MaineCare CMO on Planning for 1115 Medicaid Re-Entry Waiver

As she leads efforts to extend Medicaid in Maine to re-entry from prisons and jails, Courtney Pladsen, D.N.P, chief medical officer of MaineCare, said the agency is planing to design sets of services for each county individually rather than a one-size-fits-all approach at the state level. 

Pladsen spoke about how Maine plans to leverage a 1115 Medicaid waiver to offer re-entry services during a recent Center for Health Care Strategies webinar titled “Innovations in Substance Use Care Delivery for Medicaid Members: A No Wrong Door Approach.”

She has daily experience with both seeing patients and the administrative side of Medicaid. Pladsen works one day per week in a local healthcare-for-the-homeless clinic in Portland, where she is a family medicine addiction specialist. “I'm treating people who are currently using drugs, some people who are in recovery or are working toward recovery. I do a lot of substance use treatment daily amongst a population that has a lot of barriers to care,” she said.

The rest of the week she works at the state Medicaid program. “I think about these challenges around accessing substance use treatment from a personal and interpersonal perspective, working individually with patients and then at a system level,” Pladsen said. “I always want to keep the person at the center of this work and think about how individuals navigate these systems and how we can bring systemic solutions to this.”

She spoke about how three years ago, Maine’s state legislature passed a law requiring MaineCare to apply for an 1115 re-entry waiver, a tool that allows certain flexibilities to waive federal rules in developing pilots or demonstration projects. The re-entry waiver is requesting CMS to waive the Federal Inmate Exclusion Act, under which states are not allowed to use Medicaid dollars to cover services for someone who is in a jail or prison. This waiver opportunity would allow Maine to leverage Medicaid to cover services pre-release. 

“While someone is still in a jail or prison, we can leverage Medicaid to cover certain services, which provides an amazing opportunity to improve the period of re-entry,” she said. “This is such a vital intervention. People who are leaving carceral settings have overdose rates much higher than the general population. It is a really vulnerable time for overdose risk. So it's a really key time that people can access treatment and improve safety following release from jail or prison.”

CMS has a requirement that all states that apply for a 1115 re-entry waiver include case management, coverage of medications for substance use disorder, with a minimum of 30 days of medication in hand upon release. “We are also including physical and behavioral health consultations for youth, as that is a new federal requirement,” Pladsen said. “We are also adding optional services as well. We are currently facing an HIV outbreak in our state, and we also have the highest rate of hepatitis C in the country. We are trying to understand the unique needs of people who are in our jails and prisons and how we can use this opportunity to cover services for them before they leave these settings. We are working to develop our implementation plan of how we can utilize MaineCare to cover the services 90 days prior to someone leaving these facilities.”

Pladsen said there is quite a difference in working with jails vs. prisons. “Jails are really the ER of our criminal legal system,” she said. “The average length of stay is only 13 days in our county jails, so for a county jail, we have to think of a short-stay model — how do we layer services from the moment someone enters a jail facility? This will look very different in our jail setting than it will in our prison system and in our juvenile facilities. We will be adapting this model to each of them. We will be planning to phase in the services in each of those facilities, and we are trying to use capacity-building funding to help implement in each of these settings.”

Pladsen said she wanted to take “nothing about us without us” approach, knowing that even with her background at the intersection of health and homelessness, her patients often move through these settings. “Unfortunately, people who experience homelessness are incarcerated at higher rates, so I had a really biased perspective of jails and prisons when I started this work. I knew that I had to go to each of these facilities to understand what it was like for people to move through these settings, and I needed to better understand the staff that do this work.”

She personally traveled to all 21 jails and prisons in the state of Maine and met with the staff at each one of them. “I wanted to understand the nuances of what it was like to work at a county jail in Holton, our northern-most county. I wanted to understand the nuances between our more urban and rural settings, and that was really crucial to developing trusting relationships with community partners,” she said .”It’s also essential for me to break down some of the bias that I held. I've met really amazing people who care deeply about helping people rehabilitate, helping people to reduce recidivism. I found a lot of wonderful partners in this work in the sheriffs and jail administrators and our commissioners and Department of Corrections — people who care deeply about wanting to help people avoid coming into these settings in the first place and appropriately connecting them with needed services.”

Her team also conducted listening sessions with residents of jails and prisons. “We wanted to meet with the people who would be receiving these services, so that we can be responsive and design our implementation plan in alignment with their goals and their needs,” she said. “We sat with residents and asked, 'What are the most important things to you when you're released? Tell us about your experience receiving healthcare in this setting. What has it been like? What are the challenges? What are your priorities?’ 

That input will be used to help design the implementation plan and to provide a feedback loop. They did the same thing with the sheriffs association, adding their feedback into the implementation plan.

MaineCare also has worked to engage community partners within the Department of Health and Human Services, Department of Corrections, as well as behavioral health providers, substance use treatment and mental health providers who are providing services upon re-entry in the community. 

“We've done a lot of mapping of each county and the constellation of services within that county. What I heard really loud and clear from the sheriffs is that each county is so unique that we can't from the state level design a one-size-fits-all approach,” Pladsen said. “We need to understand that what happens in Aroostook County in this constellation of services is incredibly different from what happens in Cumberland County. And knowing that Cumberland County is our most populated with the most concentration of resources led us to develop what is we are defining as our county-informed approach, We are going to design the set of services for each county individually. We'll meet county by county to design this.”

MaineCare has partnered with the Maine Prisoner Advocacy Coalition as well as with the Maine Re-Entry Network to develop a community advisory board that will advise it on justice initiatives. “We're looking forward to having a health and re-entry conference later this year led by our community advisory board,” she said. 

MaineCare is currently in negotiations with CMS. “We are hopeful for approval sometime this year, and look forward to implementing the start of our waiver in late 2027 to the beginning of 2028,” she said. “Part of what we are looking forward to is expanding access to medications for substance use disorders. There was a study done in one of our county jails around using long-acting injectable buprenorphine. The outcomes of that study of decreasing overdoses and improving retention was profound. We see the expansion of Medicaid in this pre-release period being able to expand access to that kind of medication that's quite expensive to improve retention and care upon release.”