Criminal Justice & Medicaid

When the Affordable Care Act (ACA) was passed in 2010, COCHS was one of the first organizations to recognize that people who are at risk of justice system involvement would qualify for Medicaid coverage. Medicaid coverage became available to individuals whose income is at or below 138 percent the Federal Poverty Level (FPL). COCHS as well as other organizations have published many articles and papers that explain what the ramifications of these change are for the justice involved and their healthcare providers.

Medicaid Expansion and The Inmate Exclusion

In 2012, when the Supreme Court of the United States upheld the ACA, it was not widely understood that it had made Medicaid expansion optional for states. Nevertheless, the vast majority of states expanded and more states continue to expand. However, at the time of the passage of the ACA, there were many erroneous claims that the Medicaid expansion was for "felons". These claims ignored the fact that people covered by Medicaid lose coverage when they go behind bars. This loss of coverage is known as the inmate exclusion. States enforce the inmate exclusion by suspending or terminating Medicaid benefits.

Before Medicaid expansion, justice involved individuals with Medicaid coverage made up a relatively small percentage of people cycling in and out of jails, as Medicaid was restricted to pregnant women and children, caretaker relatives, people over age 65, and people with disabilities. After Medicaid expansion, the bulk of the expansion population is comprised of childless adults which includes a sizeable subset with criminal justice involvement. COCHS is enthusiastic about Medicaid expansion as it is seen as way to treat the health challenges such as behavioral health issues and substance use disorder (SUD) that so often lead people to have involvement with the justice system. A study from Washington State showed a decrease in arrests and costs following treatment for SUD.

The Affordable Care Act (ACA) and Justice-Involved Populations
This FAQ reviews Medicaid coverage for justice involved individuals under the ACA. It answers the question of what happens to this coverage when a person is incarcerated? Medicaid under the ACA (and prior to the ACA), does not pay for health care services provided to detainees or inmates in jails or prisons.
Medicaid and Criminal Justice: The Need for Cross-System Collaboration Post Health Care Reform
Among the 16 million people who became eligible for Medicaid in 2014 by virtue of incomes at or below 133 percent of the federal poverty level, many have untreated mental illnesses and substance abuse that predispose them to repeat arrests.
State Medicaid Eligibility Policies for Individuals Moving Into and Out of Incarceration
Kaiser Family Foundation
There is no prohbition against individuals being enrolled in Medicaid while incarcerated. However, Medicaid will not cover the cost of care for incarcerated persons, except for care received as an inpatient in a hospital. States have flexibility in choices related to eligibility and enrollment of inmates.
Health Care Reform, Medicaid Expansion and Access to Alcohol/Drug Treatment
Wa State Dep. of Soc and Health Serv
This report, by David Mancuso, describes how health care reform creates strong financial incentives for states to focus on providing services that slow the progression of chronic disease conditions that result in disability, and the important role of substance abuse treatment.
Behavioral Health Treatment: Opportunities for Health Care and Criminal Justice Cost Savings
Wa State Dep. of Soc and Health Serv
This presentation, by David Mancuso, shows that alchohol and drug treatment lowers criminal justice costs and health care costs. There is a marked decline in arrests for people receiving treatment as opposed to those who do not.
The Opioid Epidemic, Medicaid, and The Inmate Exclusion

The opioid epidemic started a re-appraisal of Medicaid's inmate exclusion. The inmate exclusion causes interruptions in care for people with SUD or opiate use disorder (OUD) cycling in and out of jails. Treating individuals with Medication-Assisted Treatment (MAT) while incarcerated could have promising impact on health and recidivism, as the studies from Washington State have indicated. Many sheriffs and wardens are in favor of allowing Medicaid coverage to be used within jails and prisons, as a way to insure that there are the resource available to provide treatment.

There have been proposals to modify or abolish the inmate exclusion. Two different bills have been introduced in congress that in various ways end the inmate exclusion. United States Senator Jeff Merkley (D-OR) introduced a bill that would preserve Medicaid benefits for an inmate who is in jail awaiting trial. United States Representative Annie Kuster (D-NH) and United States Senator Cory Booker (NJ-D) have introduced a bill to eliminate the inmate exclusion. Others have argued that it might be more prudent to go through a waiver process to modify the inmate exclusion in order to understand the implications and complexities of Medicaid coverage within corrections.

Addressing the Disparate Impact of the Federal Response to the Opioid Epidemic
Medicaid could improve the health status of the populations affected by the opioid epidemic by allowing states and counties: to work with Medicaid providers to identify patients who are receiving community-based opiate treatment and to maintain their treatment while incarcerated.
How Connecting Justice-Involved Individuals to Medicaid Can Help Address the Opioid Epidemic
Kaiser Family Foundation
Four states (Missouri, Ohio, New Mexico, Rhode Island) are connecting people leaving the criminal justice system to Medicaid coverage and services, with a focus on medication-assisted treatment (MAT) and supports for people with OUD.
Ann McLane Kuster and Cory Booker: Medicaid should be available in prisons
The Washington Post
United States Representative Annie Kuster (D-NH) has teamed up with United States Senator Cory Booker (D-NJ) to sponsor a bill that would end the federal Medicaid Inmate Exclusion policy that bans inmates from participating and terminates those already covered by the program if they are incarcerated.
Oregon sheriffs back federal bill to restore inmate medical benefits while in jail
The Stateman Journal
Numerous sheriffs have come out in support of the Restoring Health Benefits for Justice-Involved Individuals Act of 2019. A bill introduced by Oregon Sen. Jeff Merkley that would preserve Medicaid benefits for an inmate who is in jail awaiting trial. Local law enforcement officials are welcoming the potential change.
Effort underway to relax law that strips pretrial detainees of health insurance
The Standard-Examiner
The Medicaid inmate exclusion does not differentiate between a convicted inmate and one held awaiting trial. As a result, inmates suffering from substance addictions or mental health problems are more likely to reoffend having lost coverage for treatment.
Medicaid Administrative Claiming

Another source of Medicaid reimbursement available to jurisdictions that could impact health care delivery to the justice involved population is Medicaid Administrative Claiming (MAC). 96 percent of Medicaid expenditures cover traditional direct services; the other 4 percent, however, cover non-service functions including funding matches to states and localities for administrative expenses related to Medicaid. There is also targeted case management (TCM) which is an optional Medicaid service. It is different from MAC as it covers a whole range of case management services including social, educational and other services such as vocational training or housing.

Medicaid Claiming and Public Safety Agencies
Medicaid Administrative Claiming reimburses state and local agencies for many activities that they have already performed, including some that are relevant to public safety.
Medicaid Administrative Claiming FAQs For District Attorneys
District attorneys in states that have not expanded Medicaid can participate in Medicaid Administrative Claiming (MAC). By participating in MAC, district attorneys can save money and help connect people with health insurance and services.
Medicaid Administrative Claiming and Targeted Case Management: Opportunities for Public Safety
National Institute of Corrections
A presentation by Steve Rosenberg, president of COCHS, explaining how public safety can bill medicaid for either MAC or TCM. MAC is billed to Medicaid based on time; TCM is billed to Medicaid based on services provided.