Gabrielle de la Guéronnière, Legal Action Center 2014 RSAT Grantee Meeting July 18, 2014 The Affordable Care Act and the Criminal Justice System: Huge Opportunities and Needed Next Steps 1

What We’ll Discuss Today What are the ACA’s (Affordable Care Act) major opportunities to expand coverage for services and to improve access to care for justice-involved individuals? Updates on activity What should we expect next? What should our next steps be? 2

About LAC and the Coalition for Whole Health Legal Action Center National law and policy organization that works to fight discrimination against people related to substance use disorders, HIV/AIDS, and/or criminal records Grant through BJA to support a number of grantees on health reform and the criminal justice system Coalition for Whole Health A coalition of over 100 national, state, and local organizations in the mental health and substance use disorder fields and allied organizations working to ensure health reform is successfully implemented for individuals with mental health and substance use disorder needs 3

Health Characteristics of Justice- Involved Individuals 4 High rates of physical health problems, mental illness and substance use disorders (SUDs) in the criminal justice system State and local court systems and correctional agencies have spent huge amounts of money on care Most people reentering from incarceration have no or little health insurance coverage in the community Even for individuals with health insurance, coverage for mental health and substance use disorder benefits has been inconsistent and often lacking Most justice-involved people have had poor access to health care

Health and Recidivism 5 Relationship between criminal justice system involvement, high rates of recidivism and untreated mental health and SUD Drug overdose is the highest cause of death for individuals reentering the community Twelve-times higher risk of death in the first two weeks after release However, with access to care, health outcomes improve, and recidivism rates and costs to the correctional and health systems decline

Importance of the ACA to the Criminal Justice System: Coverage Expansions and Infusion of Federal Dollars 6 The ACA presents a huge opportunity to improve public health, increase public safety, and save states huge amounts of money The ACA dramatically expands health insurance coverage to millions of people In the 27 states expanding their Medicaid population, federal Medicaid will for the first time pay for non-disabled adults with no dependent children up to 138% FPL Huge federal investment: federal dollars will cover 100% of the costs for first 3 years, decreasing to 90 percent indefinitely Federal dollars likely create greater incentives in states and counties for systems reforms and collaborations Opportunities for reimbursement for enrollment activities

Leveraging Additional Federal Funding to Improve Continuity of Care Most states terminate Medicaid when someone becomes incarcerated The “inmate exclusion” prohibits federal Medicaid payments for care provided to any individual involuntarily confined in state or federal prisons, jails, detention facilities, or other penal facilities As a result, states may not use federal Medicaid funds to pay for care provided to incarcerated individuals in most circumstances 7

Medicaid, Incarcerated Beneficiaries, and the Inpatient Exclusion Medicaid can pay for services when the incarcerated individual is a “patient in a medical institution” When they’ve been admitted as an inpatient in a community- based hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility for at least 24 hours All medically necessary Medicaid covered services provided to that individual while admitted can be billed to Medicaid 8

State Cost-Savings through Medicaid Suspension 9 A number of states have recognized the huge potential for cost savings when they suspend Medicaid North Carolina saved $10 million in the first year (2011) California saved about $31 million in FY 2013 New York estimated in 2012 that it could save $20 million annually if the state billed Medicaid for eligible inpatient care The enhanced federal Medicaid share in expansion states presents an even greater opportunity Reforming state policies to suspend instead of terminating Medicaid will significantly help with continuity of care into the community

Using Medicaid to Pay for Inpatient Care Medicaid can be suspended during incarceration Although federal rules prohibit payment for services for incarcerated individuals, this has no effect on eligibility or enrollment The federal government (CMS) has encouraged states to suspend not terminate Medicaid There is no federal prohibition against screening for eligibility during incarceration HHS has also clarified “corrections department employees…are not precluded from serving as an authorized representative of incarcerated individuals for purposes of submitting a (Medicaid) application on such an individual’s behalf.” Enrollment can and should happen at all stages of justice system involvement 10

Importance of the ACA to the Criminal Justice System: Improved Coverage for and Access to Addiction and Mental Health Services 11 The ACA will dramatically improve coverage for and access to substance use disorder (SUD) and mental health (MH) services Under the ACA, SUD and MH services are essential health benefits which must be covered at parity (Mental Health Parity and Addiction Equity Act) with other covered medical benefits Requirements apply to most Medicaid and private insurance coverage; access improvements will apply to millions of people Parity requirements relate to scope of MH and SUD services and medications covered, financial requirements, and quantitative and non-quantitative treatment limitations

Related updates and potential developments 12 Developments related to the federal parity law Final rule became effective for certain plans on July 1 st State enforcement activity Expecting additional guidance from CMS later this year Discussions about supporting the full continuum of SUD care Specific focus on coverage for residential SUD treatment and the IMD exclusion Coalition for Whole Health survey to gauge transparency of MH and SUD benefits and other coverage information Network adequacy focus

Importance of the ACA to the Criminal Justice System: Improved Access to Care for People with Chronic Health Conditions 13 The ACA has a strong focus on creating incentives to help people with multiple chronic health conditions Section 2703 of the ACA created the new health home Medicaid option for beneficiaries with multiple chronic conditions. Health homes are meant to build on other care coordination models to create linkages to community and social supports, enhance coordination of physical health, mental health and substance use care, and to improve health outcomes for high-cost patients. Enhanced federal funding Huge opportunity to both improve health and reduce entry and reentry into the criminal justice system by getting people enrolled and linking them to care as early as possible

Related updates and potential developments 14 Launch of CMS Innovation Accelerator Program Technical assistance to the states with a focus on substance use disorders Focus on medication-assisted treatment Joint CMS Informational Bulletin released this week Significant focus in Washington in response to the opioid crisis around the country Federal appropriations timing and outlook Work by Senators Whitehouse and Portman

Our Next Steps 15 Understanding the landscape of decision-makers and how to determine coverage options Did your state expand Medicaid? Which services, including MH and SUD services and medications, will be covered? Is your state a Health Home state? Who is running your state’s Marketplace? Which Marketplace plans provide the strongest coverage options for people with complex health needs? Critical need for health and criminal justice stakeholders to work closely together Work between the State Medicaid agency, the State health insurance exchange board and community care providers with corrections and other justice system decision-makers and stakeholders

LAC’s Field-Initiated Project with the Bureau of Justice Assistance 16

Helping the Criminal Justice Field to Maximize the Opportunities of the ACA 17 Determining the technical assistance needs and supporting a number of BJA’s grantees Upcoming newsletter series Creating additional educational materials and practical tools to support enrollment and linkage to care and broadly disseminating them Providing assistance through TA calls, webinars, trainings, and workshops Compiling and disseminating concrete examples of successful practices and policies as well as barriers to implementation and ways of overcoming these barriers.

Questions and Discussion Gabrielle de la Guéronnière