Transitions

 

 

January 2023

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Health Care Transitions for Individuals Returning to the Community 

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Executive Summary

An estimated 80% of returning community members have chronic medical, psychiatric, or substance use disorders.1

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Introduction and Background Individuals returning to the community after incarceration in prison or jails have a variety of significant needs, including those related to access to health coverage and continuity of health care. These needs are especially important because justice-involved individuals have disproportionately high rates of serious mental illness (SMI), substance use disorder (SUD), and infectious and other chronic physical health conditions.2-4 Mortality among returning community members is significantly elevated in the post-release period; especially in the week after release, when overdose, suicide, and homicide are the leading causes of death.5,6

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Poor health status is associated with higher costs to the health care and criminal justice systems and, in some studies, increased rates of recidivism.7,8 Black and low-income individuals are overrepresented in the justice system, and negative outcomes during reentry may perpetuate existing disparities.

 

In states that expanded Medicaid eligibility under the Affordable Care Act (ACA), most returning community members are eligible for Medicaid. However, Medicaid plays a very limited role during incarceration due to a federal inmate exclusion that prohibits use of Medicaid funds to cover most services provided to people while incarcerated in prison and jails.

 

Section 5032 of the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Pub.L. 115-271) (hereinafter referred to as SUPPORT Act) requires the Secretary of HHS to convene a stakeholder group of representatives of “managed care organizations, Medicaid beneficiaries, health care providers, the National Association of Medicaid Directors, and other relevant representatives from local, state, and federal jail and prison systems” to discuss best practices for states to help inmates released from public institutions transition to the community with health care (hereinafter referred to as the Stakeholder Group). This report summarizes the identified practices of that Stakeholder Group and, as required by Section 5032 of the SUPPORT Act, informs design of a demonstration opportunity “under Section 1115 of the Social Security Act (42 U.S.C. 1315) to improve care transitions for certain individuals who are soon-to-be former inmates of a public institution and who are otherwise eligible to receive medical assistance under Title XIX of such Act.”9 This content comes from the stakeholder meeting unless otherwise cited. The Stakeholder Group is governed by the Federal Advisory Committee Act (Pub.L. 92-463) which sets forth standards for the formation and use of advisory committees.

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Challenges

Returning community members face multiple challenges which can hinder their ability to obtain health coverage and successfully transition their health care. These challenges include inability to access and afford medications and treatment--including medications for opioid use disorder (MOUD), medications for other SUDs, and medications for chronic and infectious conditions--which can contribute to post&release morbidity and mortality. Other challenges include limited electronic data sharing of health records between justice system and community providers, limited post-release resources (especially in low-income and rural areas), systemic health system biases against justice-involved individuals, and a variety of pressing health-related social needs, including obtaining housing, accessing food, securing employment, and reestablishing interpersonal relationships. Some reentrants must also navigate bureaucratic hurdles to reinstate Medicaid payment for benefits or reapply for Medicaid. Others, especially those in states that did not expand Medicaid eligibility to the adult group, may not be eligible for Medicaid and may be unable to access and afford insurance provided by employers or through the federal Health Insurance Marketplaces or state-based Marketplaces. Even when returning community members do obtain Medicaid coverage, some services that are particularly relevant to individuals with mental health diagnoses and SUD--such as rehabilitative services and case management--are optional benefits under state plans and thus may not be covered.

 

Promising Practices

State and local jurisdictions, often with federal support, can implement practices to support access to coverage and health care during reentry. These practices occur within correctional facilities and in the community. Because some justice-involved individuals cycle in and out of correctional institutions, community-based practices may be simultaneously pre- and post-incarceration, representing a key opportunity to connect with and support individuals while they are not in a carceral facility.

 

A review of relevant literature and discussion among stakeholders identified promising practices at the state and local levels to connect returning community members to health care. These practices include universal screening for SUD during intake, expanded access to MOUD within correctional settings, inreach care coordination and discharge planning, community navigators and peer support specialists, culturally competent models of care, cross-sector care coordination, assistance with access to medication post-release, crisis diversion programs and partnerships, telehealth, and information sharing between correctional health care providers and community providers.

