Medicaid Inpatient Coverage for Hospitalized Incarcerated People, Lessons Learned & Administrative Challenges

Highlighted Stories

Editor's Note

This week’s highlighted story comes from Bexar County, Texas, where officials have requested $60 million for renovations at the San Antonio State Hospital to accommodate jail inmates in need of psychiatric care. We are using this story as an opportunity to refresh our subscribers’ understanding of how Medicaid covers inpatient hospital stays of more than 24 hours.

In 1997, the Department of Health and Human Services issued a guidance letter outlining the circumstances under which Medicaid could pay for an inmate’s healthcare services (see COCHS’ founder, Steven Rosenberg’s Medicaid Coverage for Jail Inmate’s Inpatient Hospitalizations). This provision is distinct from both 1115 waivers and Section 5121 of the Consolidated Appropriations Act of 2023.

With this Medicaid coverage for hospitalized incarcerated patients, there was an added impetus for the development of locked units within non-carceral hospitals. Hospitals typically separate incarcerated patients from the general patient population. Correctional policies require one or two correctional officers to remain bedside 24/7 when no locked unit is available. This arrangement presents staffing challenges for correctional institutions and creates an awkward dynamic for hospital staff and other patients. Locked units help alleviate these issues by reducing the need for constant correctional staffing and providing a more structured hospital environment.

However, the demand for locked units can wax and wane. Readers may recall a recent story from California, where Adventist Health in Bakersfield is closing its locked unit due to underuse.

Medicaid coverage within an inpatient unit—whether locked or not—presents relatively few administrative challenges for hospitals, as the incarcerated individual is simply another patient who happens to be a Medicaid beneficiary. Similarly, the HRSA PIN 2024-05, which allows Federally Qualified Health Centers (FQHCs) to provide care in carceral settings, is unlikely to create significant administrative burdens for the FQHCs themselves, since they will simply be treating Medicaid patients within a correctional facility. The greater administrative challenges in this case are likely to stem from the relationship between the FQHCs and the correctional facility.

1115 waivers, on the other hand, are likely to pose more substantial administrative hurdles. Unlike hospitals and FQHCs, correctional institutions have not traditionally been Medicaid providers. As a result, they will have to navigate entirely new administrative systems.

Bexar County, Texas

Bexar County, Texas, officials have requested $60 million in state funding to renovate seven buildings within the San Antonio State Hospital complex. The renovations would allow the county to better meet the needs of jail inmates who require psychiatric services. In 2024, 13 people died inside the jail, down slightly from 18 in 2023. In response, Bexar County Sheriff Javier Salazar implemented a medical screening process and created a policy to reject detainees who are detoxing from drugs or alcohol, who are diabetic and dependent on insulin, and who require dialysis.

Medicaid 1115 Waivers

On January 16, 2025, Minnesota submitted a request for a new 5 year demonstration to provide reentry services to people leaving carceral settings and expand both pre-release care planning and Medicaid eligibility and enrollment supports for people returning to the community from incarceration. The state aims to address three critical challenges: reducing post-release mortality rates, decreasing recidivism, and addressing the persistent health disparities that disproportionately impact formerly incarcerated populations.

Pregnancy

Midwife Heather Soper believes pregnancy, birth and becoming a mother are transformational experiences. But when those life experiences happen while an individual is incarcerated, it adds a layer of complexity. The inmates she sees are at risk for preterm birth and low birth weight infants, which can happen when a pregnant person struggles with chronic stress or suffers from sexually transmitted infections.

Juveniles

With fewer juveniles behind bars, many states have shuttered youth facilities. Today America has 58 percent fewer of them than it did in 2000. Large facilities — those holding more than 100 juveniles — have closed at an especially rapid clip. In 2000, there were 264 youth facilities of that size; by 2020, there were just 42. The situation began to change in the early 2000s, as lawyers and journalists exposed horrific abuses in the system. In 2003, the California-based Prison Law Office sued the state over conditions in its juvenile facilities. In early 2004, a series of expert reports documented rampant violence and cruelty.

