HHS: 'Health Care Transitions For Individuals Returning To The Community From A Public Institution – Promising Practices Identified By The Medicaid Reentry Stakeholder Group' (Part 1 of 2)

WASHINGTON, Jan. 26 (TNSrep)-- The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation issued the following report on Jan. 26, 2023, entitled "Health Care Transitions for Individuals Returning to the Community from a Public Institution - Promising Practices Identified by the Medicaid Reentry Stakeholder Group."

The report was written by Rose Feinberg, Amelia Esenstad, Rachel Cannon, Colleen Staatz, Kristanna Peris, Larisa Bokota, Dara Lee Luca and Jillian Stein.

Here are the excerpts:

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Acknowledgements

The ASPE project officer for this work was Jhamirah Howard. ASPE acknowledges programming support from RTI International (Rose Feinberg, Amelia Esenstad, and Rachel Cannon), who prepared this report, and Mathematica (Colleen Staatz, Kristanna Peris, Larisa Bokota, Dara Lee Luca, and Jillian Stein), who compiled the research supporting this report.

The opinions and views expressed in this report are those of the authors. They do not reflect the views of the U.S. Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on April 8, 2022.

This communication was printed, published, or produced and disseminated at United States taxpayer expense.

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Table of Contents

EXECUTIVE SUMMARY ... 4

SECTION 1. Introduction ... 7

SECTION 2. Background ... 8

SECTION 3. Challenges ... 11

I. Health Care ... 11

II. Health Insurance ... 12

SECTION 4. Care-Related Practices ... 16

I. Institution-Based Practices ... 16

II. Community-Based Practices ... 18

SECTION 5. Coverage-Related Practices ... 23

I. Institution-Based Coverage Practices ... 23

II. Community-Based Coverage Practices ... 26

SECTION 6. 1115 Demonstration Considerations ... 29

I. Key Considerations ... 31

II. Facilitators of State Update ... 33

SECTION 7. Conclusion ... 35

SECTION 8. References ... 37

APPENDICES

APPENDIX A. Stakeholder Group Attendees ... 43

APPENDIX B. List of Acronyms ... 44

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Executive Summary

Introduction and Background

Individuals returning to the community after incarceration in prison or jail/a 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

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.

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

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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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a/Jails are administered by local law enforcement and hold those with shorter sentences (usually 1 year or less) and those awaiting trial. Prisons are state or federal facilities where people who have been found guilty of breaking a state or federal law, respectively, are sent to serve sentences typically longer than 1 year.

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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, in-reach 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.

b/The 11 states include: Arizona, California, Kentucky, Massachusetts, Montana, New Jersey, New York, Oregon, Utah, Vermont, and West Virginia.

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Conclusion

Health care and health coverage are important and impactful aspects of the reentry process. The importance of access to and continuity of health care throughout reentry is underscored by the high rates of serious health concerns (including SMI, SUD, and chronic and infectious health conditions) among the justice-involved population. Successful care transitions following incarceration benefit returning community members and the broader communities to which they return. Conversely, lack of care or gaps in care harm these individuals and communities, which are predominantly low-income and disproportionately comprised of Black and Hispanic individuals. Successful reentry is therefore a matter of--and a means of promoting--health equity.

Health transitions during reentry require coordination among corrections systems and community agencies. Promising care-related practices raised by stakeholders include SUD screening and treatment, including provision of MOUD; post-release medication prescription and/or supply; in-reach discharge planning and care coordination; peer support navigators; data sharing between correctional system and community providers; and crisis diversion services and facilities. Promising coverage-related practices include increased access to Medicaid through expanding eligibility, suspending Medicaid upon incarceration, and designating correctional facilities as qualified entities for presumptive eligibility; data sharing between the criminal justice system and Medicaid agencies; automated reinstatement of Medicaid upon release; Medicaid health homes for justice-involved beneficiaries; and enrollment assistance for SSI, SSDI, Medicare, and VA health care and benefits.

Looking ahead, an 1115 demonstration to allow Medicaid payment for pre-release care offers a significant potential opportunity to promote access to and continuity of health coverage and care for returning community members. In doing so, the demonstration could also seek to address the critically important goals of reducing health disparities and promoting equity in health coverage, access to care, and health outcomes. The justice-involved population carries a disproportionate burden of health challenges, perpetuated by deeply rooted systemic factors. Medicaid Section 1115 demonstration authority presents an opportunity to work towards current priorities for the Center for Medicaid and CHIP Services, including coverage and access, equity, and innovation in whole-person care.

Based on stakeholder discussion, key considerations for demonstration design include the scope of benefits provided pre-release, who would be eligible, the length of time for pre-release coverage for services, and strategies for addressing social supports. In addition, there should be meaningful engagement of justice-involved individuals in the design, attention to addressing health disparities, and thoughtful attention to data collection, implementation, monitoring, and evaluation of the demonstration outcomes.

Stakeholders also identified areas for further research and discussion, including disparities among different racial and ethnic groups, the divide between urban and rural areas, health coverage and access to care among the juvenile justice population, utilization of and outcomes associated with post-release Medicaid coverage, and the differences between jails and prisons that may require different reentry approaches.

The challenges associated with the transition back to the community after prison and jail are multifaceted. Promising practices to address these challenges recognize this complexity. Reentry success requires support both pre- and post-release, within and beyond the correctional facility, and related to health care access and health coverage. An 1115 demonstration to improve care transitions for Medicaid-eligible individuals preparing for release from prison or jail provides an important pathway to test and learn from promising approaches to reentry practices and supports that serve to promote health of individuals, health of communities, and health equity.

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(Continues with Part 2 of 2)

The report is posted at: https://aspe.hhs.gov/sites/default/files/documents/d48e8a9fdd499029542f0a30aa78bfd1/health-care-reentry-transitions.pdf