 90-day period immediately prior to expected release, such as for certain behavioral health conditions and including stabilizing medications like long-acting injectable anti-psychotics and medications for addiction treatment for SUDs, Washington expects that it will be able to reduce decompensation, suicide-related deaths, overdoses, and overdose-related deaths in the near-term post-release. The state will test, and comprehensively evaluate through robust hypotheses testing, the effectiveness of the extended full 90-day coverage period before the beneficiary’s expected date of release on achieving these articulated goals of the initiative.”