 

Other practices relate specifically to health coverage, which is often a prerequisite to accessing health care in the United States. Promising practices to promote coverage include expansion of Medicaid eligibility to adults up to 133 percent of the federal poverty level (referred to as the adult group), suspension (rather than termination) of Medicaid coverage upon incarceration, designation of correctional facilities as qualified entities for presumptive eligibility, data sharing across agencies to automate suspension and reinstatement, pre-release application assistance, and Medicaid Health Homes for returning community members. 

 

1115 Demonstration

Under Section 1115 of the Social Security Act, states are given the ability to apply to the Federal Government to implement time-limited experimental or pilot projects within their Medicaid programs. States have employed 1115 demonstrations to support justice-involved individuals in several ways, including targeting Medicaid eligibility, behavioral health services, or case management to returning community members; and providing this population with transitional care during reentry. As of October 2022, 11 states have submitted Section 1115 demonstration applications to HHS to demonstrate and test innovative approaches to providing Medicaid coverage for certain services provided to incarcerated individuals for a limited period prior to release. These applications are under review as of October 21, 2022.b

 

An 1115 demonstration through which states can receive federal matching in Medicaid payments for pre-release services provided to individuals who would receive Medicaid coverage for the services if not incarcerated has the potential to improve care transitions. Key policy considerations for such a demonstration include the scope of benefits provided pre-release, the ideal length of time for pre-release payment for services, strategies for addressing social supports, meaningful engagement of justice-involved individuals in the design of the demonstration, opportunities to address health disparities and strategies for monitoring and evaluating the demonstration outcomes.

 

Several key design elements may help support state uptake of the 1115 demonstration opportunity. Factors such as the ability to customize the target population of the model, support for data infrastructure, strategic partnership opportunities, inclusion of pre-arrest diversion activities, and 1115 demonstration budget neutrality considerations may generate additional state interest in an 1115 demonstration opportunity.

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Section 2.

Background

Reentry to the community after incarceration in prison or jail (jointly referred to in this report as “correctional facilities”) is a transitional period. Health care transitions (including those related to health coverage, care, and medications) are critical aspects of this process. Persons with justice system involvement carry a disproportionately high disease burden, including high rates of SMI, SUD, and infectious and other chronic physical health conditions.2-4 SUD is especially prominent among individuals in jails (in which stays range from several hours to a year or more), compared to individuals in prisons (in which stays are typically longer and where chronic health conditions are more common). According to data from the Bureau of Justice Statistics, more than half of state prisoners (58 percent) and sentenced jail inmates (63 percent) in 2011-2012 met the criteria for drug dependence or abuse, and more than a third of state and federal prisoners (37 percent) and jail inmates (44 percent) in 2007- 2009 reported previously being diagnosed with a mental health disorder.d Half of individuals in state and federal prisons (50.5 percent) and local jails (50.2 percent) reported ever having a chronic condition, including cancer, high blood pressure, diabetes, heart-related problems, kidney-related problems, arthritis, asthma, and cirrhosis of the liver. Overall, an estimated 80 percent of returning community members have chronic medical, psychiatric, or substance use disorders.1 Additionally, although HIV prevalence is declining among incarcerated individuals, it remains higher than in the general population.e,f More recently, from March through June 2020, federal and state prisoners were 5.5 times more likely than the non-institutionalized population to test positive for COVID-19.12

 

Given these substantial health needs, access to and continuation of care during reentry is crucial. However, returning community members (also referred to in this report as “reentrants”) face multiple health-related challenges which can hinder their ability to obtain coverage and successfully transition care. These challenges are extensive, varied, and include inability to access and afford medications and treatment, limited electronic data sharing of health records between justice system and community providers, limited post-release resources (especially in low-income and rural areas), and systemic health system biases against justice-involved individuals. Additionally, the immediate post-release period is a time of multiple pressing needs, including for obtaining housing, food, and employment and navigating interpersonal relationships; health care is just one of many. Furthermore, challenges in meeting basic needs such as nutrition, housing and employment can make it difficult to obtain, afford and access health care. From a coverage perspective, some reentrants must navigate bureaucratic hurdles to reinstate Medicaid payment for benefits or reapply for Medicaid. Others, especially those in states that did not expand Medicaid eligibility to the adult group, are not eligible for Medicaid and may be unable to access and afford insurance provided by employers or through the federal Health Insurance Marketplaces or state-based Marketplaces.

