this document is supported through a cooperative agreement ...section 1 — knowing the basics...

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This document is supported through a cooperative agreement 2013-DB-BX-K008 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. To learn more about the Bureau of Justice Assistance, please visit bja.gov.

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About the Author Joan M. Shoemaker, BSN, MBA, is a Bureau of Justice Assistance fellow for the American Correctional Association.

Her selection as the BJA fellow was based on more than 25 years of experience in the corrections field serving in numerous capacities. For several years, she was warden of multi-custody prisons housing both men and women. During her tenure as deputy director of prisons, she had several roles, which included supervision of wardens; supervision of department-wide programs such as education and food service; and designation as the health authority responsible for management; and delivery of all health services for all prisons.

From the Author This document would not have been possible without the support and assistance from the American Correctional

Association, the Coalition of Correctional Health Authorities, the staff at the Bureau of Justice Assistance and other federal partners.

Special thanks to Dr. Elizabeth Gondles, director, and Doreen Efeti, manager, from the Office of Correctional Health, American Correctional Association; and Ruby Qazilbash, associate deputy director; and Danica Binkley, senior policy advisor, from BJA. Their insight and expertise have been invaluable to the development of this paper.

American Correctional Association, Coalition of Correctional Health Authorities • James Greer, Wisconsin Department of Corrections • Bruce Herdman, Philadelphia Prison System • Stuart Hudson, Ohio Department of Rehabilitation and Corrections • Dr. Kathleen Maurer, Connecticut Department of Corrections • Viola Riggin, Kansas Department of Corrections • Dr. Ramah Singh, Louisiana Department of Corrections • Kellie Wasko, Colorado Department of Corrections • James Welch, Retired, Delaware Department of Corrections

Bureau of Justice Assistance staff• Andre Bethea, policy advisor• Emily Niedzwiecki, policy advisor

Office of the Assistant Attorney General• Amy Solomon, senior advisor

Federal Partners • Linda Mellgren, senior social science analyst, Department of Health and Human Services, Office of Assistant

Secretary for Planning and Evaluation • Katie Green, correctional program specialist, National Institute of Corrections • Charles Smith, Ph.D., SAMHSA Region VII Administrator, SAMHSA

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Council of State Governments, Justice Center • Alex Blandford, PMPA, CHES, deputy program director for Behavioral Health • Fred Osher, M.D., director of Health Systems and Services Policy

Legal Action Center• Gabrielle de la Gueronniere, J.D., director of Policy

TASC Inc. for Illinois• Maureen McDonnell, director for Business and Health Care Strategy Development

Urban Institute• Jesse Jannetta, senior research associate in Justice Policy Center

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Executive Summary Corrections and criminal justice professionals have continuing opportunities to utilize the Patient Protection and

Affordable Care Act in reentry planning for the justice-involved populations they serve. This document will outline the successful strategies some jurisdictions have incorporated to enroll individuals in Medicaid and private health insurance to facilitate continuity of health care from incarceration to the community. The guide provides information for each step in the process of implementing health care reform for the adult population.

Section 1 — Knowing the Basics provides information necessary to understand health care reform, specifically the Patient Protection and Affordable Care Act. This section will provide information on Medicaid and state Medicaid plans along with how states have organized the delivery of health care services to those eligible. This includes information on presumptive eligibility and its application to the correctional environment. By understanding the beneficial implications of health reform, corrections and criminal justice systems can begin to implement enhanced enrollment procedures. These procedures will facilitate seamless transition of care as individuals move through the criminal justice system.

As with any new system, it is vital to establish from the beginning the information needed to evaluate progress and success. There are suggestions about what information to gather so that correctional and criminal justice agencies will know how the efforts for enrolling justice-involved individuals are working. Establishing the right evaluation metrics will make it easier to document the impact on individuals and agency budgets.

Last, this section also includes information pertaining to the benefits of Medicaid enrollment and coverage available during confinement. Strategies to maximize enrollment of individuals in Medicaid during confinement can help correctional agencies take advantage of Medicaid to cover in-patient care for some individuals. Medicaid funds are also potentially available for some enrollment and case-management functions through administrative claiming and targeted case management reimbursement. Activities must be clearly documented by the agency for any reimbursement.

Section 2 — Begin the Change provides information on the steps needed to make changes in procedures and processes for implementation of the Affordable Care Act. It includes information on forming and working with stakeholder groups and how to understand and analyze current procedures in order to ascertain changes necessary to move forward. There is information for each intercept within the criminal justice system. The checklists in the attachments provide action steps that correspond to the information in this section.

Section 3 — Conclusion provides information regarding the ongoing challenges with implementation of the Affordable Care Act. The biggest challenge remains with states that have not adapted the expansion of eligibility criteria to include adults age 19-64 who fall below 133 percent of the federal poverty guidelines. The paper concludes with a summary of the lessons learned from jurisdictions that have implemented health care reform activities, providing valuable insights for others who want to begin.

The attachments provide additional information and references. Attachments B through E are checklists designed to guide implementation activities. There are specific checklists for use by courts, probation/parole agencies, jails and departments of corrections. Each group of checklists contains four individual lists based on whether the state has expanded Medicaid eligibility and whether benefits are suspended or terminated when justice-involved individuals become incarcerated.

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Table of ContentsAbout the Author .......................................................................................................................................................... 3From the Author ........................................................................................................................................................... 3Executive Summary ...................................................................................................................................................... 5Introduction .................................................................................................................................................................... 8Section 1 — Knowing the Basics ............................................................................................................................... 11 What Is Medicaid? ................................................................................................................................................. 12 State Plan Eligibility Criteria ............................................................................................................................. 12 Enrollment Strategies ......................................................................................................................................... 13 Expansion vs. Non-expansion ............................................................................................................................ 14 Suspend vs. Terminate Benefits ......................................................................................................................... 16 Presumptive Eligibility ...................................................................................................................................... 17 Structure for Delivery of Medicaid Services Within States .............................................................................. 17 Medically Necessary Care ................................................................................................................................. 18 Health Homes .................................................................................................................................................... 18 What Is the Marketplace? ..................................................................................................................................... 19 Qualifying Life Event (QLE) ............................................................................................................................. 20 Individual Shared Responsibility Payment ........................................................................................................ 20 Evaluation .............................................................................................................................................................. 20 Establishing Metrics for Evaluation .................................................................................................................. 21 Potential Budget Implications ............................................................................................................................... 22 Recovery of Hospitalization Costs .................................................................................................................... 22 Medicaid Administrative Costs ......................................................................................................................... 23 Medicaid Administrative Claiming (MAC) ................................................................................................ 23 Targeted Case Management (TCM) ............................................................................................................ 24 Correctional Agency Structure ............................................................................................................................. 24Section 2 — Begin the Change ................................................................................................................................... 27 Working or Stakeholder Group ........................................................................................................................... 27 Process Analysis ..................................................................................................................................................... 29 Systems Mapping ............................................................................................................................................... 29 Lean ................................................................................................................................................................... 29 Information Collection and Sharing .................................................................................................................... 30 SAMHSA Gains Center ......................................................................................................................................... 31 Intercept 1 — Community and Law Enforcement ............................................................................................ 31 Intercept 2 — Arrest and Initial Detention/Court Hearing ............................................................................... 32 Intercept 3 — Jails/Courts ................................................................................................................................ 32 Intercept 4 — Reentry From Jails/Prisons to Community ................................................................................ 37 Intercept 5 — Community Corrections ........................................................................................................... 38

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Section 3 — Conclusion ............................................................................................................................................... 41 Challenges for the Future ...................................................................................................................................... 41 Lessons Learned ..................................................................................................................................................... 42Glossary of Terms ....................................................................................................................................................... 44Attachment A — References & Resources ............................................................................................................... 46Attachment B — Evaluation Metrics ......................................................................................................................... 51 Implementation Checklists ...................................................................................................................................... 52Attachment C — Checklist – Courts .......................................................................................................................... 53 C-1 — Courts in Expansion State That Suspend Benefits ....................................................................................... 53 C-2 — Courts in Expansion State That Terminate Benefits .................................................................................... 55 C-3 — Courts in Non-Expansion State That Suspend Benefits .............................................................................. 57 C-4 — Courts in Non-Expansion State That Terminate Benefits ........................................................................... 59Attachment D — Checklist – Probation/Parole ....................................................................................................... 61 D-1 — Probation/Parole in Expansion State That Suspend Benefits ...................................................................... 61 D-2 — Probation/Parole in Expansion State That Terminate Benefits ................................................................... 63 D-3 — Probation/Parole in Non-Expansion State That Suspend Benefits .............................................................. 65 D-4 — Probation/Parole in Non-Expansion State That Terminate Benefits ........................................................... 67Attachment E — Checklist – Jails ............................................................................................................................. 69 E-1 — Jails in Expansion State That Suspend Benefits .......................................................................................... 69 E-2 — Jails in Expansion State that Terminate Benefits ......................................................................................... 71 E-3 — Jails in Non-Expansion State That Suspend Benefits .................................................................................. 73 E-4 — Jails in Non-Expansion State That Terminate Benefits ............................................................................... 75Attachment F — Checklist – Department of Corrections ....................................................................................... 77 F-1 — Department of Corrections in Expansion State That Suspend Benefits ....................................................... 77 F-2 — Department of Corrections in Expansion State That Terminate Benefits .................................................... 79 F-3 — Department of Corrections in Non-Expansion State That Suspend Benefits ............................................... 81 F-4 — Department of Corrections in Non-Expansion State That Terminate Benefits ............................................ 83

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IntroductionThe Bureau of Justice Statistics Bulletin on Correctional Populations in the United States, 2014, shows that an estimated

6,851,000 persons were under the supervision of adult correctional systems, a decline of 52,200 from 2013. About one in 36 adults (2.8 percent) were under some form of correctional supervision. These figures are not surprising to corrections and criminal justice professionals. The National Reentry Resource Center (NRRC) estimated that 95 percent of all state prisoners will eventually be released back to their communities. The incidence of serious mental illness is two to four times higher among prisoners than the general population, and three-quarters of those returning to prison have a history of substance use disorders; additionally, 70 percent of prisoners with serious mental illness also have a co-occurring substance use disorder.1

At the American Correctional Association Winter Conference in 2014, Director Gary Mohr from the Ohio Department of Rehabilitation and Correction stated that, in his 40 years of working in corrections, the Patient Protection and Affordable Care Act will be the largest catalyst that has been seen in corrections in terms of having the ability to change lives of justice-involved individuals. Prior to Medicaid expansion in Ohio, less than 10 percent of individuals left prison with health insurance. After the state expanded Medicaid, it is estimated that more than 90 percent of the released prison population will leave with Medicaid and be able to access health care services, including mental health and substance use disorders treatment. Director Mohr stated that the Affordable Care Act will positively affect incarcerated individuals and their families, which will influence the next generation. The change in Medicaid coverage, he said, is more than an opportunity to link individuals with health care services in the community; it is the responsibility of professionals working with justice-involved populations.2

There are projects throughout the country focused on Medicaid enrollment as part of reentry efforts to combat recidivism and provide justice-involved individuals with the best possible chance for successful returns to the community. These programs are working at every intercept in criminal justice systems, from courts to jails and prisons through the transition to communities. The Laura and John Arnold Foundation sponsored efforts by Harvard Medical School and Johns Hopkins Bloomberg School of Public Health to inventory the state and local initiatives for enrolling individuals in Medicaid.3 The inventory includes a brief description of initiatives in many states and local jurisdictions.

Reentry efforts at the federal level are spearheaded by the Federal Interagency Reentry Council (Reentry Council) established by former Attorney General Holder in January 2011. This represents the Reentry Council a significant executive branch commitment to coordinating reentry efforts and advancing effective reentry policies. It is premised on the recognition that many federal agencies have a major stake in prisoner reentry. Twenty-three federal agencies, working toward a mission to make communities safer by reducing recidivism and victimization, assist those who return from prison and jail in becoming productive citizens and save taxpayer dollars by lowering the direct and collateral costs of incarceration.4

All of these initiatives have the common goal of changing the way justice-involved populations access health care in the community. Being able to secure public health insurance coverage (Medicaid) or private health insurance coverage (through the Marketplace or employment) increases access to health care, including behavioral health programs that will improve health outcomes and reduce recidivism rates. Having public or private health insurance coverage will augment the chance of successful reentry, which is why efforts to enhance access to health insurance and community based services should be an integral part of reentry programs.

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Introduction

There is no one right time to enroll justice-involved individuals in health coverage. Access to coverage can impact decisions about diversion, pretrial confinement, and care during confinement and release. For example, when coverage is available, it can decrease the use of jail confinement for individuals who need mental health treatment. Because there can be different strategies for increasing access to health care at the various points of involvement with the criminal justice system, this document uses the GAINS sequential intercept model5 as part of its organizational framework. This model was developed through grant funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and identifies points of opportunity in the justice system to intervene improving outcomes for individuals with mental health needs. This model easily adapts to providing opportunities for increasing health care access.

This document will provide examples of jurisdictions that have been successful in increasing access to health care coverage; however, there is no single solution that will work for every jurisdiction. Each jurisdiction will need to identify processes and procedures that will work within their system. Implementation will be a process with multiple steps that may require criminal justice and social services partners to make changes in current practices. The Affordable Care Act creates the expectation that, in order to benefit from the new opportunities, the criminal justice system’s approach to health care access will have to change. As with most system changes, planning will be critical for success; implementation will take time and focus to ensure that new procedures meet the needs of the entire system and, most importantly, make a difference in the lives of justice-involved populations.

Change to any system is process-driven and requires focus and attention from multiple sources. It will take a group of dedicated individuals who are willing to take on the challenges of implementing new ways of doing business. Ensuring that everyone begins with the same knowledge and understanding of both health care reform and the criminal justice system will be vital in making the appropriate system changes.

This document will provide information about the necessary steps for implementing health care reform for adult populations within corrections and criminal justice agencies. Each part of the document will describe the information that will be needed to complete the checklists at the end of the document. There are separate checklists for each intercept: courts, probation/parole, jails, and prisons (Attachments C – F). Each intercept has separate checklist for states that have expanded Medicaid, and non-expansion states that have maintained eligibility criteria pre-dating the passage of the Affordable Care Act. Checklists also accommodate state policy differences on the suspension or termination of Medicaid benefits when justice-involved individuals are incarcerated.

