By Rachel Crumpler
Upon release from prison or jail, many people face significant obstacles in navigating and accessing health care services.
Historically, the transition has been difficult because most people returning to the community after incarceration were either uninsured or uninsurable.
But that’s changing since Medicaid expansion took effect in North Carolina on Dec. 1, 2023, as substantially more justice-involved individuals — people who often work in low-paying jobs or struggle to find work because of their criminal history — are now eligible to enroll in the state- and federally-funded program that provides health care for low-income children, their parents and many people with disabilities.
Expansion raised the state’s long-standing income limit for Medicaid, extending eligibility to adults who make up to 138 percent of the federal poverty level for their household size. The previous limit was 100 percent.
Prison officials estimate that about 92 percent of people reentering the community from prison are now eligible for coverage. N.C. Department of Adult Correction spokesperson Brad Deen told NC Health News that more than 100 applications are submitted per week from Medicaid information sessions held at prisons, along with additional applications submitted by case managers and social workers outside of the sessions.
Medicaid can cover a variety of services, including doctor visits, behavioral health treatments and prescription drugs at no or little cost to the person. The coverage is helping reduce gaps in health care, a welcome change for people who now have a path to getting health insurance that can pay for needed medical care — particularly as people leaving prison have high rates of chronic diseases, mental health problems and substance use disorders.
And North Carolina is now planning to do even more with Medicaid to benefit justice-involved people and smooth their transition to the community.
North Carolina submitted a waiver application in October 2023 to officials at the Centers for Medicare & Medicaid Services, which regulates the program at the federal level. If approved, North Carolina can join dozens of other states looking to provide select pre-release services to Medicaid-eligible incarcerated people up to 90 days before their release.
Federal Medicaid funds will cover the expenses, marking a significant transformation in the use of Medicaid, as states have previously been barred from using these federal dollars to provide health care to incarcerated people except for when a person is transported to an outside facility for an in-patient hospitalization.
By providing Medicaid coverage both before and after release, North Carolina hopes to reduce harmful disruptions to health care for justice-involved individuals, which state leaders say has the potential to improve health outcomes and reduce recidivism.
“We’re continuing to keep North Carolina at the leading edge of the most modern ways to use Medicaid to invest in the health of people and this is a big one that I’m very excited about,” said Kody Kinsley, secretary of the N.C. Department of Health and Human Services.
What will this do?
In April 2023, the Centers for Medicare & Medicaid Services released guidance on the new Reentry Section 1115 Demonstration Opportunity explaining how states can provide select Medicaid services to justice-involved individuals while they are incarcerated to support their reentry into the community. To do this, CMS will grant states the ability to waive Medicaid’s “inmate exclusion policy,” which has prevented federal dollars from being used to cover medical care provided in correctional facilities since 1965.
While the exclusion has been in place since Medicaid was initiated, there’s been increasing recognition that the punitive measure contradicts multiple public policy goals.
“CMS believes that provision of pre-release services to eligible individuals who are incarcerated may not only improve the health and reentry outcomes of individuals who are leaving carceral facilities, but may also benefit the Medicaid program and society at large through potential reduced drug-related deaths, decreased use of EDs and hospitalizations, and reductions in health disparities experienced by people of color,” the guidance explains.
To date, 24 states have applied for the Medicaid reentry waiver, according to KFF, a nonprofit health policy research organization tracking the status of waivers. California was the first state to receive approval to use Medicaid this way in January 2023. Ten other states have also gotten the green light to provide pre-release services to certain Medicaid-eligible incarcerated people.
Nearly half of states have applied for the Reentry Section 1115 Demonstration Opportunity to provide pre-release services to incarcerated people. The map shows which states have already received approval from the Centers for Medicare & Medicaid Services and others with pending applications. Credit: KFF
Melanie Bush, deputy director for NC Medicaid, told NC Health News that she expects CMS to decide on North Carolina’s application this fall.
Plans for each state’s Medicaid Reentry Section 1115 Demonstration Opportunity vary but must cover, at minimum, the following three pre-release services to be considered “sufficiently robust” enough to improve health care transitions:
Case management to assess physical, behavioral health and health-related social needs
Access to medications for opioid use disorder
A 30-day supply of all prescription medications in hand at the time of release from the correctional facility
North Carolina plans to make these pre-release services available to people in the state’s 53 prisons and incarcerated people at select county- and tribal-operated jails and youth correctional facilities. Additional pre-release services, including physical and behavioral health clinical consultations, laboratory and radiology services, medications and medication administration, tobacco cessation treatment and equipment such as wheelchairs and walkers upon release, will be phased in based on readiness to implement, according to the state’s application.
North Carolina also asked for $315 million in capacity-building funding to support the implementation of the pre-release services, including hiring and training new staff and strengthening health information technology systems.