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The consequences of lack of health care and/or inadequate transition of care during the reentry period can be severe. During the early post-release period, mortality rates are significantly increased among returning community members, especially from overdose, suicide, and homicide.5,6 A study of more than 76,000 persons released from Washington State Department of Corrections found that death rates among these reentrants were 3.6 times higher than expected (based on the mortality rates for the non-institutionalized population within the state), with overdose as the leading cause of death. Opioids were involved in 15 percent of all deaths, and risk of death (from any cause) was particularly high in the first week after release.13 When individuals do not get needed health care during reentry, the consequences impact not only themselves but the communities to which they have returned. Untreated health conditions and poor health status have been found to be associated with increased rates of recidivism and higher associated costs to the health care and criminal justice systems.7,8 Studies in Florida and Washington State have found that Medicaid enrollment upon release was associated with a 16 percent reduction in recidivism among former inmates with severe mental illness.14,15 Furthermore, inadequate health care transitions during reentry also perpetuate racial and socioeconomic health disparities, due to overrepresentation of Black, Latino, and low-income individuals within the justice system.16 When reentering individuals cannot and do not access needed health care, the detrimental consequences--to health and beyond--are concentrated within low-income communities and communities of color.

 

To understand the health care-related challenges facing reentering community members, and to develop effective strategies within and beyond the policy realm to connect these individuals with coverage and care, the broader policy context is key. Beginning in January 2014, the ACA created a new pathway to Medicaid coverage for millions of individuals in the states that elected to expand eligibility.g Prior to the ACA, Medicaid eligibility was generally limited to specific categories of low-income individuals, including children, pregnant women, parents of dependent children, the elderly, and persons with disabilities. Under the ACA, states can choose to expand eligibility to most low-income adults under 133 percent of the federal poverty level. Because people who are incarcerated are disproportionately low-income, expanded eligibility creates a significant pathway to Medicaid for the justice-involved population.16

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In the absence of federal requirements, states differ in how they treat an individual’s Medicaid coverage upon their entry into institutional custody. Historically, most states enacted policies to terminate enrollment upon entry, in order to prevent inappropriate Medicaid billing while in custody.17 In 2016, the Centers for Medicare & Medicaid Services (CMS) released guidance encouraging states to facilitate continuity of enrollment in Medicaid by keeping individuals enrolled but placing them into a limited benefits status to ensure that the only services that can be paid are permissible.18,i In January 2021, CMS released subsequent guidance for states in implementing the SUPPORT Act.19 Section 1001 of the SUPPORT Act prohibits states from terminating Medicaid enrollment based on incarceration for “eligible juveniles.”j Although policies vary from state to state, the process for reinstating payment for Medicaid benefits post-release is generally quicker in so-called “suspension states,” in which an individual’s coverage is either suspended upon incarceration or is maintained but with coverage limited to allowable inpatient services. In contrast, in “termination states,” enrollment is terminated upon entry (except for eligible juveniles) and individuals must reapply for Medicaid post-release.

 

Although individuals may enter prison and jail with Medicaid enrollment (and others are eligible, though unenrolled), the role of Medicaid for incarcerated individuals is extremely limited. Under the federal inmate exclusion, established in 1965 when Congress first authorized the Medicaid program, Medicaid funds cannot be used to pay for services provided to an “inmate of a public institution,” which includes people incarcerated in prison and jails (both pre- and post-sentencing), with very limited exceptions.h As a result of this prohibition, enacted in part to prevent cost-shifting from state and local government to the Federal Government, prisons and jails are responsible for provision and payment of health care services for individuals in their custody. Correspondingly, the type, quality, and quantity of services vary significantly among locations, based on resource availability.