Endnotes1 NRRC Facts and Trends, National Reentry Resource Center, Retrieved July 2015, http://csgjusticecenter.org/nrrc/facts-and-trends/

2 American Correctional Association, webcast ACA The Patient Protection and Affordable Care Act, uploaded March 10, 2014, https://www.youtube.com/watch?v=kY7FMmULlhI&feature=youtu.be

3 State and Local Initiatives to Enroll Individuals in Medicaid in Criminal Justice Settings, John Hopkins Bloomberg School of Public Health, Center for Mental Health and Addiction Policy Research, http://www.jhsph.edu/research/centers-and-institutes/center-for-mental-health-and- addiction-policy-research/research/economics-and-services-research/arnold-foundation-project-map/

4 Federal Interagency Reentry Council, webpage available at https://csgjusticecenter.org/nrrc/projects/fire

5 Munetz, Mark R., and Griffin, Patricia A. GAINS Center for Behavioral Health & Justice Transformation, funded by Substance Abuse and Mental Health Administration (SAMHSA), Center for Mental Health Services

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Knowing the BasicsSection1

The information presented will be essential for understanding health care reform. Parts of the information may be familiar to some; to others, the information will be new. However, ensuring that everyone involved begins with the same knowledge will be important. For additional reference, this document provides links to resources that have been developed by federal agencies, state and local governmental entities, national associations and nonprofit groups.

The Patient Protection and Affordable Care Act (Public Law 111-148) (hereafter “the Affordable Care Act”) created changes in the availability of health insurance by expanding coverage, holding insurance companies accountable, and guaranteeing more coverage choices for consumers. It lowers health care costs for some individuals and expands the Medicaid program in the states that opted for expansion. The Medicaid expansion removes the categorical exclusions and bases eligibility solely on income (e.g. adults without dependent children). People who are below the federal poverty guideline of 133 percent are eligible. In 2015, that is an individual income less than $15,654 annually or $1,304 monthly. This group was targeted because many were uninsured or underinsured, which has an impact on the cost of health care.

In addition to Medicaid expansion, the Affordable Care Act contains state requirements, like streamlining the Medicaid application to make it easier for individuals to apply, using the tax code definition of income for determining eligibility, and creating Marketplace sites for purchasing private health insurance. The Marketplace created ways to compare health insurance plans and pricing. There are plans that offer catastrophic coverage only or plans that have small co-pay amounts with higher premiums. These different types of plans allow the consumer to select a plan that meets their individual needs. Some states have created their own Marketplace sites, and other states are utilizing the federal site. Based on the income guidelines, individuals or families with incomes between 100 percent and 400 percent of the federal poverty level could qualify for a tax credit that would lower the cost of their premiums. Additionally, individuals with incomes between 100 percent and 250 percent of the federal poverty level could be eligible for additional cost sharing to help subsidize deductibles and co-payments.

Important to the discussion about the Affordable Care Act is mental health parity. Parity began as a result of the Mental Health Parity and Addiction Equity Act of 2008. This act prevented group health plans and health insurance carriers from setting limitations on behavioral health benefits lower than medical/surgical benefits. This concept of parity was also included in the Health Care and Education Reconciliation Act of 2010 and the Affordable Care Act. As individuals transition from incarceration to communities, they may be referred to community-based providers to continue treatment. Increasing the number of individuals who have health insurance coverage through Medicaid or Marketplace plans, the parity requirement increases the possibility that behavioral health care treatment will be available to those who need it.

There have been several challenges to the Affordable Care Act; however, not all of them will be discussed in this document. A significant challenge was presented in National Federation of Independent Business v. Sebelius, a Supreme Court case that resulted in allowing states to choose whether or not to expand Medicaid benefits. Currently, 31 states and the District of Columbia have expanded benefits and have adapted the new eligibility criteria. As allowed in the Affordable Care Act, the federal government pays a higher proportion of the cost for newly eligible individuals into

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Section 1: Knowing the Basics

the expanded Medicaid programs. The proportion that the federal government pays for individuals is called the Federal Medicaid Assistance Percentage (FMAP). In expansion states, the FMAP rate paid to the state Medicaid agency for the newly eligible population is 100 percent through FY 2016 and will decrease to 90 percent by 2020, but not go lower than 90 percent. This higher Medicaid rate has assisted states in increasing the number of people on Medicaid without comparable increases in the state share of their Medicaid budgets. States that did not expand are not receiving the increase in dollars but still get the FMAP of at least 50 percent for their existing Medicaid populations.

These changes have positive results for the justice-involved populations. High percentages of this population are likely to qualify for Medicaid or for affordable private health insurance coverage through the Marketplace. While there are various limitations and exclusions during incarceration, those limitations do not apply to individuals on pretrial release or who are on probation or parole. Additionally, Medicaid may be available for in-patient care during incarceration and states can determine whether an individual is Medicaid eligible while incarcerated so that Medicaid payments are available on release from incarceration. Beginning in January of 2017, enrollment 60 days prior to release will also be available through the Marketplace. For justice-involved individuals, access to health services may mean the difference between staying in the community and returning to jail or prison. Treatment that began in incarceration will more easily be continued in the community, providing stabilization for behavioral health and other conditions. This continuity of care is critical, especially for those with mental health and substance use disorders.

What Is Medicaid?Medicaid is a state-federal partnership to meet the health needs of vulnerable populations. It was created in 1965 through

the Social Security Act. The Affordable Care Act has increased the ability of the Medicaid program to provide health coverage for most low-income adults. Previously, it primarily covered children, pregnant women, parents, seniors and individuals with disabilities. The federal guidelines for Medicaid are determined by the Centers for Medicare and Medicaid (CMS), part of the U.S. Department of Health and Human Services. The federal guidelines allow significant state flexibility in determining benefits that will be covered, eligibility and enrollment procedures, and benefit delivery systems.

State Plan Eligibility CriteriaEach state has a State Medicaid Plan that governs what and how benefits will be provided and to whom they will be

provided. State plans are changed by submitting a State Plan Amendment (SPA) that must be approved by CMS. All states must provide Medicaid to children, pregnant women and parents either through Medicaid or a combination of Medicaid and the Children’s Health Insurance Program (CHIP). States must also provide coverage for elderly adults and disabled individuals. Eligibility criteria for coverage of the disabled differ from state to state. For example, some states link eligibility for Medicaid coverage to receipt of Supplemental Security Income (SSI), a means-tested Social Security program for low-income adults with disabilities. Other states determine eligibility based on disability that is not linked to SSI payments. Because every state establishes its own eligibility criteria, it is vital that all correctional professionals understand what eligibility categories or criteria their state is using. States must maintain their pre-Affordable Care Act eligibility criteria for mandatory Medicaid populations. For the adults newly covered by the Medicaid expansion authorized in the Affordable Care Act, eligibility is based on federal established income guidelines plus federal and state requirements regarding residency, immigration status and documentation of U.S. citizenship.

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In states that did not expand Medicaid as a result of the Affordable Care Act, it is still possible to enroll justice-involved individuals in Medicaid under the existing state plan. The number of individuals covered will be much lower and it may be more challenging; however, the reward will be worth the effort. For example, documenting that an individual has a disabling condition could result in a determination of eligibility for Medicaid coverage and approval by Social Security for SSI. This could greatly benefit the justice-involved individual as they return to the community in that they will not only have health care, but also income to meet their basic needs.

When individuals qualify for Medicaid, the coverage remains in place for a specific period of time, within the federal requirement of a yearly redetermination of eligibility. States can require more frequent eligibility redeterminations but CMS is encouraging states to use a 12-month eligibility determination period. States also have to be cognizant that there are some additional rules that govern when individuals are incarcerated. Once a person is incarcerated the federal government cannot reimburse for Medicaid eligible costs for out-patient services. The issue of suspending or terminating benefits is discussed later in this section. This information is especially relevant for justice-involved individuals who frequently move from the community to jail and back to the community. If, when arrested, an individual is allowed to remain in the community, their Medicaid coverage remains active.

Enrollment StrategiesThe Kaiser Commission on Medicaid and the Uninsured has published an issue brief that provides insight on enrollment

strategies.6 The purpose of the commission is to provide information and analysis on health care coverage and access for the low-income population, with special focus on Medicaid’s role and coverage of the uninsured. The five key lessons for developing enrollment strategies can help correctional and criminal justice agencies develop their enrollment approaches.

First, the commission found that the majority of individuals believe that health coverage is important and would enroll in Medicaid if they were eligible. The coverage that Medicaid offers provides services, peace of mind and protection from large medical bills. Being able to access health care before the need for care becomes a crisis is important and another reason why individuals would benefit from enrolling in Medicaid. These factors are the same for justice-involved populations and potentially their family members.

The second and third key lessons combine broad and targeted outreach strategies, making enrollment more accessible for individuals by reducing barriers. Targeting justice-involved individuals with high health care needs is an example of a specific group for enrollment. Making posters and educational materials visible and available in courts, probation/parole offices and throughout jails and prisons would be examples of broad outreach. Jails and prisons may engage multiple staff in outreach efforts, including correctional staff, teachers and health care providers. Probation and parole offices need to coordinate with community health care providers to reinforce the importance of enrolling in Medicaid coverage. Ensuring that information is available in English and other primary languages spoken by justice-involved individuals would assist in reducing barriers to the application process. Most Medicaid agencies have information available in English and Spanish.

The fourth lesson validates the importance of one-on-one assistance. Utilizing volunteer groups may be part of the process and could provide the one-on-one contact. Local Medicaid offices have staff that provides assistance through face-to-face contact with individuals. It is important to consider cultural competency and the availability of bilingual staff or volunteers for this type of assistance.

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The final key lesson focuses on renewals of coverage. Probation and parole offices may have more contact with justice-involved individuals and need to understand the importance of re-enrollment. However, this information should be included in any health literacy programs that are provided in jails and prisons so justice-involved individuals have an understanding of the renewal requirement and will be prepared to keep their enrollment current after they return to the community.

Expansion vs. Non-expansionUnder the Affordable Care Act, 31 states and the District of Columbia have removed the previous categorical exclusions

and expanded their Medicaid program. This coverage is available for individuals with incomes under 133 percent of the federal poverty guidelines. Many justice-involved individuals are newly eligible under Medicaid expansion. In July 2012, BJA reported that New York City estimated that 80 percent of individuals in jails are either enrolled or eligible to enroll, and Illinois estimated that 300,000 of the 500,000 to 800,000 new Medicaid enrollees would have justice involvement.7 Regardless of whether states have expanded to include single adults, there are changes to all Medicaid programs that will have positive impacts for correctional systems:

1. The simplified application form will make it easier for justice-involved individuals to complete an application. 2. Streamlined income guidelines for determining eligibility known as Modified Adjusted Gross Income (MAGI)

will make it quicker and more efficient to determine eligibility. Guidelines are based on income tax definitions.3. Increased use of presumptive eligibility (see explanation below) by hospitals and other entities will provide

more opportunities for payment of care in the community for justice-involved individuals.

Figure 1 shows the current listing of Medicaid expansion and non-expansion states. States continue to evaluate whether to expand. The following graphic illustrates expansion and non-expansion states.

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Figure 1.

States are continuing to evaluate expansion decisions. Below are two websites with interactive maps showing the most current and accurate information.

• CMS State Medicaid and CHIP Profiles: http://www.medicaid.gov/medicaid-chip-program-information/ by-state/by-state.html.

• The Legal Action Center web tool is State Profiles of Health Care Information for the Criminal Justice System. The site has information about Medicaid, health systems and health insurance options: http://lac.org/press- release-legal-action-center-announces-release-of-state-profiles-of-health-care-information-for-the- criminal-justice-system/.

Expansion states – Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota,Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, West Virginia and the District of ColumbiaNon-Expansion states – Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina,Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming

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Suspend vs. Terminate BenefitsCMS recommends that states suspend rather than terminate benefits when individuals enter jails/prisons but states

have the flexibility to make that determination for themselves. All state plans specify whether Medicaid benefits are suspended or terminated when individuals enter jails/prisons. This decision is independent of whether states expanded Medicaid. Research conducted by the American Correctional Association shows that there are 14 states (Arizona, California, Colorado, Connecticut, Florida, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, New York, North Carolina, Ohio, and Oregon) that currently suspend benefits, and one state, Texas, that suspends benefits for 30 days and then terminates. The decision to use suspension instead of termination is within the authority of the state and can be changed by submitting a State Plan Amendment (SPA) to CMS.

If the state has chosen to suspend benefits, reactivation is much easier and benefits can be reactivated anytime within the one-year eligibility period. If benefits are terminated, a new Medicaid application must be completed and approved. If benefits are suspended instead of terminated, it reduces the workload involved for both correctional agencies and state Medicaid offices because benefits are reactivated upon release from incarceration and applications do not have to be completed. Since Medicaid coverage generally remains in place up to one year, this could be especially valuable for jail populations that generally have sentences of one year or less.

Arizona (Expansion State) The state Medicaid agency made a decision to put a procedure in place for suspension rather than termination. They have

intergovernmental agreements with counties and exchange information electronically.

California (Expansion State) In 2013, the state legislature passed a bill to suspend Medicaid during incarceration and has a process for enrolling

eligible individuals prior to release.

Texas (Non-Expansion State) For the first 30 days of incarceration, Medicaid benefits are suspended. After 30 days, benefits are terminated. This is

to prevent loss of benefits for those with short stays.

States that terminate benefits when justice-involved individuals are incarcerated should consider evaluating a change to suspending benefits. The workload would be comparable for terminating or suspending benefits on initial incarceration whether it is done manually or through some electronic process. However, other aspects of managing eligibility would be reduced with suspension. For example, the number of new applications that need to be filled-out and processed would be reduced with suspension, gaining efficiencies for both the corrections and Medicaid work forces. Even when focused on short term stays, such as the Texas 30-day suspension model, there would be a reduction in duplicated efforts, especially for the jail population. The outcome for every agency involved has the potential to remove redundancy and will likely increase the probability of successful reentry for justice-involved individuals.

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Presumptive EligibilityPresumptive eligibility allows non-Medicaid agencies to determine temporary eligibility for Medicaid on the

presumption that the client most likely meets the eligibility criteria. Prior to the passage of the Affordable Care Act, presumptive eligibility was mostly used by hospitals to obtain coverage for individuals who did not have other health insurance. Its use has been expanded to other agencies administrating programs that serve individuals who are likely eligible for Medicaid, such as SNAP and TANF. Some correctional agencies have worked with their state Medicaid office to utilize presumptive eligibility as part of reentry programming. Advantages to presumptive eligibility include the ability of hospitals and other agencies to immediately enroll patients who are likely to be eligible under the state Medicaid eligibility guidelines. It is based on income, household size and, depending on the state, information regarding citizenship, immigration status and residency. Presumptive eligibility is a temporary Medicaid status, pending final determination by the state Medicaid agency. Depending on the setting and how presumptive eligibility was determined, it may be necessary to complete and submit an application to obtain ongoing Medicaid coverage.

