1. The Affordable Care Act and Corrections The Association of State Correctional Administrators Summer Meetings, August 9, 2013

2. The COCHS Approach: Public Safety and Community Health Public safety and public health systems are intertwined. Similarly, the health of the justice-involved population is intertwined with the health of the general population. Connecting health care in the criminal justice system to health care in the greater community preserves the investments jurisdictions make in their justice-involved populations. August 2013 2

3. Presentation Overview 1.Health Care, Recidivism, and Costs 2.Eligibility, Coverage, and Enrollment 3.The Role of Health Information Technology August 2013 3

4. 1.Health Care, Recidivism, and Costs August 2013 4

5. Washington State: “The Mancuso Effect” Reduced Crime / Improved Health & Safety When SUD treatment was offered to very low income adults—a population that included many individuals with histories of justice-involvement—research found: Reduced crime and recidivism, and correlated savings to crime victims and the criminal justice system. Improved physical and mental health, and significant cost savings in health care. –Mancuso, D, Felver, B. Bending the Health Care Cost Curve by Expanding Alcohol/Drug Treatment, Washington State DSHS Research and Data Analysis Division, RDA Report 4.81 (Sept 2010). –Mancuso, D, Felver, B. Providing chemical dependency treatment to low-income adults results in significant public safety benefits, Washington State DSHS Research and Data Analysis Division, Report 11.130 (Feb 2009). August 2013 5

6. August 2013 6 Washington State: Criminal Justice System Benefits April 2013 Decline in arrests relative to untreated comparison group 33% Cost savings to criminal justice system per dollar of cost $1.16 Cost savings to crime victims and criminal justice system per dollar of cost $2.83

7. August 2013 7 Washington State: Medical Costs Decrease with Treatment April 2013 Growth in medical costs relative to coverage group:

8. Justice-Involvement and Insurance Most justice-involved individuals currently lack insurance coverage, limiting access to treatment. Few justice-involved individuals today are enrolled in Medicaid because they have not been eligible as single, childless adults. One study found that 90% of individuals have no health insurance upon release from jail. August 2013 8

9. Justice-Involvement and Insurance According to a recent NASADAD study, less than 3% of Massachusetts residents are uninsured, but the uninsured residents “are likely to have elevated rates of chronic SUDs.” In fact, approximately 22% of the admissions for publicly funded SAT in MA in 2009 were uninsured. The uninsured population was disproportionately low-income and young adult, Black, and Hispanic, characteristics that mirror the demographics of the justice-involved population. August 2013 9

10. Limited Access to Treatment Limited coverage contributes to limited access to treatment in the community. One study found that 80% of individuals in jail with chronic medical conditions had not received treatment in the community prior to arrest. August 2013 10

11. Release from Prison – A High Risk of Death for Former Inmates A 2007 study reported overall increased mortality rates for former inmates in Washington State: 3.5x greater than the general population. Mortality was the highest during the first two weeks after release: 12.5x greater than the general population. The study found a high incidence of death due to: overdose, HIV, homicide, motor vehicle accidents, cancer, liver disease. Binswanger, Ingrid A., Stern, Marc. Deyo, Riahard A. Heagerty, Patrick J. Cheadle, Allen. Elmore, Joann G. and Thomas Koepsell. New England Journal of Medicine, 356:157-165. January 2007. August 2013 11

12. Health Care, Recidivism, and Costs Improving access to treatment can reduce recidivism, reduce health care costs, and reduce correctional system costs. The first step toward achieving these outcomes is maximizing coverage by enrolling eligible justice-involved individuals in Medicaid and QHPs. August 2013 12

13. 2.Eligibility, Coverage, and the Enrollment Process August 2013 13

14. August 2013 14 Expanded Coverage A.The ACA allows qualified individuals to enroll in federally subsidized qualified health plans (QHPs) offered through the states’ new health insurance exchanges. B.The ACA allows the expansion of Medicaid at state option to cover millions of society’s most vulnerable individuals.  QHP and Medicaid expansion coverage begins January 2014 with applications available October 2013.  Up to 32 million Americans will be newly covered.

15. Medicaid Eligibility In Medicaid expansion states, Medicaid will be newly available to non-elderly adults with income up to 138% FPL, regardless of health status, gender, or parental status. COCHS estimates that about 2/3 of the justice-involved population will be eligible for Medicaid under the expansion, creating access to health care for many individuals for the first time. August 2013 15

16. Medicaid Coverage for Justice-Involved Justice-involved individuals residing in the community (e.g., re-entering the community from prison, on probation/parole, etc.) can be eligible for Medicaid and can receive coverage (i.e., services provided can be paid for by Medicaid). Medicaid coverage is not available for individuals in prison or jail (i.e., services provided cannot be paid for by Medicaid), but individuals who are otherwise eligible retain their eligibility while in prison or jail and can enroll. –42 U.S.C.§1396d(a)(27)(A); 42 CFR§435.1010 August 2013 16