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In the absence of federal requirements, states differ in how they treat an individual’s Medicaid coverage upon their entry into institutional custody. Historically, most states enacted policies to terminate enrollment upon entry, in order to prevent inappropriate Medicaid billing while in custody.17 In 2016, the Centers for Medicare & Medicaid Services (CMS) released guidance encouraging states to facilitate continuity of enrollment in Medicaid by keeping individuals enrolled but placing them into a limited benefits status to ensure that the only services that can be paid are permissible.18,i In January 2021, CMS released subsequent guidance for states in implementing the SUPPORT Act.19 Section 1001 of the SUPPORT Act prohibits states from terminating Medicaid enrollment based on incarceration for “eligible juveniles.”j

 

Although policies vary from state to state, the process for reinstating payment for Medicaid benefits post-release is generally quicker in so-called “suspension states,” in which an individual’s coverage is either suspended upon incarceration or is maintained but with coverage limited to allowable inpatient services. In contrast, in “termination states,” enrollment is terminated upon entry (except for eligible juveniles) and individuals must reapply for Medicaid post-release.

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Section 3.

Challenges

When incarcerated individuals return to the community, their disease burden and existing health challenges are often compounded by a variety of challenges related to accessing health care and health coverage. Understanding these obstacles--many of which are described below--provides a foundation for developing strategies to facilitate connection to coverage, promote access to and continuity of care, and improve health status before and after release. This content comes from the stakeholder meeting unless otherwise cited. The Stakeholder Group is governed by the Federal Advisory Committee Act which sets forth standards for the formation and use of advisory committees. I. Health Care Given the high rates of SUD among the incarcerated population, provision of treatment within prisons or jails supports successful transition back to the community. One example is MOUD. MOUD is an approach to opioid use treatment that combines the use of Food and Drug Administration-approved medications (i.e., buprenorphine, methadone, or naltrexone) for opioid use disorder (OUD) that can be prescribed in combination to reduce opioid craving and use, risk of overdose, and other negative health outcomes. Providing MOUD in combination with counseling and behavioral therapies is considered by medical experts to be an evidence-based best practice, and the Substance Abuse and Mental Health Services Administration (SAMHSA) describes it as a “whole-patient” approach to treating SUDs.20 There is a strong base of correlational evidence showing that when methadone or buprenorphine is provided both during custody and after release, individuals with OUD have significantly lower rates of opioid overdose and mortality.21,22 However, this treatment approach is underutilized in criminal justice settings. As of 2018, only 14 states offered methadone or buprenorphine in any of their jail or prison facilities, 39 offered injectable naltrexone prior to release, and one (Rhode Island) offered all three medications.23 Barriers to more widespread use of MOUD in prisons and jails include concerns about cost and liability, facility policies that prohibit the use of controlled substances, and lack of trained medical providers. (Providers must receive a waiver from the SAMHSA to be able to prescribe buprenorphine, and methadone may only be dispensed in SAMHSA-certified opioid treatment programs.) Additionally, misunderstanding around use of MOUD can present a barrier to its use, as some medical and criminal justice officials may perceive it as substituting one addictive drug for another.20 Access to medications post-release can be extremely difficult for reentering individuals, many of whom have health conditions for which a consistent medication regimen is necessary, including maintenance medications for chronic physical health conditions and MOUD. Stakeholders noted that although some states (including Arizona, Connecticut, Massachusetts, and Rhode Island) provide individuals with a limited supply of their medications upon release, this is not a consistently adopted practice. When individuals do receive a limited medication supply, it is typically for less than 30 days, and they risk running out before they are able to see a provider, obtain a refill, and secure the necessary funds to pick up the prescription. The high rate of overdose in the immediate post-release period may be due, in part, to the inability of returning community members to access MOUD during reentry.