Opioid Epidemic

Black men are disproportionately dying from drug poisonings and overdoses, even as the opioid epidemic slows for others. Milwaukee County is among dozens of U.S. counties where drugs are disproportionately killing a generation of Black men, born between 1951 and 1970. In Milwaukee, Black men of the generation accounted for 12.5% of all drug deaths between 2018 and 2022. That’s despite making up just 2.3% of the total population. The county’s older Black men were lost to drugs at rates 14.2 times higher than all people nationally and 5.5 times higher than all other Milwaukee County residents.

This study found that when medication is combined with attendance at a support group, patients are over 25% more likely to finish addiction treatment. Using artificial intelligence, researchers found that when medication is combined with attendance at a support group, patients are over 25% more likely to finish opioid addiction treatment. Separate studies show that taking drugs such as methadone or buprenorphine for 60 days reduces the risk of opioid overdose by 60%. But addiction treatment requires something more than persuasive outcome data.

Peer Recovery Specialists (PRSs) have emerged as a promising intervention to support justice-involved individuals with SUD, particularly those transitioning out of jail or prison (SAMSHA, 2023). PRSs are individuals with lived experience of recovery from mental health or substance use disorders who are trained to offer non-clinical, peer-based support (DBHDS, 2024). Their role is to build trust and rapport with individuals, providing emotional support, advocacy, and resource navigation to facilitate successful recovery and reentry.

COVID-19

A new report released by the Legal Aid Society this week and shared exclusively with the Eagle details the first two years of the pandemic both inside the city’s jails and throughout the state’s criminal justice system, and the failures of local and state governments to decarcerate its jails and prisons, where the pandemic raged. The report, which comes five years after the U.S. government first declared COVID-19 as a public health emergency, found that despite warnings from health experts, lawmakers, advocates and others, New York did little to lower the population in its jails and prisons, where social distancing was nearly impossible to maintain.

BOP

Sens. Ossoff and Marsha Blackburn (R-TN) today introduced the bipartisan Prison Staff Safety Enhancement Act, which would require the Department of Justice (DOJ) to develop and implement a comprehensive strategy to mitigate inmate-on-staff sexual assault in Federal Bureau of Prisons (BOP) facilities and help end sexual abuse in prisons. The DOJ would then be required to submit data on the prevalence of inmate-on-staff sexual harassment in prisons to the DOJ Office of the Inspector General (OIG) and establish a national standard aimed at preventing and reducing sexual abuse in Federal prisons.

Transgender Bans

An incarcerated transgender woman is suing Donald Trump over an executive order that would forcibly move trans women like her into men’s facilities, exposing her to an “extremely high risk of harassment, abuse, violence, and sexual assault.” The lawsuit — the first federal complaint responding to Trump’s executive order — was filed by lawyers with the National Center for Lesbian Rights and GLBTQ Advocates and Defenders.

Nearly a year after the Justice Department filed a lawsuit against Utah alleging the state discriminated against a transgender woman incarcerated at the state prison by providing inadequate and delayed medical care, lawmakers are weighing cutting off access to gender-affirming care altogether. A bill from House Majority Whip Karianne Lisonbee would, among other things, stop incarcerated transgender people from transitioning by barring them from starting hormone treatments or pursuing gender-affirmation surgery. People who enter custody receiving hormone therapy would be able to continue that care.

State Roundup

Alabama

Attorneys who litigate cases that involve people who deal with mental illness or a mental health crisis, along with advocates seeking to improve treatment and conditions for those with mental illness state that people suffering from mental illness who are incarcerated in Alabama’s jails are placed into harsh environments that can exacerbate their suffering and, in the worst cases, can result in their death.

Michigan

Ronald Leggitt, 44, of Marshall, was sentenced for assaulting a county jail inmate under his supervision at the Hillsdale County Jail. Leggitt assaulted the inmate six times with aerosol subject restraint, commonly known as mace or pepper spray, spraying the chemical irritant into her face from a distance of mere inches. During five of the six assaults, the victim was secured in an emergency restraint chair, where she was restrained in wrist and ankle cuffs as well as a chest restraint.

