Whent h eAffordableCare Act

(ACA) became the law of theland, a situation arose in the cor-rectional arena. The ACA requiresalmost everyone to have healthinsurance. That includes inmateswho have been released, some-times after years of incarceration.Inmates already tend to be lesshealthy than the general popula-tion and often lose access to med-ical services once they arereleased from custody. They nowneed to be aligned with healthcare, and often that alignment isenrollment with Medicaid.

While the process may be com-plicated, the success of doing so

has been experienced in the 31states (and Washington, DC) thatexpanded access to Medicaidunder the ACA. Nick Little, vicepresident of Strategic Contracting& Compliance at Wexford HealthSources, a Pittsburgh, Pa.-basedprovider of correctional healthcare, notes that with the passingof the ACA, most inmates qualifyfor Medicaid benefits “as long astheir state approves the expan-sion of its Medicaid-eligible pop-ulation.”

Inmates often enter a facilitywith a substance abuse disorderor a mental illness, and thedemographic tends to have highrates of chronic conditions suchas diabetes, hypertension, andinfectious diseases such as hepati-

tis and HIV. Continuity of carehas long been an issue with theinmate population, but the ACAand Medicaid enrollment has hada significant impact on that. Forexample, says Little, “ACAMedicaid coverage reduces theduplication of medical servicesfor chronically ill inmates” and“increased Medicaid coveragereduces the number of emergencyroom visits for general and/orspecialty care.”

Martha Harbin, director ofExternal Relations at CorizonHealth, says “There is increasingawareness of the importance of asuccessful re-entry program toreducing recidivism, and manyclients are including more dis-charge-planning positions in

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BY MICHAEL GROHS, CONTRIBUTING EDITOR

‘Medicaiding’ Ex-offenders

How states are providing post-incarceration continuity of care.

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their health services contracts.”The funding, says Little, is

arranged so the states that didexpand Medicaid eligibility willreceive a 100% federal fundsmatch through 2017. (In 2020,that rate will diminish to 90%.)This match “is a significantlygreater percentage than anythingthat has been provided in thepast. State correctional agenciesare saving millions of dollarsthrough matching federal fundson inpatient hospitalization ofinmates alone.”

In May 2016, the IndianaDepartment of Corrections(IDOC) released a press releasestating that the agency hadreached a milestone by registeringmore than 12,000 releasedinmates with HIP 2.0/Medicaid.(HIP [Healthy Indiana Plan] 2.0 isessentially Indiana’s Medicaid).Qualification is based on incomeand not disability. As a 2015 PewReport pointed out, correctionalexpenses and health care are “twofiscal pressure points,” especiallywhen they intersect. The reportfurthered that in 2011, statesalone spent more than $7.7 bil-lion on inmate health care.

Indiana state law required thatthe DOC begin applying for HIP2.0/Medicaid for “all offendersreleased from their custody.” Inorder to accomplish this, IDOCmoved quickly in order to utilizePresumptive Eligibility (HPE) toenroll offenders. This allowsoffenders to be covered underMedicaid while hospitalized, thusallowing the hospital to billMedicaid rather than IDOC. Bydoing so, IDOC’s health careprovider realized significant costsavings and then reimbursedIDOC. According to an April2016 report, since July 2015, thesum of claims paid by Medicaidfor offenders with HPE has beenmore than $3.8 million.

Other states have reported simi-lar savings. According to a 2015study conducted by the RobertWood Johnson Foundation, incombined fiscal years 2015 and2016, states have reported signifi-

cant savings: Arkansas ($2.8 mil-lion), Colorado ($10 million),Kentucky ($16.4 million), andMichigan ($19.2 million). Gov.Bill Walker of Alaska advocatedexpanding the state’s Medicaidprogram anticipating that in 2016,$4.1 million in federal reimburse-ments would be realized frominmate inpatient health costsalone. According to the study, thestate auditor in Massachusettsreviewed correctional health costsfrom 2011 and 2012. She foundthat over that period, the statehad failed to submit claims forroughly $11.6 million in eligibleservices. These lost reimburse-ments were divided betweencounty jails ($7.6 million) andstate facilities ($4.1 million).