 

Continuity of care for returning community members can also be hindered by limited data sharing between health care providers in the criminal justice system and those in the community. Stakeholders discussed that because most areas lack data infrastructure for sharing medical records between these providers, health care providers in the community often have a limited understanding of reentrants’ medical histories, current medication lists, and comprehensive health care needs. The lack of interface between medical records pre- and post-release contributes to discontinuity of care, discontinuation of medication, duplicative care, and missed opportunities for health care coordination and intervention.

 

Transition of care is further complicated by the fact that returning community members face a variety of pressing--and at times, competing--needs. These include securing housing, food, and employment; navigating interpersonal relationships; and, after long periods of incarceration, adjusting to a changed society. Individuals may delay or avoid applying for health coverage or seeking health care as they focus on other immediate post-release needs. Additionally, those that do seek to access health care may face systemic barriers such as lack of transportation, inflexible work schedules,24 and few health resources, which can be an especially acute concern in rural areas. For reentrants with low health literacy and/or SMI, navigating the health care system can be even more challenging.

 

Finally, stigma towards justice-involved individuals and biases within the health care system also present barriers for reentrants seeking care. Formerly incarcerated individuals face the stigma of having a criminal record along with intersecting stigmas related to behavioral health conditions, poverty, unemployment, and housing instability.1 Collectively, experiencing stigma and discrimination from health care providers can build and reinforce distrust of the medical system among justice-involved individuals and present further barriers to seeking needed medical care during reentry. Additionally, research has found that many health care providers report feeling that they lack cultural competency in dealing with individuals who have been incarcerated.25

 

II.

Health Coverage

Reentering individuals also face specific challenges related to accessing health coverage. Access to coverage can promote continuity of care, reduce the number of hospitalizations, and lower the mortality rate among recently released individuals.26

 

Because most justice-involved individuals are low-income, Medicaid is the predominant form of health coverage for this population. One analysis found that in the year following release from state and federal prison, 45 percent of reentrants had no reported income, and among those that did, the median annual income was $10,090.27 However, an initial challenge to obtaining Medicaid is meeting eligibility criteria. In states that expanded Medicaid eligibility under the ACA, nearly all adults with incomes less than 133 percent of the federal poverty guidelines (calculated as approximately $18,075 for an

 

“Let's remember the competing priorities that these men and women have around housing insecurity, employment, clothing, links with social services, family reunification.  There's a smorgasbord of issues.” -Stakeholder

 

However, in the 12 statesk that have not adopted expansion, in addition to being below the income threshold, individuals must fall into one or more of the following categories to qualify for Medicaid: children, pregnant women, parents of dependent children, the elderly, and persons with disabilities. In these non-expansion states, many individuals who are lowincome (as is true for most individuals leaving prison and jail) lack Medicaid eligibility because they do not meet at least one of the categorical requirements. This is especially true for non-disabled, nonelderly men, who comprise a significant share of the justice-involved population. Reentrants who are ineligible for Medicaid face challenges obtaining other forms of health insurance, as private Marketplace coverage may be unaffordable. Additionally, a criminal record can present barriers to securing employment, especially employment that provides health insurance benefits.

 

In states that have implemented Medicaid expansion for the adult group, many individuals are eligible for Medicaid when they enter prison or jail. According to a 2014 report from the U.S. Government Accountability Office, officials from New York and Colorado--both states that expanded eligibility-- estimated that 80 percent and 90 percent of state prison inmates, respectively, were likely Medicaideligible.29 However, the federal statutory inmate exclusion prohibits federal financial participation for nearly all care furnished to beneficiaries while they are incarcerated. The policy does not exclude incarcerated individuals from Medicaid eligibility, but it prohibits Medicaid payments for benefits and services while incarcerated (with the exception of care provided to Medicaid-eligible incarcerated individuals who are inpatients in a medical institution). As such, in some cases, states place individuals in a suspension status and in others a state may terminate an individual’s Medicaid enrollment when they are incarcerated.l

 