Mississippi

An effort By Sen. Juan Barnett, D-Heidelberg, to phase out Mississippi's 124-year-old Parchman prison was again killed this year before it could be debated on the Senate floor. The bill would have phased out Parchman's inmate population and employees to another prison while keeping death row, the hospital and some other services at Parchman. Since the state must operate at least one state-owned prison, the Tallahatchie County Correction Facility, owned by CoreCivic, would have to be given or sold to the government. In defending the bill, Barnett asked how much longer the Legislature should "dump" more money into Parchman, which has seen increasing needs for maintenance over the last few decades.

Missouri

There are 418 Missourians across the state on a waiting list for a mental health bed, up from around 300 at this time last year. Missouri has faced a years-long struggle with this issue, due to increasing numbers of court referrals for competency restoration, staffing issues and limited psychiatric hospital capacity. In Aug. 2013, there were only 10 people waiting for an inpatient bed, but by Sept. 2021, that number had risen to 106 — and has continued to grow.

New York

It could take years for the state Commission on Correction to complete a mortality review of an incarcerated man who was beaten to death by multiple officers at Marcy Correctional Facility last month, the oversight group's chair said. The commission, which provides oversight to all state prisons, jails and juvenile detention facilities, has not publicly discussed the death of Robert Brooks since he died after a violent encounter with officers, which was captured on body-worn camera footage. No charges have been filed, but 16 Marcy staffers remain suspended without pay in connection to the incident. Two officers resigned.

After two recent incidents caused several staff and inmates to be sent to the hospital, the state has locked down Upstate Correctional Facility in Malone. The union representing correction officers said serious measures need to be taken to prevent substances from getting into facilities. After the Narcan was administered, the inmate remained combative with officers and body holds were used to contain the inmate until he became compliant, the union said. The union said that 11 officers, 8 registered nurses and 1 civilian began experiencing symptoms that included dizziness, vomiting, high blood pressure and fainting.

An investigation into a series of episodes in which state prison workers have been rushed to hospitals after exhibiting symptoms ranging from fainting to slurred speech has not produced evidence that the physical reactions were caused by exposure to toxic substances or the synthetic drugs rampant in the facilities. That result has stoked questions about what's driving the rash of unusual reactions, including whether they may be a stress-induced phenomena that has increasingly been blamed for similar cases involving law enforcement officers and first responders.

North Carolina

A mobile reentry center travels the state and deliver services to communities with high needs for reentry support — hoping to help people overcome common barriers to getting re-established in their communities. Kerwin Pittman, executive director of the nonprofit Recidivism Reduction Educational Program Services, has been working to enhance support for people recently released from incarceration. As a fomert inmate, he knows that timely connections to resources are crucial to improving reentry success and to lowering recidivism rates in North Carolina.

Law enforcement transports of mental health patients are happening more frequently in North Carolina. Involuntary commitment petitions increased by at least 97 percent from 2011 to 2021. Counties are responsible for the transportation of patients under involuntary commitment, according to state law, and traditionally this role has fallen to law enforcement. A Duke Law report evaluated responses to people in crisis nationwide and recommended that policymakers remove law enforcement from all mental health interventions as much as possible.

Oklahoma

State health officials want inspectors allowed into the dangerous Oklahoma County jail anytime without notice, and county jail trustees want them barred from ever conducting surprise inspections — two diametrically opposed arguments before two different courts of law. But the cases could go together as one before the court that ultimately matters: the Oklahoma Supreme Court. Critics of the long-troubled jail say the issue is literally a matter of life or death. The jail has failed several inspections because inspectors were denied entry, and it failed one in December after inspectors were allowed inside and reported numerous health and safety violations --For more background on this story, see the Editor's Note of January 14, 2025 and the Editor's Comment of January 7, 2025.