State-to-stateDifferences

The enrollment process is notuniversal. Corizon’s Harbin says,“There is no standard process foraligning inmates with Medicaidservices. Medicaid coverage eligi-bility varies from state to state asdo the services that prisons andjails have the staffing and fund-ing to provide. For example, afterpassage of the Affordable CareAct, some of our clients invitedNavigators into their facilities toenroll patients while other com-munities did not have Navigatorsavailable.”

Inmates who are in custody arenot eligible for Medicaid coverage(unless they are hospitalized), andif they are on Medicaid uponarrival, that coverage is suspendeduntil the time at which they arereleased. IDOC screens eachoffender who enters theDepartment using a daily reportand master tracking database.Those tools are used by the facili-ty’s Medicaid Processing Unit tofulfill one of HIP 2.0’s require-ments, which involves reportingoffenders who have active cover-age to the Indiana Family andSocial Services Administration(FSSA) for suspension. Upon notifi-cation, FSSA completes a status

change, and the offender’s cover-age is suspended throughout incar-ceration. (Coverage can be easilyreactivated upon the inmate’srelease.) In an effort to facilitatethe on-boarding process, IDOCimplemented the MedicaidProcessing Unit, which completesMedicaid applications on behalf ofall offenders 60 days before release.As part of the re-entry process, theunit’s staff encourages offenderswho are about to be released to usetheir coverage for mental healthand substance abuse treatments inaddition to their medical needs.

Transitional CaseManagement Program

Krissi Khokhobashvili, PublicInformation Officer at theCalifornia Department ofCorrections and Rehabilitation(CDCR) explains that their facili-ties’ reentry plan begins about120 days prior to release when theDivision of Adult ParoleOperations (DAPO) uses contract-ed social workers to provideTransitional Case ManagementProgram (TCMP) for inmates tran-sitioning back into the communi-ty. TCMP provides services in twocomponents: institutional basedand community based. There are68 case workers statewide whohelp inmates with the applica-tions for Medi-Cal and get theapplications to the countieswhere the inmate will be going 60to 90 days prior to release. Thecounty then sends back a benefitcard. Before release, there is anexit interview in which the bene-fit worker and inmate discuss thebenefit status, which is availableupon release. On the institutionalbased component, TCMP providescounseling, guidance and paroleplan services for those with HIVand/or AIDS. This is voluntary onthe inmate’s part. According theCDCR’s website, TCMP also pro-vides “pre-release assessments ona prioritized workload for inmatesidentified as part of the prison'sMental Health Services DeliverySystem, by way of information

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gathering, and referral to the DAPO ParoleOutpatient Clinics (POC).” In this case, as a condi-tion of parole, inmate participation is mandatory.TCMP also serves as a liaison between prison staffand DAPO's Nursing Consultant, Program Review(Medical Placement Coordinator) to identify andrefer inmates who will require continuity of careupon release. TCMP also participates in the comple-tion of inmate service plans and documents thedetails in the database.

As for community-based components, TCMPdevelops parole service plans prior to release and,within the first 90 days of release, offers guidancecounseling to parolees who have been diagnosedwith HIV and/or AIDS. Similar services will be pro-vided for high risk inmates who have been identi-fied as having needs for services based on the assess-ment tool the Correctional Offender ManagementProfiling for Alternative Sanctions, as well as servingas a resource person to DAPO staff, referring paroleesrequiring medical placement to the DAPO MedicalPlacement Coordinator, and documenting the ser-vice plan components in the appropriate database.

The Minnesota DOC, says Nanette Larson, direc-tor of Health Services at the Minnesota Departmentof Corrections, “Employs dedicated release plannersto assist the inmate with the application process.We have worked directly with the Department ofHuman Services, the state’s Medicaid agency, todevelop an enrollment process for those whoreceive release planning services.”