There is substantial variation in how states approach this issue; as of January 2019, 41 states plus the District of Columbia suspend (versus terminate) Medicaid upon incarceration in jail, and 42 states plus the District of Columbia suspend upon incarceration in prison.30 In some of these states, suspensions are for a short period of time only (e.g., 30 days) before proceeding to termination, or they apply only to specific prisons and jails. In the remaining states, enrollment is terminated when an individual is incarcerated in a prison or jail. In cases when enrollment has been terminated, reentering individuals must reapply for Medicaid to obtain coverage post-release. Reentrants may find it difficult to complete the application due to lack of a steady mailing address, documentation, proof of residency, and/or other information that is necessary to verify their eligibility.31 This population may also have low health literacy, which can make the Medicaid application process more difficult and daunting. Given these challenges, termination of enrollment presents a barrier to securing health care coverage immediately following release and increases the likelihood of gaps or lapses in coverage and care.

 

Even when Medicaid is suspended during incarceration, returning community members face barriers to reinstating and using their coverage upon release. Among the more than 40 states that suspend Section 1001 of the SUPPORT Act prohibits states from terminating Medicaid enrollment for “eligible juveniles.” Eligible juveniles are individuals under age 21 and individuals enrolled in the mandatory eligibility group for former foster care children. Medicaid, just over half (23 states) have electronic, automated data sharing systems in place between the criminal justice system and state Medicaid agency. In some of these states, the data system alerts the Medicaid agency when an enrollee has been incarcerated and when they have been released, to facilitate automatic suspension and reinstatement of Medicaid. However, multiple stakeholders stated that even in many so-called “suspension states,” reentrants can experience lapses in coverage during reentry due to bureaucratic delays to reinstate coverage, limited communication between the relevant systems, and variation in practices at the local level. Timing of reinstatement and the associated gaps in coverage and care can be especially challenging for individuals leaving jail, many of whom experience frequent short-term stays in jail and therefore cycle in and out of Medicaid.

 

Returning community members who obtain Medicaid also face challenges related to coverage for needed services. Stakeholders noted that some services that are particularly relevant to individuals with mental health diagnoses and SUDs are optional benefits under Medicaid and may not be covered. These include clinic services, rehabilitative services (such as counseling and recovery support), personal care, and case management. Stakeholders also discussed that two promising approaches for supporting this population (crisis diversion facilities and peer support services) could be challenging for reentrants to access if the benefit is not covered in their state.

 

Among older reentrants, Medicare is another important coverage option. However, even when Medicare eligibility requirements are met, the time-limited Initial Enrollment Period can present challenges. Individuals must enroll during the 7-month period starting 3 months prior to turning 65 and ending 3 months after turning 65, or else they are subject to a monthly late enrollment penalty for the duration of their Part B coverage (and/or Part A coverage if the individual is ineligible for premium-free Part A). Justice-involved individuals may be unaware of this enrollment window or may be unable to complete enrollment documents during this time due to long periods of incarceration. In the proposed rule titled “Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules”, published in the Federal Register on April 27, 2022 (87 FR 25090), CMS proposed a special enrollment period (SEP) for formerly incarcerated individuals. The SEP, as proposed, would be available beginning on or after January 1, 2023, and be available for 6 months following the individual’s release from incarceration. Additionally, Medicare Part A--which covers hospital, skilled nursing facility, home health services (for individuals not enrolled in Part B)--is available premium-free to individuals with disabilities under age 65 who have received Social Security Disability benefits for 24 months, have End Stage Renal Disease, or they or their spouse is 65 and older and have worked and paid taxes under the Federal Insurance Contributions Act for at least 10 years. Individuals with a substantial criminal justice system history may not meet this requirement, further increasing their out-of-pocket expenditures, as individuals eligible for and enrolled in Medicare Part A without sufficient eligible work history would be required to pay a monthly premium.

 

“Until we recommend that there be investments in states and local governments to be able to automate both enrollment and suspension, we're never going to achieve the seamless transitions that we're hoping for.” -Stakeholder

 

The next two sections describe two categories of practices (those related to health care [Section 4] and those related to health coverage [Section 5]) that workgroup members identified as promising approaches to address the challenges described above