Health Reform: Understanding and Navigating the Affordable Care Act and Its Implications for Justice-Involved Individuals The National Association of Medicaid Directors Panel Fall Meeting November 7, 2016

1. Morbidity of Incarcerated Individuals

Health Status of Justice-Involved Individuals Individuals in jail are disproportionately young, male, persons of color, and poor. They have high rates of health problems (chronic and infectious disease, injuries), mental health disorders, and substance use disorders (SUDs). 80% of individuals in jail with chronic medical conditions have not received treatment in the community prior to arrest.

Source: A Binswanger, PM Krueger, JF Steiner, Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population, J Epidemiol Community Health. 2009 Nov;63(11):912-9. doi: 10.1136/jech.2009.090662. Epub 2009 Jul 30. September 2013

Source: A Binswanger, PM Krueger, JF Steiner, Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population, J Epidemiol Community Health. 2009 Nov;63(11):912-9. doi: 10.1136/jech.2009.090662. Epub 2009 Jul 30. September 2013

Sources: Substance Abuse and Mental Health Services Administration Sources: Substance Abuse and Mental Health Services Administration. (2003). Results from the 2002 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NHSDA Series H-22, DHHS Publication No. SMA 03–3836). Rockville, MD. Bureau of Justice Statistics, Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002, September 2013

Sources: Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration. Henry J. Steadman, Ph.D.; Fred C. Osher, M.D.; Pamela Clark Robbins, B.A.; Brian Case, B.A.; Steven Samuels, Ph.D., Prevalence of Serious Mental Illness Among Jail Inmates, Psychiatric Services 2009; doi: 10.1176/appi.ps.60.6.761. September 2013

2. When are Justice-Involved Individuals Covered by Medicaid?

Clarifications Made by the April 28, 2016, CMS Letter in Reference to Halfway Houses, Work Release Programs, and Day Treatment Programs Inmate: someone who has lost their “legal ability to exercise personal freedoms” Clarified that individuals remain covered by Medicaid if they reside in corrections-related, supervised community residential facilities unless they have lost freedom of movement Sleeping in a locked facility or being on count of a correctional institution does not disqualify an individual for FFP Source: Wachino, Vikki. RE: To Facilitate successful re-entry for individuals transitioning from incarceration to their communities. pg. 3-14. From Medicaid.gov. https://www.medicaid.gov/federal-policy-guidance/downloads/sho16007.pdf (accessed October 17, 2016)

Clarifications in Reference to Hospital Stays of Greater than 24 Hours Correctional providers that have contracted to pay for inpatient stays will not be reimbursed from Medicaid (TPL) FFP is only available for inpatient services furnished to patients admitted to an inpatient stay who stay 24 hours or more (i.e., not observation beds) Inmate inpatient hospitalizations to community hospitals are now modified to exclude admission based on justice status. Beds used by justice involved individuals must relate to their clinical condition (same concept in reference to SNF) Source: Wachino, Vikki. RE: To Facilitate successful re-entry for individuals transitioning from incarceration to their communities. pg. 3-14. From Medicaid.gov. https://www.medicaid.gov/federal-policy-guidance/downloads/sho16007.pdf (accessed October 17, 2016)

In states that have expanded Medicaid under the Affordable Care Act, nearly all individuals are presumed to be eligible for Medicaid following release from jail or prison. Source: Davis, Matthew and Winkleman, Tyler. Improving Outcomes for Justice-Involved Individuals with Lessons from Veterans Programs. October 6, 2016. Website, http://healthaffairs.org/blog/2016/10/06/improving-outcomes-for-justice-involved-individuals-with-lessons-from-veterans-programs/ (Accessed October 16, 2016) October 16, 2016)

Medicaid Enrollment for Justice-Involved Individuals Released inmates have a markedly elevated risk of death, driven by factors including overdose, cardiovascular disease, liver disease, HIV-related conditions, and suicide. Former prisoners have mortality rates 12 times higher then the general public in the first 2 weeks after release Connection to services reduces rates of recidivism for those with serious mental illness Source: Davis, Matthew and Winkleman, Tyler. Improving Outcomes for Justice-Involved Individuals with Lessons from Veterans Programs. October 6, 2016. Website, http://healthaffairs.org/blog/2016/10/06/improving-outcomes-for-justice-involved-individuals-with-lessons-from-veterans-programs/ (Accessed October 16, 2016)

Key Considerations for Medicaid Enrollment of Justice-Involved Individuals Providers, state Medicaid agencies, and beneficiaries may look at the issues surrounding enrollment differently Enrollment is different than plan selection Enrollment does not ensure exchange of claims data to expedite care

3. Where Will Medicaid and Justice Involvement Intersect in the Future?

Novel Waiver Initiatives National Association of Counties response to the opiate epidemic New York State’s 1115 Waiver

Daniel Mistak dmistak@cochs.org Questions? www.cochs.org 510-595-7360 Daniel Mistak dmistak@cochs.org