For correctional agencies, the dissension to apply presumptive eligibility needs to be carefully thought out. It may create duplication of applications and approval processes. For example, if someone leaving jail/prison has presumptive eligibility, it remains in place for a limited timeframe. Prior to the end of the limited timeframe, that individual must apply, utilizing the regular Medicaid application, generally within 60 to 90 days. If the individual does not complete the application, Medicaid coverage ceases, and the individual could not reapply for one year. For presumptive eligibility to be successful, it is critical that mechanisms be in place to ensure completion of the application, as well as, close follow-up to prevent a lapse in coverage. This step could be completed by local Medicaid agencies or volunteer enrollment groups in the community, but it is imperative that the process happens. The process for enrollment may be streamlined by using the standard Medicaid application and working out mechanisms for approval or denial prior to leaving jail/prison. This process requires a single application and approval rather than layering and potentially duplicating steps.

Structure for Delivery of Medicaid Services Within StatesMedicaid has contracts for health services through mechanisms similar to other health insurance programs. There are

managed care options, traditional fee-for-service delivery models, and combination models. The trend is for states to move to a system of managed care. Thirty-nine states contract with comprehensive managed care organizations (MCOs) for services to some Medicaid clients; nationally, however, more than half of all Medicaid clients are receiving their care through these plans.8 Managed care models differ from state to state, with most having the enrollee select which MCO they want to participate in. Regionally based MCOs are assigned depending on the enrollee’s geographic location. It will be important to understand how enrollees are assigned within a state’s MCO structure as part of any enrollment strategies.

Each MCO has a network of health care providers that represent all aspects of health care, including specific hospitals or hospital systems with which they contract for services. They generally focus on preventive care as well as encouraging clients to utilize appropriate services. For example, often MCOs will have a call center staffed by registered nurses who will answer questions and help clients make decisions about health care needs. This might result in being seen in an office visit the following day instead of going to the emergency room.

Understanding how to navigate the health care system can be challenging, especially for justice-involved individuals. Health literacy programs can assist in understanding how to access primary health care providers and behavioral health services. Discussions might include the use of office visits versus the emergency room and how to locate pharmacies in the network. The basic structures of MCOs and how they contract and manage care would be useful information to include.

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Medically Necessary CareMedicaid, like commercial health insurance plans, uses criteria to determine that the health care being provided is

necessary to prevent, restore or treat illness in a clinical manner consistent among community providers. The definitions of medically necessary care for Medicaid are set by each state. It is important to understand this concept when dealing with treatments that are part of a court order or included as conditions of probation/parole. Treatment must meet the state’s definition of medical necessity for Medicaid to cover the costs. While court-ordered treatment for substance use disorders is certainly within the range of services that could be paid for by Medicaid, it will be important to ensure that treatment providers have input into the types of treatment that the justice-involved individual needs. Treatment providers must document in health care records how the treatment is “medically necessary care” for payment through Medicaid.

Treatment programs or providers must be approved Medicaid providers to receive payment from the Medicaid system. Criminal justice agencies will want to ensure programs they utilize for services, either existing or new programs, are Medicaid approved treatment providers. For those new programs, it will be important to establish relationships prior to referring the first new clients. Meeting with the new providers will begin the process of understanding the needs of the criminal justice agency as well as the treatment program requirements. Discussion about documentation requirements should be part of the conversation, including any release of information that the treatment program might request. Participation by the justice-involved individual will need to be documented for reports back to the courts or probation and parole. Some criminal justice information may be helpful to the treatment program, including risk/need assessments. Establishing a memorandum of understanding may facilitate the flow of information between the treatment providers and the criminal justice agency.

Health HomesIncluded in the Affordable Care Act was the opportunity for states to improve care coordination and care management

for Medicaid beneficiaries with complex needs through “health homes.” Health homes do not involve a physical location where services are obtained — rather they have staff who help clients manage their care to ensure that the appropriate services are provided. As of May 2015, 19 states, both expansion and non-expansion, had developed plans for health homes. Health homes integrate coordination of physical and behavioral health, long-term services, and support for high-need, high-cost populations. Health homes are designed to improve quality of care while reducing costs. Individuals who have two chronic conditions, or one chronic condition and are at risk for a second chronic condition or have serious mental illness, are targeted for health homes. The chronic conditions dictated for inclusion in health homes per Medicaid include mental disorders, substance use disorders, asthma, diabetes, heart disease, and obesity. States may choose to include other conditions in the health home plans as well.

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According to CMS: “The goal of the Medicaid health home state plan option is to promote access to and coordination of care. States have flexibility to define the core health home services, but they must provide all six core services, linked as appropriate and feasible by health information technology:

• Comprehensive care management; • Care coordination; • Health promotion; • Comprehensive transitional care and follow-up; • Individual and family support; and • Referral to community and social support services.”9

In the state plan amendments, health homes do not have to be available to all Medicaid beneficiaries; however, selective criteria cannot be utilized to isolate certain populations (such as the justice involved). As states establish health homes for beneficiaries with chronic conditions, the justice-involved population should be included since they experience a high incidence of chronic conditions. For example, many of these justice-involved individuals have mental health and substance use disorders as well as a high need of medical care and would benefit from comprehensive care management through a health home.

When justice-involved individuals are linked to health homes, they should receive enhanced case management services from the MCO that ensures the right health care is being provided. The intense level of case management assists in coordination between physical and behavioral health care. In Ohio, once a justice-involved individual chooses a managed care organization (MCO) and they have two or more health conditions, they participate in a health home and are targeted for at least one in-reach visit from the MCO to develop a health care transition plan. In Ohio, this is known as the Critical Risk Indicator Program. MCOs use the Ohio Department of Rehabilitation and Correction’s telemedicine system to communicate with the individual prior to their release. This coordination of care improves the transition from incarceration to community; justice-involved individuals have an increased understanding of where they will be receiving health care services in the community before they leave the correctional facility.

What Is the Marketplace?Each state has made a decision whether to create a web-based system for obtaining private health insurance, known as

the Health Insurance Marketplace (“Marketplace”). States either manage their own state-run Marketplace or rely on the federal site to house their state Marketplace. These sites have numerous health insurance plans available that can compare the types of coverage offered, and the cost for premiums, and health care insurance can be purchased. For individuals who qualify, there may be assistance with premium costs and reducing out-of-pocket costs.

The majority of justice-involved individuals will meet the financial guidelines for Medicaid; however, if they do not qualify for Medicaid, they may apply and be found eligible for reduced premiums through the Marketplace. Premiums are subsidized through tax credits, which require filing individual tax returns even when no payment may be owed. Typically, there will be a separate application for obtaining health care insurance through the Marketplace. If possible, corrections should consider how to facilitate the submission of a Marketplace application as part of their health care reform planning.

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Qualifying Life Event (QLE)There are two circumstances in which people can make changes in their Marketplace health insurance coverage. The

first way is during open enrollment periods. Open enrollment takes place annually and is usually publicized broadly in mailings and through newspaper and television advertising. Individuals who are in jail pending disposition of charges are eligible to enroll in Marketplace coverage as individuals or as part of their family’s coverage.

The second way changes can be made to health insurance enrollment is through Qualifying Life Events (QLE). Tribal members are exempt from needing a QLE and can apply any time for health insurance. Listings on the Marketplace websites and in health insurance information explain the kinds of circumstance that are QLEs. Commonly understood examples are the birth of a child or changes in family status, such as divorce. Moving from one geographic location to another or being released from jail or prison are also examples. QLEs allow for justice-involved individuals to sign up for health insurance within a specific time after release. Any post-release enrollment process should include this information, since the time-frame for making changes is usually within 60 days.

Individual Shared Responsibility PaymentBeginning in 2014, the Affordable Care Act requires each individual to maintain a minimum level of health care

coverage, and if coverage is not maintained, it requires an individual to make a shared responsibility payment when filing federal income tax returns. Most people who had insurance coverage for the entire year whether government sponsored, employer-based, or purchased through the Marketplace will not need to make a payment. There are several exemptions to the required payment including incarceration. Other types of exemptions include when coverage is considered unaffordable, there are short coverage gaps, or they are not eligible for Medicaid in non-expansion states. More information on payments and exemptions are available through the Internal Revenue Service and state or federal Marketplace websites.

Evaluation Evaluation strategies should be developed by first considering the desired end result. Any component or metrics for

evaluation should provide answers and information about how new procedures and processes are working. Evaluation metrics will indicate whether the program has been successfully implemented or will point to areas that need improvement.

“Putting the plan in writing helps ensure that the process is transparent and that all stakeholders agree on the goals of both the program and the evaluation. It serves as a reference when questions arise about priorities, supports requests for program and evaluation funding, and informs new staff.”10

Enrollment in Medicaid is one of the foundational goals of implementation of the Affordable Care Act. Some of the evaluation criteria may include the number of enrollments in correlation to the number of justice-involved individuals who qualify for Medicaid or some other form of health insurance.

Both financial and staffing resources are limited and may be maximized by conducting a cost-benefit analysis. A cost-benefit analysis offers a comprehensive, realistic way to understand all of the costs associated with doing business. This analysis captures the usual cost of staffing and resources but also helps to compare the investment dollars and the long-

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term benefits. For example, long-term benefits could be a reduction in recidivism rates. The Vera Institute of Justice’s Cost-Benefit Analysis and Justice Policy Toolkit11 is one resource that can be used in conducting a cost-benefit analysis. The toolkit outlines detailed steps necessary to complete the analysis.

Establishing Metrics for EvaluationWhen establishing an evaluation plan, it is vital to first identify the measures and targets for measuring the outcomes of

the project. The evaluation should help define what success looks like and how stakeholders and working group members will know when it is accomplished. The evaluation components should be structured to show both short- and long-term accomplishments. Data that is meaningful and accurate will justify the continuation or expansion of the program. Cost-benefit analysis is one aspect of evaluation, but there will also be other factors to consider. Time studies, as discussed in the Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM) section will need to be part of any evaluation metrics. MAC and TCM are discussed in detail beginning on page 23 of this section.

It is important to understand the data already being collected within the agency or system. This will assist in understanding the current functions and may provide measures to gauge the success of the proposed changes. This data may be utilized to establish a baseline. If the data points needed for future evaluations are not being collected, sampling may need to be completed prior to implementation of new programs. As the review of data collection is conducted, some elements may not be needed in the future. However, there are some data points that will continue for other informational purposes. If, after thoughtful analysis, the data is not needed, consider not collecting in the future, reducing the agency’s workload. Whenever possible, data collection should be conducted through electronic means.

The next table contains evaluation metrics that may be easy to implement and will provide information about the program’s success. This information is the minimum needed for an evaluation and could provide the baseline for more complex evaluations. Attachment B has more extensive metrics and it should be the goal to gradually integrate into the data collection. The long-term goal would be implementation of all the metrics in attachment B. Agencies will need to determine whether the sample metrics will provide the needed information or whether there are different metrics that would be more meaningful for evaluation purposes.

Table 1 Basic Metrics (Minimum Needed) New Admissions Eligible Enrolled

Any health care coverage Total Number Number Number

Of those, how many have Medicaid coverage

Number Number

Releases Eligible Enrolled

Any health care coverage Total Number Number Number

Of those, how many have Medicaid coverage

Number Number

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Agencies may want to consider contracting for evaluation services. The decision to contract for the evaluation should be made early in the process so they can assist with defining measures and other aspects of the evaluation. Colleges and universities would be another resource to explore for assistance. They may need student projects or internships that could assist with evaluation methods. Their services do not have to be limited to research, although that would be highly valuable. Colleges and universities might also be appropriate for working group membership, if they are available.

Potential Budget ImplicationsThere are costs associated with any project, and understanding the budget implications of implementation of certain

provisions of the Affordable Care Act will be important. Utilization of existing funded staff may reduce some costs of health care reform implementation; for instance, staff in the booking center of a jail may be asked to add more questions to screening tools or intake forms. Although this would increase workload, it should not require new or additional staff. Volunteers are another resource that may be used to conduct enrollment activities, which would not impact the budget and could help to relieve existing workload issues.

Linking justice-involved individuals to health care services, including treatment programs, may contribute to reductions in the number of individuals returning to confinement and, consequently, budgetary reductions. However, identifying the costs associated with the revolving door of justice-involved individuals may be difficult to capture. Reducing recidivism may translate to fewer occupied beds in jails and prisons or may translate to fewer community supervision staff needed to monitor individuals, potentially generating considerable savings.

In addition to reducing recidivism, there are at least two ways that Medicaid dollars can have a positive impact on criminal justice budgets. For jails and prisons, recovery of hospitalization costs will be essential. Courts, probation and parole as well as jails and prisons may be able to access Medicaid Administrative Claiming (MAC). (See page 23 of this section for a further discussion.)

Recovery of Hospitalization CostsWhen authorized in 1965, the Medicaid program was prohibited from covering the cost of health care provided to

individuals incarcerated in public institutions, like jails or prisons. The law provided an exception for justice-involved individuals hospitalized in health care facilities not controlled by the correctional system for more than 24 hours.12 The justice-involved individual must meet state plan eligibility criteria for enrollment into Medicaid for this cost to be recovered. Numerous hospitals have the ability to complete Medicaid applications for their patients, and this same system could be utilized with justice-involved individuals. If justice-involved individuals qualify by using either presumptive eligibility or Medicaid determinations, then the hospitalization costs could be billed to Medicaid for payment instead of to the correctional agency. This would generate a significant savings for jail and prison budgets.

Enrollment of justice-involved individuals during intake processes in jails/prison could positively impact the jail’s ability to obtain Medicaid coverage during hospitalizations. If this information is identified and tracked, and if justice-involved individuals are hospitalized, the hospital would submit billing to Medicaid instead of to the jail or prison.

Denver County Jail, Colorado (Expansion State)In the fall of 2013, the Denver County Jail began a process of enrollment for justice-involved individuals. They

worked closely with their local Medicaid agency and community hospital. During the first three to four months of

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implementation, Denver County Sheriff’s Department saved approximately $600,000 in outside medical costs.13 This savings was for hospitalizations longer than 24 hours.

North Carolina (Non-Expansion State)North Carolina Department of Public Safety and the state Medicaid office were directed by the state legislature to

establish a process for determining Medicaid eligibility for the DOC population. In 2012, the first year of implementation, 45 percent of hospitalizations were longer than 24 hours and were billed to Medicaid. This resulted in savings of approximately $13 million in 2012, and savings continue to be over $1.0 million each month.

Wisconsin (Non-Expansion State)Wisconsin Department of Corrections worked with the state Medicaid office to implement a procedure for

hospitalizations longer than 24 hours in April 2014. During fiscal year 2014, the savings were $2.4 million and in fiscal year 2015 totaled $9.1 million. Wisconsin is a non-expansion state; however, there is a waiver to cover single adults who are at or below 100 percent of the federal poverty threshold.