Senate Bill 601, authored by Sen. Dave Rader, R-Tulsa, pauses all pending executions, prevents the state from scheduling new execution dates and establishes a task force to review Oklahoma’s execution practices. The “Oklahoma Jail Standards Act,” or Senate Bill 595 by Darrell Weaver, R-Moore, would mandate jails implement stricter security measures, improve medical care and enhance staff training. The bill also requires the State Department of Health to review and approve jail construction and remodeling plans – a measure that would go into effect before the construction of the new Oklahoma County jail.

Tennessee

Another inmate has died at the Shelby County Jail, bringing to at least 55 the number of deaths in that facility since 2019, records show. There has been at least 40 deaths inside 201 Poplar between 2019 and mid-2023. That number has steadily grown since then with the deaths often caused by drugs, violence or inmate health conditions.

Rikers Island

At least 127 people found unfit to stand trial by psychiatrists are languishing on Rikers Island because there is no space at state-run mental health facilities. Jail insiders say that number has gone up in recent years, after usually hovering around 100. Department of Correction officials have never publicly shared historical data on that figure. Meanwhile, internal 2024 DOC data shows that detainees deemed unfit to stand trial are stuck behind bars for an average of 80 days — with 25 people waiting 100 or more days to be sent to a secure medical center.

Correctional Officers

Night-shifters live in a perpetual shadow of fatigue. Their internal clocks defy societal norms. But it’s more than tiredness — it’s a bone-deep weariness. I could go in on day watch and stay 16 hours until midnight, that was no problem, but put me on midnight shifts for a quarter and I was useless. I felt useless. Shift work can do that for you. Although shift workers like us make do, study after study shows the negative effects of lack of sleep and working non-traditional hours on the human body. We are not only tired, but our immunity is lowered, our stress is increased, and we suffer from a decrease in our good hormones and an increase in our weight and hunger.

Correctional Healthcare Providers

Wellpath

Bankrupt prison health-care firm Wellpath Holdings Inc. failed to drum up qualified bids for one of its business divisions, forcing it to explore new options as incarcerated people who have sued the company worry about how their claims will be treated. Wellpath is the second prison health-care provider to file for bankruptcy in the past two years. Like Tehum Care Services Inc. (YesCare/Corizon) in 2023, Wellpath was deep in personal injury, medical malpractice, and wrongful death claims when it sought Chapter 11 protection. as Tehum prepares to seek court approval of a proposed settlement to end its bankruptcy, Wellpath is still working to resolve allegations that its initial restructuring proposal insufficiently addressed tort claims. Clues about Wellpath and Tehum’s future could be found in Armor Health Management LLC’s case. It faced more than 100 lawsuits, including ones from current and former inmates and families of deceased prisoners, with some cases receiving judgments totaling more than $12 million.

Bankrupt prison health-care company Wellpath Holdings Inc. is working to revise its restructuring plan proposal amid objections from junior creditors. The amended documents, including disclosures about the plan, will be materially different from the current proposal, a spokesperson for Wellpath said. Judge Alfredo R. Perez of the US Bankruptcy Court for the Southern District of Texas expressed concern earlier this month during a hearing over the lack of details related to the treatment unsecured creditors, who are largely incarcerated individuals.

State Rep. Phil Green recently led discussions on an issue that has stretched hospital, ambulance and pharmaceutical services thin both within his House District and across Michigan. The issue originates from the state’s former health care contractor, Wellpath, failing to pay for services rendered to inmates in 2023 and 2024. The Michigan Association of Ambulance Services estimates over $6 million in unpaid bills are owed to emergency medical service (EMS) agencies across Michigan. Last year, Green proposed to amend a budget bill so that surplus Emergency Management funds would be shifted to the Michigan Department of Corrections to help reimburse unpaid Emergency Medical Service Providers and hospitals.

Advanced Correctional Healthcare

The daughter of a Minnesota man who died while in state custody is suing after she says jail staff failed to provide him medical care, despite his pleas for help. A federal lawsuit was filed Jan. 27 against multiple defendants including Olmsted County, Advanced Correctional Healthcare, Inc. and USA Medical & Psychological Staffing, S.C.. Other inmates pleaded with jail staff to get medical attention for Bush as he yelled in pain from his cell, according to the complaint.