By Suzanne Wikle

With efforts like “ban the box,” restoration of voting rights, and “Second Chance Pell” grants, the tide is turning for people re-entering communities after incarceration.  New guidance from the U.S. Centers for Medicare and Medicaid Services (CMS) reinforces the importance of access to health care for citizens re-entering their communities, provides clarification of exactly when eligibility for Medicaid begins, and encourages states to help people apply for Medicaid prior to their release. Access to Medicaid is especially important because people in correctional facilities have profound health problems, experiencing dramatically higher rates of mental illness, substance abuse, infectious disease, suicide, and violence than the general population. Medicaid enrollment breaks down an important barrier to establishing stability and provides access to behavioral health care and prescription medication—two resources that may often be critical factors for a successful re-entry to communities.

For example, many youth involved in the justice system have been exposed to high levels of toxic stress—resulting from extreme poverty, neglect, abuse, or witnessing violence—which can interrupt their normal brain development with long-term consequences for learning, behavior, and physical and mental health. The negative effects of these experiences often endure into adulthood. Conditions in detention centers and juvenile justice facilities, including violence and use of seclusion and restraint, can exacerbate existing mental health issues. The trauma brought on by these adverse childhood experiences necessitates that justice-involved youth in community settings be connected to high-quality, culturally competent health care and mental health interventions.

A major part of the new CMS guidance is defining who is considered an inmate for the purpose of Medicaid eligibility. While incarcerated, individuals receive their health care through the justice system and are not eligible for Medicaid. States have been uncertain whether individuals on parole, probation, or released to the community pending trial are considered “inmates,” with the guidance clarifying that such individuals are not inmates and are therefore eligible for Medicaid, assuming all other eligibility criteria is met.  

Furthermore, the guidance also clarifies that people living in supervised community residential facilities (i.e. halfway houses) are eligible for Medicaid as long as they have freedom of movement to participate in the community (and they meet other Medicaid eligibility criteria). By ensuring people are connected with Medicaid in the transition period after leaving incarceration, they will be better able to have their health needs met by, for instance,  refilling prescriptions or receiving therapy, as they begin their re-entry.

Recognizing the importance of continuous health coverage, the guidance encourages states to help individuals apply for Medicaid as they prepare to leave incarceration. States are also encouraged to transfer medical records from correctional institutions to new primary care, mental health, and substance use treatment providers.

The guidance also addresses options states have when someone enrolled in Medicaid becomes incarcerated, suggesting that states choose to suspend, rather than terminate, eligibility during the time of incarceration. This option meets the states’ obligation not to use Medicaid dollars for care provided in a correctional facility but will allow the individuals to have their eligibility reinstated when they re-enter the community. Because the Affordable Care Act (ACA) requires a 12-month eligibility certification, this option is especially beneficial for people incarcerated less than a year. The guidance also specifies that any suspension of eligibility “must be promptly lifted” when the person is no longer an inmate, which will require coordination among the state Medicaid and Correctional agencies.

Because returning citizens are at an increased risk of relapse, injury, or death during the week following return into the community from a period of incarceration, this is is an extremely vulnerable time. Therefore, immediately providing individuals with access to primary care, behavioral health care, and substance use treatment as they re-enter their communities offers some of the necessary tools to reduce recidivism. With people of color experiencing disproportionate contact with the justice system at all levels, including arrest, adjudication, probation, and incarceration, CMS’s new guidance will make a huge difference for low-income communities of color.

However, this access to health care won’t be available to everyone re-entering their communities. In the 19 states that have not yet chosen to expand Medicaid, the majority of adults (over age 18) won’t qualify for Medicaid, even if they have extremely low incomes. Some parents with dependent children may qualify, but it varies among states and eligibility limits are very low. Providing individuals with greater stability and reducing recidivism rates is just one more reason why expanding Medicaid is beneficial to states and communities.