Louisiana (Non-Expansion State)Louisiana Department of Public Safety and Corrections has collaborated extensively with the state Medicaid office;

during fiscal year 2014-2015, 60 percent of all inpatient admissions were covered using the existing state Medicaid plan criteria. In fiscal year 2015-2016, Medicaid has already paid approximately $10 million and has $11.4 M in claims pending.

Medicaid Administrative CostsIt is possible to obtain up to 50 percent reimbursement for administrative activities directly related to obtaining

Medicaid coverage or assisting beneficiaries in obtaining care. This mechanism for reimbursement is often used by school systems, and states have developed written guidance regarding schools. Criminal justice agencies will need to have a discussion with the state Medicaid office and complete several pieces of documentation before billing for administrative costs can occur. Reimbursement will require a written plan and documentation of time spent on the administrative activities. The two specific types of reimbursement are Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM).

Documentation of time spent on administrative activities will require either a perpetual time study or random moment time study. Both require activity records of types and time to complete each activity. This will determine how much staff time is used to complete the administrative activities. There may be more than one staff member who would be included in any time study. The goal is to establish how much staff time could be included for billing purposes. If an agency is completing only one activity, then it could be done using direct billing while maintaining the records of the time spent on the activity. Accurate accounting for activities will be essential for successful billing.

a. Medicaid Administrative Claiming (MAC) is a joint federal-state program that provides reimbursement for the costs of administrative activities that directly support efforts to identify and/or enroll individuals in Medicaid or assist individuals gaining access to needed health care services. Some activity codes are reimbursed at rates up to 50 percent of costs for salary, benefits and other associated costs.

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Reimbursement could be for work that is already being done by existing staff. These activities could be billed through the following codes:

1. Medicaid Eligibility Intake — Applicable to most agencies and occurs when assisting individuals in completing a Medicaid application.

2. Medicaid Outreach — Applicable to agencies outside of jails/prisons; assisting justice-involved individuals to determine where services can be obtained and assisting in scheduling appointments.

3. Referral, Coordination and Monitoring — Applicable to agencies outside of jails/prison; may include activities monitoring justice-involved individual’s progress in treatment programs.

4. Arranging Transportation to a Medicaid-Covered Service — Applicable to agencies outside of jails/prisons; may include driving or arranging transportation to health care appointments, including behavioral health services.

b. Targeted Case Management (TCM) services are designed to help Medicaid clients access needed medical,

social, education and other services. Some of these services include accessing non-health care-related support, such as emergency housing, SNAP benefits, and energy bill assistance. TCM must include four areas: assessment, development of a care plan, referrals/scheduling and monitoring/follow-up. Most probation and parole staff currently include these four components in their casement of justice-involved individuals. All four components must be present in order to obtain reimbursement for the administrative activity. Appropriate documentation will be critical.

Correctional Agency StructureThere might be multiple stakeholder groups involved in the planning and implementation process for increased access

to health care that may not understand corrections or criminal justice systems and how they are organized. Providing an overview may be very useful as a baseline for developing potential solutions for implementing health care reform strategies. Remember to include information about the different levels of the court system, how they are connected and differences between city, county, and regional jail and prison systems. The information should describe jail/prison management, including topics like risk/need assessments and programing. Discussion should include community supervision, such as probation, parole and community corrections (halfway houses).

Another topic to include in the discussion will be how health care services are structured within jails and prisons. There are four primary staffing models for delivery of health care. Health care staff is often employed by the corrections agency and have a reporting structure within the system. Some corrections agencies employ some health care staff and have contracts for physicians, nurse practitioners, psychiatrists, mental health and substance use disorders treatment providers. Other agencies contract for the entire health care staff through vendors who specialize in correctional health care. The final model involves contracts with universities who provide the health care staff.

Regardless of the model for delivery, health care staff, including contract administrators who might be external to the agency, will need to be involved in the implementation process and should be part of the stakeholder or working group to assist with implementation strategies. They will be integral to the management of hospitalizations longer than 24 hours for possible Medicaid billing. The health information of the justice-involved individuals will be important for both prioritizing enrollment activities and linkages to health homes for reentry.

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Endnotes6 The Kaiser Commission on Medicaid and the Uninsured, Key Lessons from Medicaid and CHIP for Outreach and Enrollment under the Affordable Care Act, June 2013, Issue Brief, http://files.kff.org/attachment/key-lessons-from-medicaid-and-chip-for-outreach-and-enrollment-under-the-affordable-care-act-issue-brief. The commission is part of the Henry J. Kaiser Family Foundation.

7 Bainbridge, Andrea A., July 2012, The Affordable Care Act and Criminal Justice: Intersections and Implications, Washington D.C.: Bureau of Justice Assistance, U.S. Department of Justice.

8 Medicaid Moving Forward — Issue Brief, March 2015, The Kaiser Commission on Medicaid and the Uninsured, http://files.kff.org/ attachment/issue-brief-medicaid-moving-forward.

9 http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/downloads/ medicaid-health-homes-overview.pdf.

10 Brooks-Martin, A. (2015) “Plan for Program Evaluation from the Start,” National Institute of Justice Journal 275 (June), http://www.nij.gov/journals/275/pages/plan-for-program-evaluation.aspx?utm_campaign=eblast-ncjrs&utm_medium=eblast&utm_campaign=jnl275- progeval052015.

11 Vera Cost-Benefit Analysis and Justice Policy Toolkit, December 2014, http://www.vera.org/sites/default/files/resources/downloads/cba-justice-policy-toolkit.pdf.

12 The Council of State Governments, December 2013, Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System, http://csgjusticecenter.org/wp-content/uploads/2013/12/ACA-Medicaid-Expansion-Policy-Brief.pdf.

13 Video of Gary Wilson, Division Chief, Denver County Sheriff Department, 2014, Take Care — Health Matters, Colorado Criminal Justice Reform Coalition, at http://takecarehealthmatters.org.

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Begin the ChangeSection2Working or Stakeholder Group

This group will be instrumental in designing, implementing and ensuring that new processes are successful. When considering the appropriate members of the group, think about who will be champions of change. Looking at current structures may identify people who have been early adapters in other projects. The goal is to create an environment where creative solutions are welcomed, it is safe to institute new processes and change will take place. The following considerations may be helpful in assembling a working or stakeholder group:

1. Utilize an existing group(s) — There may be working groups already in existence within a jurisdiction that

may be effective for this purpose. These groups generally have structure and working relationships that would provide a forum for implementation of the new process. Because of the existing relationships, there may already be a degree of trust within the group that could be capitalized on to build momentum for a new program. However, the existing group membership may need to be modified. If members are added or removed, dynamics within the group will be different and may be more like a new group.

2. Establish working group — Whether you utilize an existing group or form a new one, refrain from making assumptions that community partners have worked together just because they are in the same community. The working group will need to spend some time establishing ground rules for working together. Membership in the group needs to be consistent, especially at the beginning of the project. This will reduce the re-education of members and allow the project to move forward more rapidly.

3. Consideration of potential stakeholders — Some stakeholders may be critical to developing the process, whereas others might be “messengers” for getting out the word on the process. There may be agencies/groups that will not have a role in implementing the process, but may still add value to the group. After an initial meeting, there may be groups who will opt out of the process. However, it may be important to continue to include them in documentation and educational processes. The stakeholder group would likely consist of top-level administrators; however, working group membership might also include lower-level staff in the organizational structure.

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Section 2: Begin the Change

Stakeholders selected for participation in designing and planning for implementation should represent all aspects needed for implementation. This will include individuals from the correctional or criminal justice agency as well as other agencies and groups. The following table identifies potential stakeholders who should be considered for membership in the stakeholder group. They are listed in the appropriate SAMHSA Gains Center sequential intercept.

Table 2

Intercept 1 Intercept 2 Intercept 3 Intercept 4 Intercept 5

Police Chief Crisis Intervention Team Leaders

*Staff involved with this Intercept may participate in working groups in Intercept Two and Three

JudgesPretrial ServicesDistrict Attorney/ ProsecutorPublic DefenderProbation OfficeLaw Enforcement/Police ChiefLocal Medical AgencyInformation/Data SpecialistLocal Safety Net Providers

• Food Bank• Housing• Federally Qualified Health Clinic

• Behavioral Health Clinic

Local Hospital(s)Nonprofit OrganizationsFaith-based Organizations

SheriffJail AdministratorCorrectional Health AdministratorCounty Governmental Officials

• Commissioners• Health Department

Local Medicaid AgencyProbation/Parole OfficeInformation/Data SpecialistSafety Net Providers

• Food Bank• Housing• Federally Qualified Health Clinic


Local Hospital(s)Nonprofit OrganizationsFaith-based OrganizationsMedicaid MCO

Department of Corrections ExecutiveState Medicaid AgencyState Budget OfficeGovernor’s OfficePrison WardensProbation/Parole OfficeInformation/Data SpecialistLocal/Regional HospitalsSafety Net Providers

• Federally Qualified Health Clinic


Nonprofit OrganizationsFaith-based OrganizationsSupport Groups for Justice-involved individualsMedicaid MCO

*If Jail – may have mem-bers from Intercept Three

Probation/Parole OfficeChief JudgeDepartment of Corrections Executive or Jail AdministratorCommunity Corrections Director/StaffInformation/Data SpecialistLocal/Regional Hospital(s)Safety Net Providers

• Food Bank• Housing• Federally Qualified Health Clinics

• Behavioral Health Clinics

Nonprofit OrganizationsFaith-based OrganizationsSupport Groups for Justice-involved IndividualsMedicaid MCO

Dispatch911

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Process AnalysisThere are many ways to analyze the current processes and systems. Any analysis needs to focus on

1. Understanding the current system, including strengths, gaps and weaknesses. 2. Identifying potential changes. 3. Designing the future process and system.

This is more than a SWOT (strengths, weaknesses, opportunities and threats) analysis. Participants in the stakeholder or working group may be familiar with various types of analysis that can be conducted. Systems mapping and Lean are two similar processes described below. The goal of these analyses is to understand how the current system works, including examination of gaps in the system that will inform the design of a new process that meets unmet needs and provides the anticipated results.

Systems MappingThe National Institute of Corrections (NIC) recently published guidance specifically for criminal justice systems that

are working on implementation of health care reform. The document states that

“Systems mapping creates opportunities for dialogue and relationship building between health and justice stakeholders. By working together to build a visual portrait of how individuals progress through the criminal justice system, health and justice stakeholders gain better understanding of their respective policies and practices. In addition, mapping allows jurisdictions to consider decision points throughout the entire criminal justice system when exploring opportunities to enroll criminal justice-involved individuals in insurance coverage.”14

The NIC document is based on work with the state of Connecticut and has step-by-step instructions that will be helpful in understanding the current system and the potential areas for change. It focuses on enrollment of justice-involved individuals in Medicaid, which is the initial step in implementing health care reform. Systems mapping could be used for other process changes that need to be accomplished, such as developing strategies for linking justice-involved individuals with health homes. If more than one facet is being mapped at the same time, it will be critical that a plan for implementation is completed for each facet and that the group has an understanding of the order of the steps. For example, it is not possible to link individuals to a health home until Medicaid eligibility is determined.

LeanAnother method of analysis is the Lean process. Lean was first utilized in manufacturing enterprises as a way to

identify waste and improve the end product. Edward Deming was one of the first to suggest that Toyota utilize Lean as a way to do more with less while empowering employees to improve processes.15 Lean is now utilized in many areas of business as a way to improve quality of operations through streamlining practices and reducing redundancy. It is similar to systems mapping in that both are identifying how things are currently done and what differences might be expected in the future. Several cities, counties and states have adopted Lean as the way to improve governmental agency

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functions. Attachment A Resources and References includes specific information from Colorado, Connecticut, Iowa, and Wisconsin about how they utilized the Lean process to improve state government. The following example provides information about applying the Lean process to corrections in Colorado.

ColoradoPrior to the expansion of Medicaid, the Department of Corrections (DOC) and the state Medicaid agency held a Lean

Rapid Improvement Event to plan for the expansion. The working groups had representatives from all areas that would be affected by the change, and an action plan was developed. In addition to that work, a document that describes another Lean process related to the DOC and the Colorado Board of Parole is Case Study: Lean Thinking in Corrections https://www.colorado.gov/pacific/sites/default/files/Case%20Study%20-%20Lean%20Thinking%20in%20Corrections.pdf.

Lean work is often completed in focused sessions of three to five days. The focused sessions are often referred to as rapid improvement events, or Kaizen events. Participants are selected for their knowledge of the identified processes. This may include representatives from multiple groups or agencies. This cross-functional team will identify the needed improvements and will develop a very detailed plan of implementation steps. Each step will have designated individuals responsible for tasks and target completion dates. Expected goals for the project will also be identified and evaluation metrics will be established. Often, the team will brief leaders of the organizations or agencies at the end of each day as to the progress in the focused event.

After the focused event, there will be periodic meetings to report on the progress of implementation. Completion of tasks are discussed and potential modifications considered. There may be items that have taken longer than expected to complete and may have to be reconsidered. A review of data will provide insight on the success of the project.

Information Collection and SharingInformation collected at every intercept may be valuable to some other part of the process. Reducing duplication of

information gathered and not having to repeat the questions will streamline efforts while reducing the potential for errors. In an ideal situation, the information would automatically populate and migrate from one setting to another. Imagine

if, at the time of initial arrest, information gathered such as name, date of birth, and address could begin to automatically populate other necessary documents and perhaps include health care insurance information. At court processing, the next step might be to gather more information that would be provided to the detention setting. Some of the information might populate portions of the health care record. The information would also flow back and forth through all of the intercepts without anyone having to reenter the information.

Pima County, Arizona Pima County and state officials are working to connect the jail’s correctional health system to Arizona’s community

Health Information Exchange (HIE). Phase One developed a system that allowed health care staff to access the jail’s booking information to populate the electronic health record.16

Sharing information is complicated, even within the same agency. The complications are multiplied when the information is being shared across agencies. Criminal justice and health information are governed by different rules, and it is critical that any information-sharing meets all necessary laws, regulations and sometimes professional standards. For example, most people are familiar with the Health Information Portability and Accountability Act (HIPAA) and how some

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areas of health care changed as a result. It will take many discussions to sort through what and how information should be shared. Here are two resources that have detailed information about sharing health information between agencies:

The Justice and Health Connect website has a tool kit that provides the framework for planning and implementation of records sharing. The toolkit has four modules that will guide agencies through steps involved in sharing information. It is available online at: http://www.jhconnect.org/toolkit.

The American Probation and Parole Association and the Association of State Correctional Administrators have a document titled Corrections and Reentry: Protected Health Information Privacy Framework for Information Sharing. This document will assist in planning and implement the sharing of appropriate records. It is available online at: http://www.appa-net.org/eweb/docs/APPA/pubs/CRPHIPFIS.pdf.

