Medicaid Enrollment/Utilization Analysis of FDOC Populations in

Purpose Understand how FDOC categorizes people with mental illnesses who were enrolled in Medicaid prior to admission and are likely to be eligible upon release Determine areas where internal FDOC processes could be adjusted to improve identification and discharge planning 2

Key Findings There are missed opportunities to target scarce FDOC reentry resources toward individuals likely to eligible for federal income supports and entitlement The categorization of people with mental illnesses within FDOC does not match Medicaid records Many more people enter FDOC with prior Medicaid enrollment than are re-enrolled following release 3

Figure 1: Medicaid Status of Admissions (N=37,489) Enrollment Status Pre-Admission 4

Enrollment Status Pre- and Post-Release Figure 2: Medicaid Status of Released Population (N = 28,728) 5

Service Utilization: Admissions  No prior enrollment  Prior enrollment within 7 years of admission Figure 3: Medicaid Service Utilization of Previously Enrolled Admissions (N = 37,489) 6

Service Utilization: Released Population  No prior enrollment  Prior enrollment within 7 years of admission Figure 4: Prior Medicaid Service Utilization of Released Individuals (N = 28,728) 7

Service Utilization: Released Population Figure 5: Medicaid Service Utilization of Previously Enrolled Individuals 1-year Post-Release (N = 2,719) 8

Table 1: FDOC Service Grade Descriptions Service GradeDescription S1Routine Care S2Ongoing Svc Outpatient psychology (intermittent or continuous) S3 Ongoing svc outpatient (case management, group and/or individual counseling as well as psychiatric or psychiatric ARNP care) S4Assigned to a transitional unit (TCU) S5Assigned to a crisis stabilization unit (CSU) S6Assigned to a Corrections Mental Health Treatment Facility (CMHF) S9Scheduled to be evaluated 9

Medicaid Status Pre- and Post-Release Previously Enrolled Enrolled 1 Year Post-Release S-Grade S-Grade TotalN% of S-Grade Total N % of Previously Enrolled in S-Grade S123,6582, S S33, S S S S Unknown Grand Total28,7282, Table 2: Medicaid Status, within S-Grade, of Individuals Previously Enrolled in Medicaid during the 7 Years Prior to Admission versus One Year Post-Release 10

Service Utilization Prior to Admission N (%) Service GradeService Grade TotalMental HealthSubstance UseMH and SUPhysical Health S12, (18.9)16 (.8)201 (10)763 (37.8) S (26.6)0 (0)28 (20.1)21 (15.1) S (30.6)3 (.7)90 (21)145 (33.9) S4112 (18.2)0 (0)7 (63.6)1 (9.1) S573 (42.9)0 (0)2 (28.6)0 (0) S620 (0) 2 (100)0 (0) S9328 (25)0 (0)9 (28.1) Unknown8113 (16)0 (0)16 (19.8)25 (30.9) Grand Total2, Table 3: Medicaid Service Utilization by S-Grade for Individuals Previously Enrolled in Medicaid during the 7 Years Prior to Admission

Service Utilization Post-Release N (%) Service GradeService Grade TotalMental HealthSubstance UseMH and SUPhysical Health S (4.2)2 (.8)11 (4)106 (40) S2 345 (14.7)0 (0)3 (8.8)16 (47.1) S (20)2 (1.5)12 (9)41 (30.4) S4 42 (50)0 (0) 1 (25) S5 11 (100)0 (0) S6 22 (100)0 (0) S9 112 (18)0 (0)1 (9.1)3 (27.3) Unknown 204 (20)0 (0)1 (5)7 (35) Grand Total Table 4: Medicaid Service Utilization by S-Grade for Individuals Previously Enrolled in Medicaid during the 7 Years Prior to Admission, One Year Post-Release

Diagnoses: FDOC vs. Medicaid Files Serious Mental Illness DiagnosisSchizophrenia Diagnosis S-Grade MedicaidDOCOverlap (%)MedicaidDOCOverlap (%) S (4.3)1520 (0) S (12)721 (14.3) S (65) (51.4) S4988 (89)711 (14.3) S5544 (80)422 (50) S6222 (100)22 S9673 (50)100 (0) Unknown1711 (5.9)811 (12.5) Grand Total Table 5: FDOC vs. Medicaid File Diagnoses, by Service Grade, for Individuals Enrolled in Medicaid during the 7 Years Prior to Admission Meeting Criteria for Serious Mental Illness

Cost Thus, if patterns of service utilization post release mirrored those pre-incarceration, there may be roughly $2.17 million in service costs for which Florida is not receiving any federal share for Medicaid reimbursable services Of the 472 individuals who re-enrolled post-release, 299 accessed roughly $835,000 of services in the 365 days after their release Of the 2,719 people released from FDOC who had prior Medicaid enrollment, 1,007 accessed Medicaid services at an average cost of roughly $3 million per year, prior to incarceration 14

Key Findings Revisited There are missed opportunities to target scarce FDOC reentry resources toward individuals likely to be reconnected to income supports and entitlement The categorization of people with mental illnesses within FDOC does not match Medicaid records Many more people enter FDOC with prior Medicaid enrollment than are re-enrolled following release 15

Limitations Individuals may be eligible for Medicaid for a variety of reasons in addition to disability. Most of sample was in the SSI/SSDI or TANF program types, but we were unable to examine this variable in greater detail. Diagnoses recorded on Medicaid files not a gold standard, and thus may not be completely valid or reliable. We did not examine all of the reasons in addition to incarceration that individuals may have been dropped from Medicaid rolls. 16

Recommendations Better identify individuals with SMI entering FDOC Ensure that individuals with history of SMI end up in appropriate S-Grade Improve screening and diagnosis Obtain weekly or monthly reports from FMHI flagging admissions with prior Medicaid enrollment Cross-check Medicaid service utilization history with S- Grade categorization Match records Target resources toward “low-hanging fruit” -- individuals with SMI who were enrolled in Medicaid before admission Use FMHI reports to begin re-enrollment process as early before release as possible for these individuals Improve transition planning 17

Conclusions Conservative estimate for increased Medicaid enrollment for individuals involved with FDOC, for people with SMI and those in other eligibility categories Potential for FDOC, FMHI, AHCA to work collaboratively to better align screening, assessment, and categorization procedures Potential for FDOC, FMHI, AHCA to work collaboratively on discharge planning for individuals with SMI who are likely to be eligible for Medicaid enrollment upon release 18