INFORMED MEDICAID COVERAGE AND THE NEED FOR CONTINUITY OF CARE
The United States incarcerates more people than any other country in the world, with 2.2 million inmates currently in custody−a 500% increase over the past 30 years. Individuals suffering with mental illness are disproportionately represented in the criminal justice population with 56% of state prisoners and 64% of jail inmates affected by a mental health condition. Those with mental illness are 3x times more likely to be incarcerated compared to the general population, and probationers with mental illness have higher recidivism rates.
In 2010, the Office of Research and Affairs surmised that the mental health epidemic in our nation’s prison system meant there are now three times more seriously mentally ill persons in jails and prisons than in hospitals.
Medicaid and the Prison Population
According to Medicaid.gov, more than 60% of incarcerated individuals throughout the U.S. fall below the Medicaid income threshold, meaning that pre- and post-imprisonment, these individuals likely qualify for Medicaid benefits.
Once incarcerated, an individual’s benefits cease for the duration of his or her sentence. Each state determines whether benefits are either terminated or suspended. In states that terminate benefits, inmates must reapply for Medicaid upon their release. In states that suspend coverage, the incarcerated beneficiary remains on the Medicaid roll in a “suspended” status, retaining his/her eligibility while cutting off benefits for the duration of their incarceration.
In states that suspend Medicaid coverage while beneficiaries are incarcerated, upon release from custody, reinstating their benefits can be a fairly straightforward process. As long as the Medicaid agency is aware of their release, it can typically process the reinstatement of benefits with few hurdles. Alternatively, in states that terminate beneficiary coverage, regaining benefits requires a.) the Medicaid agency to be aware of the beneficiary’s release from custody, and b.) the beneficiary must again undergo eligibility determination−a very long and tedious process.
Due to lack of communication between those involved in a beneficiary’s care plan (i.e., prison staff, Medicaid agencies, and healthcare facilities), once a beneficiary is released from incarceration, it often results in a gap in their medical and behavioral care regimens. Accessing benefits upon re-entry is especially problematic for individuals with mental illness who−due to issues with transportation, difficulty in interpersonal communication, substance abuse, and/or homelessness−are more likely to struggle navigating the months-long reinstatement process. Ensuring continued access to appropriate care during key transitions, such as booking and release, is critical. Unchecked or interrupted treatment often means serious regression in health conditions.
A common need within the Medicaid community is to better ensure that incarcerated beneficiaries receive seamless continuity of care, from the time they are booked into custody, throughout their incarceration, and upon release back into the community−and that the appropriate parties finance their care at each stage.
Determining Eligibility in Light of Incarceration: Challenges Faced
Medicaid agencies face significant challenges when determining eligibility and distributing proper benefits against a backdrop of beneficiaries whose incarceration statuses may be changing at any given moment.
State Medicaid agencies spend hours, days, even weeks attempting to locate and subsequently monitor beneficiaries who are in various stages of the incarceration lifecycle. An agency may perform some or all of the following tasks in attempt to locate a single beneficiary:
- Multiple calls to multiple jails and DOC facilities
- Searching through online jail databases
- Scanning shared in-custody lists (when available and if up-to-date)
Along with disrupting beneficiary continuity of care, these manual, intensive, and inefficient processes often result in further negative consequences:
Increased rates of recidivism
During a transition in incarceration status, those with mental illness conditions are particularly vulnerable to recidivism. It is vital to ensure that individuals leaving incarceration are equipped to make positive choices for their mental and physical well-being to avoid relapse, compromised health, or further criminal activity.
The consequences can even be deadly. A 2015 study by the Treatment Advocacy Center found that people with untreated mental illness are 16x more likely to be killed during a police encounter than other civilians approached or stopped by law enforcement. In addition, the risk of death for all individuals post-incarceration sharply increases in the two weeks immediately following release−driven by drug overdose, cardiovascular disease, liver disease, HIV-related conditions, and suicide.
If a beneficiary’s incarceration status is unknown to the Medicaid agency, and coverage is not properly terminated, suspended, or reinstated, the opportunity for improper payments dramatically increases. Each year, billions of dollars are spent on improper Medicaid payments (over $60 billion in 2014!). This overspend is not only harmful to the Medicaid agency providing this improper financial support, but burdensome to the taxpayers who must contribute to that support.
Additionally problematic, Medicaid agencies are often subject to intentional fraud, leading to improper payments. If an agency is not notified that one of their beneficiaries has been incarcerated, benefits may be fraudulently requested and subsequently paid.
Increased Community Expenses
The cost of interrupted care financially affects the greater community in several ways:
- Individuals without a primary source of healthcare are far more likely to become “super users” of expensive services such as ambulance rides and emergency room visits. These are expenses absorbed by the community.
- Untreated illnesses become increasingly expensive the longer that care is delayed. Meaning, by the time an ill individual does receive treatment, their care will likely be more expensive than it would have been had they received consistent care all along.
- Behavioral health issues and recidivism cycles costs the community in law enforcement services, legal services, and re-incarceration expenses.
These issues are not isolated or unique to certain areas−they are crippling issues faced by Medicaid agencies nationwide.
The Solution: Real-Time Incarceration Intelligence
It is critical that Medicaid agencies are aware of a beneficiary’s incarceration status the moment it changes. Access to real-time incarceration data from a single information source allows Medicaid agencies to update beneficiary status easily−as it changes.
Implementing an effective solution to locate and monitor beneficiaries creates a number of opportunities for Medicaid agencies and taxpayers alike to protect assets and gain cost efficiencies, such as:
- Support Continuity of Care
- Reduce Recidivism
- Reduce Improper Payments
- Reduce “Super Users”
Accurate status information leads to accurate payments. Accurate status information also leads to enhanced communication between informed stakeholders and care teams responsible for establishing beneficiaries’ continuity of care−key to curbing the mental health epidemic plaguing a very vulnerable segment of our nation.