17. Medicaid Coverage: Inpatient Hospitalization However, there is a significant exception to the preclusion of Medicaid coverage for prison and jail inmates: Medicaid coverage is available for prison and jail inmates who are eligible for Medicaid and who are inpatients in non- correctional medical facilities for at least 24 hours. Correctional agencies could achieve major cost-savings by developing processes to enroll eligible individuals. –42 U.S.C.§1396d(a)(27)(A); 42 CFR§435.1009(b) August 2013 17

18. Medicaid Coverage: Suspension vs. Termination In many states, an individual’s Medicaid enrollment is terminated upon incarceration. A previously enrolled beneficiary would be required to re-apply for Medicaid in the event of a potentially billable hospital stay and upon re-entry into the community. August 2013 18

19. Medicaid Coverage: Suspension vs. Termination However, federal guidelines urge states to suspend rather than terminate Medicaid upon incarceration. Suspension would make it easier to reinstate coverage in the event of a hospital stay and upon re-entry into the community. –Letter from Centers for Medicare and Medicaid Services to State Medicaid Directors, May 25, 2004, Subject: Ending Chronic Homelessness, http://jfs.ohio.gov/ohp/bcps/OHMedAdvComm/documents/ENDING_CHRONIC_HOMELESSNESS.PDF http://jfs.ohio.gov/ohp/bcps/OHMedAdvComm/documents/ENDING_CHRONIC_HOMELESSNESS.PDF August 2013 19

20. QHP Eligibility Qualified individuals with income from 138% - 405% FPL will be able to purchase QHPs with federal premium subsidies through the health insurance exchanges. COCHS estimates that about 1/3 of the justice-involved population will be eligible for premium subsidies to buy QHPs through the exchanges. August 2013 20

21. QHP Coverage for Justice-Involved Regarding QHPs available through health insurance exchanges, the ACA specifies that: “[a]n individual shall not be treated as a qualified individual if, at the time of enrollment, the individual is incarcerated, other than incarceration pending the disposition of charges.” This means that, subject to the requirements of health plans, individuals may be able to newly enroll or maintain existing coverage through a QHP while incarcerated while pending disposition of charges. Services provided while the individual is pending disposition can potentially be paid for by the QHP. August 2013 21

22. QHP Coverage for Justice-Involved As is the case with Medicaid, justice-involved individuals residing in the community, (e.g., re-entering the community from prison, on probation/parole, etc.) can be eligible for federally subsidized QHPs and can receive coverage. August 2013 22

23. Enrollment: Single Application Individuals will be able to apply for Medicaid and QHPs through a single application. Application will be available online, in-person, over phone, i.e., a “no wrong door” approach. Application for Medicaid and QHPs opens in October 2013. August 2013 23

24. Enrollment: Federal Data Hub The federal government will establish an electronic service, the “data hub,” that states can use to obtain or verify eligibility information. Information will be available from the Social Security Administration, the Department of Treasury, and other third party sources. Information available through the data hub could include income, citizenship status, identity, etc. States must use the data hub if the necessary information is available rather than requesting the information from applicants. August 2013 24

25. Enrollment: Authorized Representatives An individual can designate an authorized representative, or “A-Rep,” to manage the enrollment process on his or her behalf. Designating an A-Rep generally requires the beneficiary’s signature. Correctional officials could act as A-Reps for individuals under various forms of criminal justice supervision. August 2013 25

26. Enrollment: Various Models for Justice-Involved Populations Population of data fields through existing databases, as in Connecticut. Authority for state or county essentially to act as authorized representative, as in California. Eligibility workers stationed in correctional settings, as in Maryland. Community-based organization assists with application at facility intake, as in Cook County, IL. August 2013 26

27. Enrollment: Connecticut Model The Department of Social Services has collaborated with the Department of Corrections. The Medicaid application populates with data from the Department of Corrections database. Enrollment is targeted to begin upon discharge. August 2013 27

28. Enrollment: California Model California SB 92 (2011) allows the California Department of Corrections and Rehabilitation to act on behalf of a state prison inmate for purposes of applying for Medicaid or determining Medicaid eligibility, without requiring the participation of the inmate. August 2013 28

29. Enrollment: Maryland Model Medicaid eligibility workers are stationed at correctional facilities. Eligibility workers assist inmates with applications prior to release. Enrollment is targeted to begin upon discharge. August 2013 29

30. Enrollment: Cook County Model A community-based organization has a contract with the Cook County Health and Hospital System to assist justice-involved individuals with enrollment. Application assistance begins at jail intake. Enrollment is targeted to begin upon discharge. August 2013 30

31. 3.The Role of Health Information Technology August 2013 31

32. Bridges to Connectivity August 2013 32

33. Health Information Technology HITECH Act Meaningful use Corrections and EHRs More reason for Medicaid suspension rather than termination August 2013 33

34. Questions? www.cochs.org 510-595-7360 Steve Rosenberg srosenberg@cochs.orgsrosenberg@cochs.org Ben Butler bbutler@cochs.orgbbutler@cochs.org August 2013 34