SAMHSA Gains CenterThe SAMHSA Gains Center focuses on expanding access to services for justice-involved individuals with mental

and/or substance use disorders. Their website has a number of valuable tools and information and is listed in attachment A, Resources & References. This portion of the document is organized utilizing the SAMHSA Gains Center sequential intercept model. Each intercept will have information about activities that could be completed within the agencies involved. There are activities and processes that can potentially be duplicated in several intercepts; however, they may be completed by different personnel. Information that can be shared between the intercepts will reduce the duplication by multiple staff members and increase continuity. It is important to note that justice-involved individuals may not want to participate in enrollment the first time it is offered; however, they may want to enroll at a later point in the process.

Intercept 1 — Community and Law Enforcement Early Diversion Programs and Teen Court Programs For justice-involved individuals who are permitted to remain in the community during the pretrial phase, Medicaid

and Marketplace benefits do not change. This could have a significant impact on the individual’s ability to obtain health services, including treatment for mental health or substance use disorders. Even after sentencing, if the justice-involved individual can be safely managed in the community, their health care benefits do not change. While this will not be applicable in all cases, it will be critical for judges to understand the positive impact that continuing access to services would have for the individual and the community.

Several documents are available online for more assistance with this intercept. One example is A Culture of Coverage for Justice-Involved Adults in Illinois.17 Even though the document is written for Illinois, it contains valuable information that could assist other jurisdictions. Another document is a case study of Cook County, Illinois, and their pretrial system.18

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Intercept 2 — Arrest and Initial Detention/Court Hearing During the initial detention, pretrial or booking process, there are opportunities to gather additional information

without delaying these processes. It is critical to obtain information about health insurance and other benefits somewhere during the initial processing of the justice-involved individuals. Ideally, there would be an electronic system in place that would easily allow the information to be shared between different areas, such as pretrial and booking in the jail.

The additional questions would include

• Are you or have you been enrolled in Medicaid? If yes, when?• If not Medicaid, do you have some other type of health insurance?

o If Marketplace, do you have private insurance or is your coverage employer-based? • Have you been receiving disability benefits?

If pretrial services are not available, it may be important for public defenders or prosecutors to ask this additional information. For example, if the person being arraigned has Medicaid benefits and remains in the community, nothing changes in their ability to access health care services. Remaining in the community would also ensure that SSI and Marketplace insurance coverage will not be suspended or terminated. This might be particularly helpful with diversion or specialty courts. If the individual does not have Medicaid but would be eligible, then a referral to an enrollment assister could be valuable and provide an opportunity to obtain needed services. Ideally, this could be done prior to the individual leaving the courthouse. If not, then providing information about possible enrollment mechanisms will be important. Enrollment might be completed by local Medicaid staff, contracted groups doing enrollment work, perhaps through the Marketplace, or volunteers from nonprofits such as Enroll America.

Intercept 3 — Jails/Courts If the information obtained from pretrial or booking is provided and shared, the next steps in the process will be

simplified. If the information has not been asked, then the same questions as listed above in Intercept 2 should be included during the booking process.

Another opportunity to gather information would be during the health screening. Along with those listed in the text box, more focused questions about the health status of the individual is vital. These questions are designed to understand the health insurance status of the justice-involved individuals and create a prioritized list. It is likely that there would not be sufficient resources to enroll everyone being processed into the jail/prison. The information gathered will assist in creating a priority list of names for the staff or volunteers who are doing the enrollment processing. Prioritization would include previous enrollment, health conditions or emergent conditions requiring community treatment and a potential release date from jail/prison. Health conditions would include physical and mental health status as well as substance use disorder treatment needs.

If electronic records are being utilized, the information ideally would appear in both the health record and the custody management system. However, if the records systems are separate or being managed by a paper process, it will be important that information is being shared across units. Reduction of duplication of efforts requires that only one unit ask for the information and subsequently share with other appropriate units. Information flow is challenging and may take special focus to ensure that all appropriate units receive key information.

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The group or groups designated to complete the enrollment process would ideally begin their work later in the process. There are several avenues to explore in obtaining assistance with enrollment activities. Navigators may be available through the Marketplace in your state and are grant funded. Another option may be certified application assisters; these may be provided by a variety of sources, including the local Medicaid agency, community health centers, contracted groups doing enrollment work through the Marketplace or volunteers from nonprofits such as Enroll America.19 If your agency wants to develop its own volunteer or paid workforce to provide enrollment assistance, thoughtful assessment is required. Agencies should consider accessing MAC as one avenue for financing the effort. Most agencies will want to consider external resources, since staffing can be financially challenging.

Medicaid and private health insurance are just one facet of reentry programming. Other programs with specialized case management services will be helpful for managing justice-involved individuals. Identification of other possible services early in the process will allow more opportunity to connect individuals with services. Veterans and those eligible for Indian Health Services (IHS) coverage are two groups that can receive specialized services. Social Security disability determination should also be discussed. Adding questions about veteran and IHS status at booking and assigning disability determination to the health care staff would help streamline identification of applicable services.

Notification of incarcerated status may need to be provided to state Medicaid agencies as a result of this process. When discussing notifications with state Medicaid officials, it will be important to avoid using arrest and booking as the determining factor for notifications. Notifications that occur after an individual has been incarcerated for several days may reduce the workload for both criminal justice agencies and state Medicaid staff. The discussion should streamline reporting and reduce the number of individuals who would need to reapply for benefits. Potential solutions should be applicable whether the state suspends or terminates Medicaid benefits and might even apply for notifications to the Marketplace.

Arizona The Arizona Medicaid agency (Arizona Health Care Cost Containment System, AHCCCS) developed several

documents for the transfer of information regarding Medicaid from jails. In the Intergovernmental Agreement for AHCCCS enrollment suspension, an individual detained at a jail will not be considered incarcerated until both of the following have taken place: an initial court appearance has occurred and a minimum of 24 hours have elapsed since the time of the individual’s detention. Additionally, those individuals serving a sentence on weekends will not be included in the information.

TexasTexas implemented suspension of benefits for the first 30 days of incarceration. This process reduces the number of

justice-involved individuals who will lose benefits, since average length of stay in jails is frequently shorter than 30 days. It also reduces the number of re-applications that must be processed by enrollment specialists and the state Medicaid office.

Enrollment activities commenced in this intercept should prioritize efforts toward justice-involved individuals with health needs. The correctional health care staff may identify individuals through the course of their work and provide those names to the enrollment assisters. The list may include individuals who have received community health care after the booking process was completed. If the individual was seen in the community and hospitalized for more than 24 hours, enrollment should be a priority. The hospital may have enrollment assisters and be able to submit an application directly to Medicaid. Hospitals may also be utilizing presumptive eligibility, which would provide temporary enrollment

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into Medicaid. If the justice-involved individual is found to be eligible and requires an appropriate length of stay in the hospital, these expenses should be billed directly to Medicaid rather than paid from the correctional facility budget.

Hospitals utilizing presumptive eligibility may not utilize the regular Medicaid application process. If an individual did not complete the application in the hospital, they will need to be prioritized to complete the application prior to leaving the jail or prison. Submitting an application through the regular channels must be completed usually within 60 days for coverage to begin at community reentry. This will be especially important in jail settings, since the justice-involved individual may be released within the 60-day timeframe. There may be a few states that approve presumptive eligibility for 90 days instead of 60. This should be verified with the state Medicaid office. Presumptive eligibility provides Medicaid for only a short period of time.

It should be understood that justice-involved individuals who are incarcerated are not eligible to receive full Medicaid benefits until leaving the jail or prison. Depending on the state, the application may be processed within a specific number of days prior to release with the Medicaid benefit beginning upon release. For other states, the application may need to be held and processed at the time of release. If possible, the justice-involved individual should leave with a Medicaid card in hand so that they will immediately have access to any community health care services they may require. Ideally, individuals with health care needs would also have appointments scheduled with community-based health care providers upon release. Arizona, Colorado and Ohio have instituted issuing Medicaid cards to individuals as they are released.

One of the results of the Affordable Care Act was a streamlined application for Medicaid. Most states have developed an online application that may be accessed through appropriate channels within the jail/prison system. If paper applications are utilized, the enrollment assisters must obtain a written consent signed by the justice-involved individual. This will allow the enrollment assisters to enter application information on behalf of the individual.

Enrollment activities can be accomplished in many ways depending on the intercept and will often be available multiple times. Justice-involved individuals may not want to participate in enrollment in jail or prison, but may be interested in completing the application once they are in the community. The following strategies adopted by various states illustrate different approaches.

OhioOhio Department of Rehabilitation and Correction (ODRC) have been working closely with their Department of

Medicaid on establishing an enrollment process. They began enrollment in the women’s facilities and will be adding all-male prison facilities in 2016. ODRC utilized offenders to produce an infomercial type video about the enrollment process and is showing the video on closed circuit television throughout their facilities. Additionally, they selected and trained inmates in the enrollment process and the MCOs in Ohio. This program is called the Peer to Peer Medicaid Guide. These individuals are helping others understand the process and what each MCO has to offer. The enrollment process is completed, and the MCO selected prior to leaving the prison and by telephone. Corrections staff are present while the offender is on the phone with the Medicaid agency. The inmate receives the Medicaid card when they leave the prison.

Maricopa County, ArizonaIn 2013, the Maricopa County Sheriff’s Office, Adult Probation Department and Correctional Health Services, the

contractor for health services in the jails, along with other county agencies formed the Health Care Integration (HCI) working group to develop enrollment strategies. Activities began in the probation department in February 2014 and in jails in June 2014. Several groups assist with enrollment activities and educational programs for justice-involved individuals. Nonprofit groups Enroll America, Keogh Health Connection, Phoenix Day and the Maricopa Integrated

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Health System work together to provide enrollment and educational programs for justice-involved individuals in the court, jails and probation offices. Probationers can earn community service credit hours for attending educational classes. There is on-site enrollment at the courts, and probation officers screen for health insurance information, referring those without to enrollment assisters. Health care outreach contact cards are available in the jail clinics, and information posters are displayed throughout the jails and probation offices.

Philadelphia, Pennsylvania Philadelphia Prison System (Jail) is beginning enrollment work with the recent expansion of Medicaid in Pennsylvania.

The first group they will focus on is justice-involved, sentenced individuals who are seriously mentally ill. These applications will be submitted electronically, and when released the justice-involved individuals will go the city reentry center which will contact the state Department of Welfare to activate their Medicaid benefit. Another effort in development is use of the “Benefit Bank of Pennsylvania.” The Benefit Bank has a lengthy, online application that allows individuals to apply for multiple services to include Medicaid, housing and other programs. To assist justice-involved individuals, the jail will first use its social services staff. Philadelphia is exploring engagement of graduate level nursing and social work students from local colleges to aid additional inmates, and church volunteers to aid families of incarcerated individuals who also need benefit supports. In addition, the jail has an electronic health record of inmates clinical histories, current complaints, current medications, pending appointments, etc., all of which can be sent electronically to community providers upon release of an inmate. Ultimately Philadelphia aims to secure community appointments for all chronically ill inmates to ensure continuity of care after release.

Denver, Colorado The Denver County Jail has worked closely with their local Medicaid agency to enroll individuals while still

incarcerated. All individuals booked into the jail are matched against the Colorado Medicaid database. Medicaid staff can identify eligible individuals who are not already enrolled and prioritize individuals with health care problems, especially if they have needed community hospitalization. Interviews are scheduled in all housing units at both county jails. Paper applications and consent forms are utilized that allow for Medicaid staff to complete the electronic application. At the time of release, the justice-involved individual signs the paper application and it is transmitted electronically for approval or denial.

ConnecticutConnecticut has a unified system of prisons and jails. Connecticut DOC conducted a pilot with the state agency

for mental health several years prior to implementation of the Affordable Care Act. Since then, they have developed strategies for enrollment activities at every intercept. Court services staff hand out applications, and when completed, the application is faxed to Medicaid. Probation officers utilize DOC prison personnel to assist in getting the application completed. Health care staff assists justice-involved individuals who have health problems and need medications with enrollment activities. Reentry specialists and reentry teachers assist with paper applications. Connecticut DOC utilizes presumptive eligibility for Medicaid, and when released, justice-involved individuals on medications are given a voucher. With the medication voucher, individuals obtain their medications at the community pharmacy.

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Enroll America Enroll America is a nonprofit group that focuses on enrollment activities throughout the country. They have

volunteers in numerous communities who are trained to assist others in completing applications. Their program, “Get Covered America,” has a plan to work in Arizona, Colorado, Florida, Georgia, Illinois, Michigan, North Carolina, Ohio, Pennsylvania, Tennessee and Texas. They continue to work on expanding their services in other locations and may be another option for agencies to utilize.

It is likely that correctional systems are already tracking justice-involved individuals who have been hospitalized in the community and monitoring them closely. In addition to monitoring the individual in the hospital, a focus should also be on ensuring that a determination of Medicaid eligibility be made. A process for tracking any hospitalization for more than 24 hours could trigger a discussion with the community hospital and may result in a determination of Medicaid eligibility. These measures have the potential to positively affect the budget of the jail/prison. A mechanism to work closely with community providers and hospitals should be built into the communication plan so that when hospitalizations occur, a determination of Medicaid eligibility can be completed.

If hospitals are not utilizing presumptive eligibility and want to exercise this option, they should discuss the process with their state Medicaid agency. Enroll America has information and a tool kit to assist hospitals with presumptive eligibility. From their website:

“For years, states have had the option to use presumptive eligibility to connect pregnant women and children to Medicaid. The Patient Protection and Affordable Care Act gives hospitals a unique new opportunity to use presumptive eligibility to connect all patients to Medicaid, as long as they appear to meet the state’s income guidelines for Medicaid eligibility. Hospitals in any state can elect to make these determinations — regardless of whether the state expands Medicaid eligibility or exercises the existing ability to allow presumptive eligibility for other populations or settings. Hospitals must agree to abide by state policies and procedures, but the choice to make presumptive eligibility determinations rests with each individual hospital, not with the state.”20

As with any new process, it will be essential that staff at all levels and throughout the facility understand the plan and the importance of the efforts. During the planning process, it is recommended that a strong communication plan is developed. Informing staff as the process unfolds will increase the success.

Another part of planning will include a communication plan targeted to the justice-involved population. Navigating the health care system can be difficult for the general public, and even more difficult for the justice-involved population. They may have limited experience with Medicaid or other health insurance and may not know what this means for themselves and their families. Information about what it means to have health insurance, why it is important and how to access health care are examples of information that should be covered.

Several innovative approaches are utilizing justice-involved individuals as part of the health literacy educational process. Flyers, posters and videos in addition to classroom programs can be valuable tools. Staff from different areas of the facility might also be involved; for example, health care staff might teach one class, and then a teacher or correctional officer might teach another.