At Wexford, says Little, there are two steps toensuring an inmate has access to Medicaid benefitsupon his or her release. The first is that inmate mustgo through a process to be enrolled. Correctionsagencies coordinate with their state’s Medicaidagency to develop policies and procedures to effi-ciently register inmates in Medicaid and align themwith services. “Wexford Health currently works withmultiple states with effective Re-Entry Programs thathave policies and procedures in place to ensure asmany inmates are enrolled as possible.”

The second step is that the inmate being releasedwill need to be connected to a medical provider work-ing in the community. “Our correctional dischargeplanners are crucial in identifying medical providersin the inmate’s community that see Medicaidpatients and can provide the care that is specificallyneeded for that inmate.” Discharge planners are theones who often make the initial doctor’s appoint-ment for the soon-to-be released inmate as well asfacilitate the release of medical records from the cor-rections agency to the medical provider in the com-munity to ensure accuracy and consistency of care.

Harbin notes that in facilities that work withCorizon, Medicaid alignment “ideally begins aboutthree months before release and includes educatingpatients about the options available to them andhelping them with their applications. In the Arizona

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DOC, where we recently launcheda re-entry program, our staff workswith about 10 to 12 inmates perweek, and we are actively workingwith our client to greatly increasethe number being served.”

Qualification does not seem topose a challenge for those in the31 states or Washington, D.C.,that opted to expand Medicaid.Most inmates qualify because sofew earn more than $15,000 peryear while incarcerated. (The ACAexpanded Medicaid eligibility tothose who had an income of lessthan 133% of the federal povertylevel.) Says Little, “The 19 statesthat have chosen not to expandtheir Medicaid eligible populationin accordance with the ACA arenot able to receive federal match-ing funds for inmates that areadmitted to a community hospi-tal.” They are also not eligible toreceive federal funding for addi-tional community programs suchas mental health, substance abusetreatment, etc.

‘Unique Challenges’The process is not simple.

“Enrolling inmates in Medicaidpresents a number of unique

challenges,” says Little. For one,Medicaid requires having a mail-ing address and very often aninmate’s address changes frominstitution to institution, or theydo not have a permanent addresswhen they are released into thecommunity. Larson agrees. Aserious challenge is “findinghousing for persons with felonyhistories and mental health andmedical challenges.”

There is also the matter of fol-low-through on the inmate’s partto keep the appointment and seethe community physician, whichis necessary for success “but notalways a guarantee.” In addition,there is the concern of findingspecialty providers that meets thespecific needs of the inmate intheir community. Harbin pointsout that the ACA has provided abridge to released inmates andhealth care; however, “Even inthose states, instituting changesin both the correction andMedicaid agencies is challenging.Some states, such as Arizona,Colorado and Oregon have madesignificant efforts to align process-es.” She furthers that the goal isfor those who are now eligible for

Medicaid or other insurance tohave better access to primary careservices upon release so they willbe better able to manage chronicconditions. “Continuity of care isparticularly important for thosewith mental illnesses. Withoutaccess to regular health care andnecessary medications, they oftendecompensate and wind up backin the criminal justice system.”

A critical aspect for success,stresses Little, is coordinationbetween the various state agen-cies. “At a minimum, the correc-tion agency and Medicaid agencyneed to agree on policies. In manystates the human services agencydoes the Medicaid enrollment, sothey need to be involved.” Harbinfurthers, “An important role forthe correctional health careprovider is to help ensure thatindividuals leaving the criminaljustice system have their personalmedical histories. Often, the cor-rectional health care provider hasbeen the patient’s only consistentprimary care provider and maypossess the most complete history.Successful application for coverageoften requires documentation ofconditions.” J

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Released inmates can be coveredunder Medicaid in 31 states andthe District of Columbia thatexpanded access to heath careunder the Affordable Care Act.

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