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Ohio Ohio Department of Rehabilitation and Corrections is using offenders to teach others about the choice in Medicaid

Managed Care Organizations. These groups of trained individuals (Peer to Peer Medicaid Guides) have the materials and discuss one on one regarding the MCO, their similarities and differences. It has been a very positive experience for all involved. They have also utilized videos produced by offenders to provide information about the roll out plan and the information that offenders will need to provide when they visit with their medical liaison.

Denver, Colorado Denver County Jail is using video messages about the Affordable Care Act along with flyers and brochures in the

housing units. Justice-involved individuals can receive one day of earned time if they write an essay after viewing the video and review the written materials available.

Colorado Criminal Justice Reform Coalition This coalition created a website devoted to educating justice-involved populations. Take Care/Health Matters,

available at http://takecarehealthmatters.org, has videos and other resources including information for justice-involved individuals, criminal justice professionals and health care providers in Colorado. The videos may be used in any state as they discuss the importance of obtaining health insurance and are not specific to Colorado.

Intercept 4 — Reentry From Jails/Prisons to Community Jails and prisons must be focused on reentry efforts from the time justice-involved individuals first become

incarcerated. Utilizing the provisions of the Affordable Care Act should be only one aspect of a comprehensive plan that includes housing, job and other issues. It is critical that justice-involved individuals with health care needs are linked to essential services prior to leaving jail or prison. The ideal would be to match an individual with treatment providers in the community and set an appointment for follow-up treatment. Any process developed must also include continued access to medications.

If justice-involved individuals have not already completed applications for Medicaid earlier in the process, reentry planning would be another possible opportunity for enrollment. Most individuals will be eligible for Medicaid, but some segment of the justice-involved population may need to have assistance with Marketplace enrollment. Until January, 2017, when prospective enrollment will become possible, obtaining assistance for completing a Marketplace application will likely take place after the individual’s return to the community. It may be possible to provide them with contact information about community groups that can assist them. Enroll America has volunteers in many communities that would be available to help.

Linkages to community health services may be accomplished in a variety of ways. Resources like Federally Qualified Health Centers (FQHC) are one avenue that should be considered. Using the Medicaid health home model is another avenue to pursue. Establishing processes for transmitting health records to community providers is another key facet of developing reentry plans. Ideally, records would be transmitted electronically, however, even with paper records, it is important to ensure information is given to community providers.

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OhioMedicaid in Ohio wrote into their MCO contracts a requirement that justice-involved individuals who meet the criteria

for Medicaid eligibility and meet health home criteria have a visit from the MCO prior to leaving prison. The MCO visit is done using video conferencing.

ConnecticutConnecticut is maximizing access to FQHCs especially for justice-involved individuals with specialized needs. The

referral is provided prior to the individual leaving the prison.

Reentry planning would also include consideration of eligibility for other types of benefits such as veterans, disability through Social Security and Indian Health Services. These benefits are often not available or terminated as a result of being incarcerated for more than 30 days but can be reinstated to commence upon release.

Department of Veterans Affairs The Department of Veterans Affairs (VA) will reinstate veteran health care and disability benefits after incarceration.

Disability benefits will require documentation of release from parole boards or other official prison source indicating the scheduled release date. The VA has two programs designed specifically to reach justice-involved veterans. Health Care for Reentering Veterans provides direct outreach to veterans nearing their release date to ensure linkages to health care and other VA community services. The second program, Veterans Justice Outreach, is designed to reach veterans on the “front end” of the system to provide access to mental health, substance abuse disorders and other treatment resources. Every VA medical center has a Veterans Justice Outreach Specialist who can serve as the liaison between the veteran and criminal justice systems.21

Social Security AdministrationSocial Security benefits are suspended during incarceration with generally no time limit. Benefits can be reinstated

without filing a new claim but will require documentation of release. If a justice-involved individual wants to pursue obtaining benefits, there is a pre-release application procedure allowing for a new claim to be filed several months before the release date. If the individual was also receiving SSI before incarceration, these benefits are suspended if incarcerated for a full calendar year but can be reinstated. If the incarceration is more than 12 months, SSI eligibility is terminated and a new claim must be filed.22

Reentry planning should include information that will be provided to probation/parole staff. It will be important for them to know if the justice-involved individuals they supervise have Medicaid or other types of health insurance coverage; there may be required treatment as part of the probation or parole plan which may be covered through Medicaid. Any appointments that are arranged should be shared with probation and parole staff. It may also be appropriate to share basic health information with the probation and parole staff.

Intercept 5 — Community Corrections Planning for this intercept should include processes for the reintegration of justice-involved individuals from court

or incarceration in jails/prisons back into the community. Enrollment activities may be conducted in this intercept also. This will be especially important for individuals who may have been processed through the courts and spent a very short period of time in a jail setting. If the individual previously had Medicaid coverage, it may have been terminated during

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the jail stay, and the individual may have to reapply. Other options like employee-based health insurance may not be available any longer.

The 1997 CMS guidance states that justice-involved individuals on parole or probation are eligible for Medicaid benefits.23 However, there may be some justice-involved individuals residing in a community corrections or halfway house that are not eligible for Medicaid. They might be able to apply, but, as with incarceration, they would not receive benefits until leaving the community corrections center. Eligibility while in the community corrections setting is under review by CMS, and further guidance may be released in the future.

Strategies outlined previously in the document may also be used by probation, parole offices, and other community supervision agencies. Local Medicaid agencies and community groups that assist with enrollment should be considered when developing the plan for obtaining and processing an application. Justice-involved individuals may have more access to completing an online application in the community, but may still need assistance with answering all the questions.

When justice-involved individuals are released from jails or prison, the reentry plan should inform probation and parole staff about services that have been arranged. Despite efforts in the jails/prison, there still may be gaps in services; probation and parole staff may need to assist the justice-involved individuals with accessing health care services in the community.

A strong communication plan as part of the process design will be important in this intercept. Education for staff and justice-involved individuals could mirror the types of education outlined in previous intercepts. The community offers additional opportunities for outreach, including flyers and posters that may assist justice-involved individuals. Community partners will be critical to these types of efforts. Waiting areas are good locations to place outreach and information materials.

It is possible to access Medicaid administrative claiming and targeted case management resources in this intercept. Thoughtful and careful analysis of the cost benefit is recommended before implementation. For small agencies, it may not be cost-effective if the amounts of dollars flowing back into the budget do not justify the workload involved. Also, with limited staff resources, it may be difficult to complete the time studies and other documentation that are necessary for a thorough analysis.

Endnotes14 Mapping the Criminal Justice System to Connect Justice-Involved Individuals with Treatment and Health Care Under the Affordable Care Act, page 3, https://s3.amazonaws.com/static.nicic.gov/Library/028222.pdf.

15 Anvari, A. R., Y. Ismail, and S.M.H Hojjati, A Study on Total Quality Management and Lean Manufacturing: Through Lean Thinking Approach, World Applied Sciences Journal 12 (9): 1585-1596, 2011, retrieved from http://www.idosi.org/wasj/wasj12(9)/34.pdf.

16 Cloud, David, and Chelsea Davis, February 2015, Bridging the Gap — Improving the Health of Justice-Involved People through Information Technology, Vera Institute of Justice, http://www.vera.org/sites/default/files/resources/downloads/samhsa-justice-health-information-technology.pdf.

17 A Culture of Coverage for Justice-Involved Adults in Illinois, http://www2.illinois.gov/gov/health-carereform/Documents/Health%20Benefits%20Exchange/IL%20ACA%20%20Justice%20Pop.pdf.

18 The Affordable Care Act and the Pretrial System: A “Front Door” to Health and Safety — National Association of Pretrial Service Agencies Enrolling Offenders in Medicaid at Pretrial Jail Intake: A Case Study of Cook County, IL, http://www.pretrial.org/download/law- policy/The%20Patient%20Protection%20and%20Affordable%20Care%20Act%20and%20the%20Pretrial%20System%20-%20NAPSA%202014.pdf.

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19 Ways to Help Consumers Apply & Enroll in Health Coverage Through the Marketplace, Centers for Medicare and Medicaid Services, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/AssistanceRoles_06-10-14-508.pdf.

20 Enroll America — Presumptive Eligibility toolkit for hospitals http://www.enrollamerica.org/resources/toolkits/pe/.

21 Federal Interagency Reentry Council, Reentry Myth Buster on Veterans Health Care, http://csgjusticecenter.org/documents/0000/1177/Reentry_Council_Mythbuster_VA_Health_Care.pdf and Reentry Myth Buster on Veterans Benefits, http://csgjusticecenter.org/wp-content/uploads/2012/12/Reentry_Council_Mythbuster_VA.pdf.

22 Federal Interagency Reentry Council, Reentry Myth Buster on Social Security Benefits, http://csgjusticecenter.org/documents/ 0000/1056/Reentry_Council_Mythbuster_SSA.pdf.

23 The Council of State Governments, December 2013, Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System, http://csgjusticecenter.org/wp-content/uploads/2013/12/ACA-Medicaid-Expansion-Policy-Brief.pdf.

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ConclusionSection3

The Affordable Care Act created opportunities to improve access to health insurance like Medicaid, which ultimately provides the promise of better health care. Ensuring that individuals have insurance coverage and are linked into to health care systems, their health care outcomes will improve. When corrections and criminal justice agencies facilitate enrollment in Medicaid or Marketplace insurance, they increase the continuity of health care available to the justice-involved population. These efforts are vital to strong reentry programs and will increase the likelihood of successful reentry back into the community.

Challenges for the FutureThere remain several challenges with implementation of the Affordable Care Act across the country for corrections

and criminal justice professionals. At the top of the list are states that have not expanded Medicaid. These states will have more difficulty enrolling the justice-involved population into Medicaid. Some of this population may qualify for the Marketplace tax credit, but they will still have difficulty securing the resources to purchase health insurance. Another challenge is the issue of whether the state terminates or suspends Medicaid benefits as a result of incarceration.

Another issue is the current interpretation that the inmate exclusion applies to justice-involved populations in community corrections centers or halfway houses. Centers for Medicare and Medicaid Services (CMS) has been reviewing the current guidance. Correctional and other criminal justice professionals must be able to articulate how community settings differ from jails and prisons. The justice-involved populations housed in some of these settings are required to seek employment, and have access to community services, and often are held responsible to search for and obtain their own health care. The diverse population in the community corrections setting compounds the problem for CMS in understanding their status and eligibility.

Another challenge will be evaluating the use of Medicaid Administrative Claiming (MAC) in individual agencies. This financial resource may be difficult to validate, depending on the size of the agency and other community resources available for assistance. Mechanisms to complete time studies, analyze the results and appropriately bill may be cost-prohibitive depending on the amount of potential reimbursement. If there are available community resources who are already trained and ready to assist, MAC may not be a high priority.

There continue to be ongoing challenges linking justice-involved individuals into health homes. Whether the individual is in a community setting or incarcerated, this process will consume resources. Appropriate identification and mechanisms for transferring their care will need ongoing monitoring. The lack of available capacity in community health services will exacerbate the challenge, especially in some areas both geographically and by specialty. A shortage of substance use disorder treatment capacity has been challenging in most states. The perception of the community that justice-involved individuals are dangerous has the potential to be yet another part of the challenge.

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Section 3: Conclusion

When looking at all of the Medicaid programs available, there will need to be discussion and evaluation of the possible ways home and community based services (HCBS) might assist in community placement of justice-involved individuals. These services include targeted case management, personal care services, family and caregiver training and support, rehabilitative services, housing coordination to help individuals locate and obtain community housing, and a diversity of other services. Medicaid is the main payer for post-acute institutional and community-based long-term care in the U.S., financing 40 percent of the total spending in this area.24 If a justice-involved individual needs high levels of health care and can be managed in a home setting, HCBS should be explored. If access to these services could be made available, it might allow the individual to be placed in the community.

Lessons LearnedSeveral groups and individuals were interviewed in the process of developing this document. Their advice is invaluable

as agencies consider implementation. Much of it is similar to known best practices for implementation of any new project, but it is worth repeating as a reminder that change is a difficult process.

Implementation will take time and focus by many people. A project of this size cannot be implemented alone. Look for ways to obtain early success and build on the momentum. Identify the allies who will support the project. Spending time building relationships among the stakeholder groups will ensure strong dividends as the project moves forward, as these stakeholders may not have worked together before even if they are in the same community. In the end, the strongest supporters may be those who were the biggest skeptics in the beginning.

Success requires support from the highest levels in the agency. This initiative may have been started by the health care staff in the agency or by volunteer community groups, but it will not succeed without the support of the judge, sheriff or head of corrections and the Medicaid agency. Costs for implementation may be higher in the beginning, with cost savings accruing in the future. Communicating the long- and short-term benefits will be critical to gaining their understanding and support.

It is also vital that staff throughout the organization understand the project. Correctional officers in the jail or prison housing unit should understand how their job will be impacted. They have an important role in answering questions from the justice-involved population; they see the individuals much more than other staff in the agency. As with correctional officers, probation and parole officers should understand the project goals for the community. All will be able to positively influence the active participation of justice-involved individuals in their health care.

Undoubtedly, there will be changes or updates to existing computer systems, or it may be necessary to implement new systems. This is often more complicated than it first appears so it takes thoughtful programming. It may be very resource intensive, both in staff time and budget costs. Often this component is underestimated in terms of the amount of time and resources it will take to complete. An agency generally has multiple computer projects underway, which can further delay the end product.

Evaluation has its own unique set of considerations. Successful evaluation takes detailed planning from the beginning. Being clear about expectations and goals is essential. Implementing ongoing performance measures that are reasonable and realistic will be valuable in ensuring a successful comprehensive evaluation in the end.

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Section 3: Conclusion

Enrollment must be the first activity, but it should not be the end goal. None of the other enhancements outlined in this document are possible without enrollment, but the focus should remain on the larger, long-term goal of providing continuity of care for the justice-involved population, from the community to incarceration and back to the community. Ultimately, breaking the cycle of reincarceration has benefits for everyone in the community by improving public safety and public health.

For additional information or to answer questions about implementation of health care reform, please contact the American Correctional Association at (800) 222-5646 and ask for the Office of Correctional Health or visit their website at www.aca.org.

Endnotes24 Kaiser Commission on Medicaid and the Uninsured/The Henry J. Kaiser Family Foundation, March 2015 Issue Brief, Medicaid Moving Forward, http://kff.org/health-reform/issue-brief/medicaid-moving-forward/.

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Glossary of Terms Centers for Medicare and Medicaid Services (CMS) — One of the agencies of the U.S. Department of Health and

Human Services (HHS); responsible for the administration of Medicare and Medicaid programs.

Children’s Health Insurance Program (CHIP) — An insurance program that provides free or low-cost health coverage to children in low-income families. The program is partially funded by both federal and state dollars.

Enrollment Assisters — Individuals who are assisting with health insurance education and enrollment activities. Other titles include navigator, non-navigator assistance personnel and certified application counselor. All have training in helping consumers understand and apply for health insurance. Navigators are funded through the Marketplace navigator grants. Non-navigators are through the Marketplace but have other funding sources instead of navigator grants. Certified application counselors are often available through community health centers, health care provider networks, hospitals or social services agencies. All states have programs and can be identified by using this website. https://local help.healthcare.gov.

Federal Medicaid Assistance Percentage (FMAP) — Because Medicaid is a federal program administrated by states, the costs are shared between the federal and state governments. CMS pays each state a percentage of its total Medicaid expenditure based on the state’s per capita income. The average CMS rate is 57 percent but can range from 50 to 82 percent. The rate is adjusted every three years.

Federally Qualified Health Centers — These heatlh centers are community-based organizations that provide comprehensive primary care and preventive care, including health, dental care, as well as mental health/substance use disorder services to persons of all ages, regardless of their ability to pay or their health insurance status.

GAINS Sequential Intercept Model — This model was originally developed for the intercepts between criminal justice and mental health. It was developed by Mark R. Munetz and Patricia A. Griffins from the Center for Behavioral Health & Justice Transformation. This project was funded by the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA) at the Department of Health and Human Services.

Medicaid Administrative Claiming (MAC) — This is a joint federal-state program that provides reimbursement for the costs of administrative activities that directly support efforts to identify and/or enroll individuals in Medicaid or to assist individuals in gaining access to needed health care services.

Managed Care Organization (MCO) — Managed Care Organizations combine the functions of health insurance, delivery of care and administration of health plans through contracted network of hospitals, physicians, and other health care providers.

Memorandum of Understanding (MOU) — This is a written agreement between two or more parties that describes the working relationship and defines each party’s responsibilities in the relationship.

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Glossary of Terms

SAMHSA GAINS Center — A part of the CMHS Transformation Center, the GAINS Center serves as a resource and technical assistance center for policy, planning, and coordination among the mental health, substance abuse, and criminal justice systems. The Center’s initiatives focus on the transformation of local and state systems, jail diversion policy, and the documentation and promotion of evidence-based and promising practices in program development. The SAMHSA GAINS Center is funded by the Center for Mental Health Services and is operated by Policy Research Associates Inc., of Delmar, New York.

Social Security Disability Insurance (SSDI) — This federal social insurance program provides monthly cash benefits to disabled workers and their families.

State Plan Amendment (SPA) — This document is required to be completed by states in order to change part of the state Medicaid plan. Amendments must be approved by CMS prior to implementation.

Supplemental Nutrition Assistance Program (SNAP) — This program is run by the U.S. Department of Agriculture and offers nutrition assistance to eligible, low-income individuals and families.

Supplemental Services Income (SSI) — Federal funds are provided to individuals determined to be disabled by the Social Security Administration which is based on financial need.

Targeted Case Management (TCM) — These services are specifically designed to help Medicaid clients access needed medical, social, education, and other services. Costs of these administrative activities can be reimbursed through joint federal-state programs.

Temporary Cash Assistance to Needy Families (TANF) — This program is run by the U.S. Department of Health and Human Services and provides temporary assistance to families. Recipients must be working within two years of starting TANF benefits.

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Attachment A — References & Resources

Professional AssociationsAmerican Correctional Association Coalition of Correctional Health Authorities, Key Elements of the Patient Protection and Affordable Care Act: Interface with Correctional Settings and Inmate Health Care, American Correctional Association, February 2012.

Riggins, Viola, The Patient Protection and Affordable Care Act: What Are the Facts and Where Do We Go From Here?, Corrections Today, November/December 2013, http://www.aca.org/ACA_PROD_IMIS/docs/ochc/Riggin_Nov-DecCT13.pdf.

Wilson, Gary, The Patient Protection and Affordable Care Act in Jails, Corrections Today, March/April 2014.

Association of State Medicaid DirectorsA brief overview of the issues surrounding health care reform http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/incarcerated_populations_issue_summary_0.pdf

Case study — North Carolina http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/nc_case_study.pdf

Case study — New York http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/ny_case_study.pdf

Case study — Ohio http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/oh_case_study_1.pdf

Association of Probation and Parole Authorities Corrections and Reentry: Protected Health Information Privacy Framework for Information Sharing http://www.appa-net.org/eweb/docs/APPA/pubs/CRPHIPFIS.pdf

Council of State Governments (CSG)CSG Justice Center Website http://csgjusticecenter.org/

Reentry Issues http://csgjusticecenter.org/reentry/issue-areas/health/Justice-involved Population Education.pdf

http://csgjusticecenter.org/wp-content/uploads/2013/12/2013-CMS-10-Ways-Corrections-Can-Link-Returning-Offender-to-Hlth-Insurance.pdf

http://csgjusticecenter.org/wp-content/uploads/2013/12/2013-CMS-10-Ways-Jails-Can-Help-Make-Connections-to-Health-Insurance.pdf

47


http://csgjusticecenter.org/wp-content/uploads/2013/12/2013-CMS-10-Ways-Probation-and-Parole-Officers-Can-Help-Link-People-to-Health-Insurance.pdf

http://csgjusticecenter.org/wp-content/uploads/2013/12/2013-CMS-10-Ways-Court-Systems-Can-Connect-Individual-to-Health-Insurance.pdf

National Criminal Justice AssociationTaking the First Step: Medicaid Enrollment Strategies within the Criminal Justice System, Webinar of June 3, 2014: http://www.ncja.org/sites/default/files/documents/Taking-the-First%20Step-webinar-slides.pdf

Planning for Success: Leveraging Health Care Reform to Enhance Successful Reentry, Webinar of Feb.26, 2015: http://www.ncja.org/sites/default/files/documents/Planning-For-Success-Webinar-Slides.pdf

National Association of Counties Health Coverage and County Jails: Suspension vs.Termination http://www.naco.org/programs/csd/Documents/Suspension-termination-DEC2014%20(2).pdf

National Association of Pretrial Service Agencies The Patient Protection and Affordable Care Act and the Pretrial System: A “Front Door” to Health and Safety http://www.pretrial.org/download/law-policy/The%20Patient%20Protection%20and%20Affordable%20Care%20Act%20and%20the%20Pretrial%20System%20-%20NAPSA%202014.pdf

Governmental Organizations —

Federal Agencies

Centers for Medicare and Medicaid Services Medicaid Overview — Links to all state Medicaid plans. http://www.medicaid.gov/medicaid-chip-program-information/medicaid-and-chip-program-information.html

Overview of The Patient Protection and Affordable Care Act — PowerPoint slides produced by Medicaid and CHIP Learning Collaborative (MAC) http://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/downloads/primer-for-eligibility-workers.pdf

Medicaid and CHIP Learning Collaborative (MAC) State Toolkits http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Learning-Collaborative-State-Toolbox/State-Toolbox- Expanding-Coverage.html

48


Medicaid Fact Sheet on Health Homes http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/downloads/medicaid- health-homes-overview.pdf

State Medicaid & CHIP Profiles — Interactive map that provides information about each state http://www.medicaid.gov/medicaid-chip-program-information/by-state/by-state.html

Medicaid.gov — Indian Health and Medicaid http://www.medicaid.gov/medicaid-chip-program-information/by-topics/indian-health-and-medicaid/indian-health-medicaid.html

Medicaid Administrative Claiming for Schools http://www.cms.gov/Research-Statictics-Data-and -Systems/Computer-Data-and-Systems/MedicaidBudgetExpendSystem/Downloads/Schoolhealthsvcs.pdf

Ways to Help Consumers Apply and Enroll in Health Coverage Through the Marketplace https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/AssistanceRoles_06-10-14-508.pdf

Health and Human Services (HHS)Health Insurance Marketplace — This site has a feature that helps individuals determine if they have a qualifying life event (QLE) to be eligible for special enrollment. https://www.healthcare.gov/

Substance Abuse and Mental Health Services Administration (SAMHSA)SAMHSA-HRSA Center for Integrated Health Solutions http://www.integration.samhsa.gov/

SAMHSA — GAINES Center http://www.samhsa.gov/gains-center

Federally Qualified Health Center http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fqhcfactsheet.pdf

Rural Assistance Center — FQHC Frequently Asked Questions http://www.raconline.org/topics/federally-qualified-health-centers#whatis

National Institute of Corrections (NIC)National Institute of Corrections Affordable Care Act Resources http://nicic.gov/library/package/aca

Health Reform and Public Safety: New Opportunities, Better Outcomes (Internet Broadcast) http://nicic.gov/library/028236

49


State and Local Level AgenciesColorado Department of Health Care Policy and Finance (Medicaid agency) Criminal Justice Page https://www.colorado.gov/pacific/hcpf/medicaid-and-criminal-justice-involved-populations

Denver County Sheriff — Document for County Sheriffs http://www.denvergov.org/content/dam/denvergov/

Case Study: Lean Thinking in Iowa https://www.colorado.gov/pacific/sites/default/files/Case%20Study%20-%20Lean%20Thinking%20in%20Iowa.pdf

Case Study: Lean Thinking in Corrections https://www.colorado.gov/pacific/sites/default/files/Case%20Study%20-%20Lean%20Thinking%20in%20Corrections.pdf

What is Lean from LeanCT http://www.ct.gov/opn/lib/opn/What_is_Lean.pdf

Wisconsin Lean Government Metrics Guide http://walker.wi.gov/sites/default/files/documents/Lean%20Government%20Metrics%20Guide.pdf

FoundationsArnold Foundation — Harvard Medical School and Johns Hopkins Bloomberg School of Public Health State and Local Initiatives to Enroll Individuals in Medicaid in Criminal Justice Settings http://www.jhsph.edu/research/centers-and-institutes/center-for-mental-health-and-addiction-policy-research/research/economics-and- services-research/arnold-foundation-project-map/

Kaiser Family Foundation/Kaiser Commission on Medicaid and the Uninsured http://files.kff.org/attachment/key-lessons-from-medicaid-and-chip-for-outreach-and-enrollment-under-the-affordable-care-act-issue-brief

Issue Brief — Medicaid Moving Forward, March 2015 http://kff.org/health-reform/issue-brief/medicaid-moving-forward/

Summary of The Patient Protection and Affordable Care Act http://files.kff.org/attachment/fact-sheet-summary-of-the-affordable-care-act

Robert Wood Johnson Foundation — State Health Reform Assistance Network, Charting the Road to Coverage Issue Brief, April 2015, States Expanding Medicaid See Significant Budget Savings and Revenue Gains http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf419097

Community Oriented Correctional Health Services (COCHS) Issue Paper: Medicaid Claiming and Public Safety Agencies http://cochs.org/files/medicaid/cochs_medicaid_Public_Safety.pdf http://cochs.org/files/medicaid/TCM-SPA.pdf

The FAQs: The Medicaid Administrative Claiming (MAC) Program http://cochs.org/files/medicaid/cochs_medicaid_MAC.pdf

50


Enroll Americahttp://www.enrollamerica.org/

Frequently Asked Questions https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/uploads/2014/07/20130924_FAQs-small.pdf

Glossary https://s3.amazonaws.com/assets.enrollamerica.org/wp-ontent/uploads/2014/07/20130924_Glossary-small.pdf

Presumptive Eligibility Toolkit for Hospitals http://www.enrollamerica.org/resources/toolkits/pe/

Legal Action Committee State Profiles of Health Care Information for the Criminal Justice System http://lac.org/press-release-legal-action-center-announces-release-of-state-profiles-of-health-care-information-for-the-criminal-justice-system/

Legal Action Centerhttp://lac.org/what-we-do/criminal-justice/expanding-health-coverage-among-justice-involved-people/working-with-bja-to-improve-health-coverage-and-care-in-the-justice-system/

Vera Institute of JusticeCost-Benefit Analysis and Justice Policy Toolkit http://www.vera.org/sites/default/files/resources/downloads/cba-justice-policy-toolkit.pdf

Bridging the Gap — Improving the Health of Justice-Involved People through Information Technology http://www.vera.org/sites/default/files/resources/downloads/samhsa-justice-health-information-technology.pdf

Using Cost-Benefit Analysis for Justice Policymaking http://www.vera.org/sites/default/files/resources/downloads/using-cost-benefit-analysis-for-justice-policymaking.pdf

Justice and Health Connect WebsiteThe Toolkit has a step by step process to utilize when starting information sharing. http://www.jhconnect.org/toolkit

51

Attachment B — Evaluation MetricsATTACHM

ENT B Evaluation M

etrics

INPUTS

C

orrectional O

fficers C

ourt Staff Probation O

fficers Parole O

fficers H

ealth Care Staff

Financial Reports

ACTIVITIES

Enrollment

Appointm

ents

Education C

lasses

Disability

Evaluations

Referrals:

VA

Services H

ealth Hom

es

OUTPUTS

Medicaid

Enrollment

Marketplace

Enrollment

Approval for

Disability B

enefits &

Services A

pproval for V

eterans Benefits

and Services A

ccess to Health

Care Provider

OUTCO

MES

Increased access to benefits and services R

eductions in em

ergency room

visits G

reater awareness of

health care benefits and services Increased access to other com

munity

services and supports

Sample

Measures

Adm

issions # Insured %

Medicaid

% M

arketplace %

Employer

provided insurance %

Disabled w

ith SSI %

Veteran

Receiving

services

Sample M

easures # interview

s scheduled # interview

s conducted # applications com

pleted # education classes delivered # of enrollees for education classes # attendees in education classes # evaluations for disability # referrals to veterans services # referrals to health hom

es

LONG-TERM

IM

PACTS R

eduction in recidivism

rates

Reduction in health

care costs

Sustained access to health care benefits and services

Continued health

insurance coverage

Positive budget im

pact

Sam

ple Measures

# Enrolled: M

edicaid M

arketplace # A

pproved for/receiving M

edicaid

Marketplace

D

isability benefits and services

Veterans benefits and

services # M

edicaid Cards issued

# Clients w

ith health insurance upon release # C

lients with health care

provider # C

lients with health care

appointment

# Clients linked to health

homes

# Clients using FQ

HC

# C

lients using comm

unity health care services

Sample M

easures C

hange in # of services received/health care needs addressed C

hange in # of clients using em

ergency room

for services C

hange in self-reported aw

areness of health care benefits and services C

hange in # clients accessing other com

munity services

and supports (e.g., housing, em

ployment,

education)

Sample M

easures C

hange in recidivism

rate C

hange in jurisdiction’s health care costs # C

lients maintaining

enrollment in health

care benefits # C

lients continuing to access health care services in the com

munity

# Clients m

aintaining health insurance coverage

A

dmissions

# admitted

(booked/intake) # w

ith insurance # D

isabled # V

eterans R

eleases #bonded out

#probation #transferred to

prison #discharged

Baseline Data

52

Attachment B — Evaluation Metrics

Implementation Checklists

Jurisdictions should select the checklist that describes how Medicaid is managed in their state. The checklists are intended to assist in guiding an implementation process, but may not include every consideration.

Attachment C C-1 — Courts in Expansion State That Suspend Benefits C-2 — Courts in Expansion State That Terminate BenefitsC-3 — Courts in Non-Expansion State That Suspend Benefits C-4 — Courts in Non-Expansion State That Terminate Benefits

Attachment D D-1 — Probation/Parole in Expansion State That Suspend Benefits D-2 — Probation/Parole in Expansion State That Terminate BenefitsD-3 — Probation/Parole in Non-Expansion State That Suspend Benefits D-4 — Probation/Parole in Non-Expansion State That Terminate Benefits

Attachment E E-1 — Jails in Expansion State That Suspend Benefits E-2 — Jails in Expansion State That Terminate BenefitsE-3 — Jails in Non-Expansion State That Suspend Benefits E-4 — Jails in Non-Expansion State That Terminate Benefits

Attachment F F-1 — Department of Corrections in Expansion State That Suspend Benefits F-2 — Department of Corrections in Expansion State That Terminate BenefitsF-3 — Department of Corrections in Non-Expansion State That Suspend Benefits F-4 — Department of Corrections in Non-Expansion State That Terminate Benefits

53

C-1 — Courts in Expansion State That Suspend Benefits

Date Completed Lead

I. Beginning the Process Internal agency discussion Meeting with local/state Medicaid Determine which Medicaid eligibility criteria is appli-cable Identify stakeholders (See page 28)Schedule stakeholder meeting

II. Setting the Stage Convene stakeholder meeting Define Goals and Objectives Discuss assessment process — Lean/Mapping Determine members of assessment group (working group)Schedule meeting for creating future process

III. Creating Future Process Determine current process

• Pretrial• Jail• Probation

Create Vision for future process Define Implementation Steps

• Identify enrollment activities to be completed in court/pretrial services

• Identify enrollment activities to be in completed jails

• Identify resources for enrollment process in com-munity and jail

o New enrollments o Reactivation of benefits

• Define how applications will be processed in com-munity and jail


• Identify resources for linking individuals to health home

• Identify treatment needs that are ordered/ required by courts during probation

Discuss MAC/TCM Define information flow from courts to jail to probation and community providers Define other aspects of Probation Plan

Attachment C — Checklist – Courts

54


Date Completed Lead

IV. Establish Evaluation and Metrics Develop evaluation plan Determine existing data collection efforts Determine metrics to be measured If volunteers from community, use V.

V. Volunteer Resource Process Security clearance for volunteer resources if neededWhen and where volunteers will meet with individuals

VI. Implementation of Enrollment ProcessQuestions added to initial meeting (See page 32)Identify how information will be shared Flag justice-involved individuals with disabilities Flag justice-involved individuals with high health care needs

VII. Create Priority List for Enrollment — may be completed by another agency or volunteer group Utilize priority list for enrollment Schedule appointments for enrollment Consent form signed for processing enrollment (if com-pleted at time of visit, may not be necessary)

VIII. Health Literacy Class Develop curriculum Develop instructors Determine how often classes will be presented

IX. Transfer of Information Is electronic records systems available? Determine information flow from court, jails/prisons to probation/parole Determine information flow to community providers Develop MOU for transfer of information

X. Evaluation of Changes Set schedule for evaluation Monitor for data collection Schedule periodic stakeholder meetings Develop feedback mechanism for staff, volunteers and other interested groups

55


C-2 — Courts in Expansion State That Terminate BenefitsDate Completed Lead






• Identify enrollment activities to be completed in courts/pretrial services

• Identify enrollment activities to be completed in jails




• Identify treatment needs that are ordered/required by courts during probation

Discuss MAC/TCM Define information flow from courts to jail to probation and community providers Define other aspects of Reentry Plan

56


Date Completed Lead


V. Volunteer Resource Process Security clearance for volunteer resources if needed When and where volunteers will meet with individuals






57


C-3 — Courts in Non-Expansion State That Suspend BenefitsDate Completed Lead







• Identify enrollment activities to be in jails• Identify individuals who were disabled through

Social Security and reactivate benefits, which might include Medicaid






• Identify treatment needs that are ordered/required by courts during probation

Discuss MAC/TCM Define information flow from courts to jail to probation and community providers Define other aspects of Probation Plan

58


Date Completed Lead








59


C-4 — Courts in Non-Expansion State That Terminate BenefitsDate Completed Lead







• Identify enrollment activities to be in jails• Identify resources for enrollment process in com-

munity and jail • Define how applications will be processed in com-

munity and jail • Identify resources for linking individuals to health

home • Identify treatment needs that are ordered/required

by courts during probation

Discuss MAC/TCM Define information flow from courts to jail/prison to parole and community providers Define other aspects of Reentry Plan

60


Date Completed Lead








61

D-1 — Probation/Parole in Expansion State That Suspend BenefitsDate Completed Lead

I. Beginning the Process Internal agency discussion Meeting with local/state Medicaid Determine which Medicaid eligibility criteria is applicable Identify stakeholders (See page 28)Schedule stakeholder meeting


III. Creating Future Process Determine current process Create Vision for future process Define Implementation Steps

• Identify enrollment activities that were completed in court/pretrial services

• Identify enrollment activities that were completed in jail/prison

• Identify individuals who were disabled through Social Security and reactivate benefits, which might include Medicaid

• Identify resources for enrollment process in com-munity


• Define how applications will be processed in com-munity



• Identify treatment needs that are ordered/required by probation or parole plan


Attachment D — Checklist – Probation/Parole

62


Date Completed Lead



VI. Implementation of Enrollment ProcessQuestions added to intake appointment (See page 32)

Identify how information will be shared Flag justice-involved individuals with disabilities Flag justice-involved individuals with high health care needs

VII. Create Priority List for Enrollment — may be completed by another agency or volunteer group Utilize priority list for enrollment Schedule appointments for enrollment Consent form signed for processing enrollment (if complet-ed at time of visit, may not be necessary)



X. Medicaid Administrative ClaimingEvaluate workload factors for MAC/TCM Schedule discussion with State MedicaidWrite plan for submission to Medicaid OfficeConduct time studiesDo cost-benefit analysisDevelop structure for billing

XI. Evaluation of Changes Set schedule for evaluation Monitor for data collection Schedule periodic stakeholder meetings Develop feedback mechanism for staff, volunteers and other interested groups

63


D-2 — Probation/Parole in Expansion State That Terminate Benefits

Date Completed Lead






• Identify individuals who were disabled through Social Security and reactivate benefits which might include Medicaid

• Identify resources for enrollment process in community

• Define how applications will be processed in community




64


Date Completed Lead



VI. Implementation of Enrollment ProcessQuestions added to intake appointment (See page 32)Identify how information will be shared Flag justice-involved individuals with disabilities Flag justice-involved individuals with high health care needs






65


D-3 — Probation/Parole in Non-Expansion State That Suspend BenefitsDate Completed Lead





• Identify individuals who were disabled through Social Security and reactivate benefits, which might include Medicaid


• Identify resources for enrollment process in com-munity


• Define how applications will be processed in com-munity





66


Date Completed Lead









67


D-4 — Probation/Parole in Non-Expansion State That Terminate Benefits

Date Completed Lead






• Identify individuals who were disabled through Social Security and reactivate benefits which might include Medicaid

• Identify resources for enrollment process in community

• Define how applications will be processed in community




68


Date Completed Lead









69

E-1 — Jails in Expansion State That Suspend BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarceration for suspension of benefits

• Identify resources for enrollment processo New applicationso Reactivate suspended benefits

• Define how new applications will be processed • Identify resources for health home • Determine process for Hospitalization/Medicaid

Discuss MAC/TCM Define information flow from jail to probation/community providers Define other aspects of Reentry Plan

• Reactivate Social Security benefits • Veteran

IV. Establish Evaluation and Metrics

Develop evaluation plan Determine existing data collection efforts

Determine metrics to be measuredIf volunteers from community, use V.

V. Volunteer Resource ProcessSecurity clearance for volunteer resources if neededDetermine access to justice-involved individualsWhen and where volunteers will meet with individuals

Attachment E — Checklist – Jails

70


Date Completed Lead

VI. Implementation of Enrollment ProcessQuestions added to booking process (correctional staff)(See page 32)Questions added to Health care review (correctional health care staff) (See page 32)Identify how information will be shared Flag justice-involved individuals with hospital services Flag justice-involved individuals with high health care needs

VII. Create Priority List for Enrollment Utilize priority list for enrollment Schedule appointments for enrollment Consent form signed for processing enrollment


IX. Reentry to CommunityDetermine date of release Determine process for signature if needed Match to community resources Schedule health care appointments

X. Transfer of Information Is electronic records systems available? Determine information flow to probation Determine information flow to community providers Develop MOU for transfer of information

XI. Medicaid Administrative ClaimingEvaluate workload factors for MAC/TCM Schedule discussion with State MedicaidWrite plan for submission to Medicaid OfficeConduct time studiesDo cost-benefit analysisDevelop structure for billing

XII. Evaluation of Changes Set schedule for evaluation Monitor for data collection Schedule periodic stakeholder meetings Develop feedback mechanism for staff, volunteers and other interested groups

71


E-2 — Jails in Expansion State That Terminate BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarcera-tion for termination of benefits

• Identify resources for enrollment process• Define how new applications will be processed • Identify resources for health home • Determine process for Hospitalization/Medicaid

Discuss MAC/TCM Define information flow from jail to probation/commu-nity providers Define other aspects of Reentry Plan






72


Date Completed Lead








73


E-3 — Jails in Non-Expansion State That Suspend BenefitsDate Completed Lead





• Track disabled individuals determined by Social Security prior to incarceration

• Identify resources for enrollment process for new applications

• Define how new applications will be processed • Identify resources for health home • Determine process for Hospitalization/Medicaid







74


Date Completed Lead








75


E-4 — Jails in Non-Expansion State That Terminate BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarceration for termination of benefits


• Identify resources for enrollment process • Define how new applications will be processed • Identify resources for health home • Determine process for Hospitalization/Medicaid







76


Date Completed Lead








77

F-1 — Department of Corrections in Expansion State that Suspend BenefitsDate Completed Lead






• Identify resources for enrollment process in prison and in communityo New enrollments o Reactivation of benefits

• Define how applications will be processed in prison and in communityo New enrollments o Reactivation of benefits

• Develop mechanism for identifying individuals who become dis-abled during incarceration

• Identify resources for health home • Determine process for Hospitalization/Medicaid






V. Volunteer Resource ProcessSecurity clearance for volunteer resources if needed

Attachment F — Checklist – Department of Corrections


Date Completed LeadDetermine access to justice-involved individualsWhen and where volunteers will meet with individuals

VI. Implementation of Enrollment ProcessQuestions added to booking process (correctional staff) (See page 32)Questions added to health care review (correctional health care staff) (See page 32)Identify how information will be sharedFlag justice-involved individuals with hospital services Flag justice-involved individuals with high health care needs

VII. Create Priority List for EnrollmentUtilize priority list for enrollmentSchedule appointments for enrollmentConsent form signed for processing enrollment

VIII. Health Literacy ClassDevelop curriculumDevelop instructorsDetermine how often classes will be presented

IX. Reentry to CommunityDetermine date of releaseDetermine process for signature if neededMatch to community resourcesSchedule health care appointments

X. Transfer of InformationIs electronic records systems available?Determine information flow to probation Determine information flow to community providersDevelop MOU for transfer of information

XI. Medicaid Administrative ClaimingEvaluate workload factors for MAC for prisons and parole offices Schedule discussion with State MedicaidWrite plan for submission to Medicaid Office that includes both prisons and parole officesConduct time studiesDo cost-benefit analysisDevelop structure for billing

XII. Evaluation of ChangesSet schedule for evaluationMonitor for data collectionSchedule periodic stakeholder meetingsDevelop feedback mechanism for staff, volunteers and other interested groups

78

79


F-2 — Department of Corrections in Expansion State That Terminate BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarceration for termina-tion of benefits


• Identify resources for enrollment process in prison and in com-munity

• Define how new applications will be processed in prison and in community

• Develop mechanism for identifying individuals who become disabled during incarceration


Discuss MAC/TCM Define information flow from jail to prison to parole and community providers Define other aspects of Reentry Plan








VI. Implementation of Enrollment ProcessQuestions added to booking process (correctional staff) (See page 32)Questions added to health care review (correctional health care staff) (See page 32)Identify how information will be sharedFlag justice-involved individuals with disabilities Flag justice-involved individuals with high health care needs




X. Transfer of InformationIs electronic records systems available?Determine information flow to parole Determine information flow to community providersDevelop MOU for transfer of information


XII. Evaluation of ChangesSet schedule for evaluationMonitor for data collectionSchedule periodic stakeholder meetingsDevelop feedback mechanism for staff, volunteers and other interested groups80

81


F-3 — Department of Corrections in Non-Expansion State That Suspend BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarceration for suspen-sion of benefits



• Identify resources for enrollment process for new applications • Define how new applications will be processed in prison and

community• Identify resources for health home • Determine process for Hospitalization/Medicaid







82



VI. Implementation of Enrollment ProcessQuestions added to booking process (correctional staff) (See page 32)Questions added to health care review (correctional health care staff) (See page 32)Identify how information will be sharedFlag justice-involved individuals with hospital servicesFlag justice-involved individuals with high health care needs




X. Transfer of InformationIs electronic records systems available?Determine information flow to probationDetermine information flow to community providersDevelop MOU for transfer of information

XI. Medicaid Administrative ClaimingEvaluate workload factors for MAC for prisons and parole offices Schedule discussion with State MedicaidWrite plan for submission to Medicaid OfficeConduct time studiesDo cost-benefit analysisDevelop structure for billing


83


F-4 — Department of Corrections in Non-Expansion State That Terminate BenefitsDate Completed Lead




• Determine how to notify Medicaid of incarceration for termina-tion of benefits



• Identify resources for enrollment process in prison and in community

• Define how new applications will be processed in prison and in community








84



VI. Implementation of Enrollment ProcessQuestions added to intake/receiving process (correctional staff) (See page 32)Questions added to health care review (correctional health care staff) (See page 32)Identify how information will be sharedFlag justice-involved individuals with hospital servicesFlag justice-involved individuals with high health care needs




X. Transfer of InformationIs electronic records systems available?Determine information flow to paroleDetermine information flow to community providersDevelop MOU for transfer of information