North Carolina’s Medicaid Reform Section 1115 Demonstration Renewal application, which also covers requests for other uses of Medicaid besides reentry, is for five years starting Nov. 1, 2024. North Carolina estimated in its written application that approximately 39,000 people will receive pre-release services over this period, with yearly volume ramping up as processes get worked out.
Bush said this change, along with others, such as using Medicaid dollars to address social determinants of health, marks a significant shift in thinking about Medicaid and its use.
“I think people are looking to Medicaid in different ways — focusing more upstream,” Bush said.
Improving health outcomes
North Carolina has set out to substantially improve reentry success for the people returning home from incarceration by 2030. One of the main target areas is improving access to physical and behavioral health care. Approval of North Carolina’s 1115 waiver to provide certain Medicaid services before release is a strategy outlined in the state’s Reentry 2030 Strategic Plan championed by outgoing Gov. Roy Cooper.
Lauren Brinkley-Rubinstein, a professor in the Department of Population Health Sciences at Duke University School of Medicine who studies the impacts of the criminal legal system, said she’s glad North Carolina applied for the authority to provide pre-release services. She said she’s hopeful continuity of health care will be improved.
“It provides resources that have not otherwise been available to this population,” Brinkley-Rubinstein said. “Being able to bill the government for care will certainly hopefully provide more access to care than folks are already receiving.”
Mary Grillo, social work services director at the N.C. Department of Adult Correction, who is leading the prison system’s Medicaid expansion efforts, agreed that the waiver will allow the prison system to do more.
“We see a lot of people who are very sick who are returning to the community, so we are very excited and hopeful for the 1115 waiver,” Grillo said.
Brinkley-Rubinstein explained that the reentry period is a critical time for people to reconnect to health care to help combat poor health outcomes. She noted that in the first two weeks after a person is released from prison, their mortality risk is more than 12 times higher than that of the general population and that the risk of overdose death is particularly pronounced.
Research shows that when people have access to Medicaid during the reentry period, they are more likely to use health care services, more likely to find employment and less likely to go back to jail or prison.
“It’s very challenging for people once released who don’t have connections or resources to be able to understand how to navigate the system,” said Dana Rice, a professor at UNC Gillings School of Global Public Health studying the impact of incarceration on public health. “We have a very complex health care system, and anything that we can do to expedite and streamline that process is impactful.”
Kinsley said connections to health care upon release and treatment availability in the community are crucial in helping break cycles of incarceration. But, for too long, he said, it’s often been out of reach.
“We’re spending a whole lot of money on jail and prison when that is not actually helping people,” Kinsley said. “And when these people leave jail and prison, they get stuck in a cycle. Not only are they stuck in a cycle where it’s driving up a lot of costs for jails and for prisons, which are all costs that society bears. It’s also driving up a lot of lost value, right? Those people are not able to work. They’re not able to support their families. Who has to pay for that? They’re not able to pay taxes on their earned income. That is a cost to our state as well.
“Investing in people’s health breaks these cycles and is a financial win,” Kinsley said.
More changes
Once approved, Bush said, it will take about a year for North Carolina to implement these pre-release services.
In the meantime, NC Medicaid and prison staff are working together to streamline Medicaid enrollment processes to ensure that eligible people are applying and getting approved for Medicaid before leaving prison so they do not fall into a health coverage gap.
Applying while incarcerated is a more difficult task than it is in the community. That’s because incarcerated people do not have email addresses to apply online, requiring prison staff to help people fill out paper applications. There are also complicating factors with what county Department of Social Services office to apply to as many people leaving incarceration don’t have their home plans figured out until the final days before their release.
Maggie Brewer, chief deputy secretary of the N.C. Department of Adult Correction, said the prison system recently received access to NCTracks, a Medicaid management information system, which is easing the process.
“Now we can see, do they have Medicaid? Has it been approved? Was it just suspended? So it takes out a lot of guessing work,” Brewer said. “We are working with the Department of Information Technology to automate the Medicaid application so that we’ll have a nightly feed that’ll go back and forth.”
Prison officials and state health leaders also recognized that Medicaid Standard Plans — what people leaving prison are currently being enrolled in by default — do not offer the array of benefits needed by many of the people reentering society who have high levels of mental health and substance use treatment needs.
“There is a way to change health plans, of course, but as you are trying to reenter and establish your life, it’s an administrative burden,” Bush said.
To better address this population’s health needs, language in Senate Bill 425 — which became state law in July — changes the default plan all Medicaid-eligible people leaving prison will be enrolled in to Medicaid Direct starting Jan. 1, 2025. Bush explained that Medicaid Direct offers additional coverage for mental health, substance use and intellectual and developmental disability services.
Improving Medicaid enrollment and eligibility processes for people in county jails is also in the works, Bush said.
The goal is to establish a process similar to what is currently in place with the prison system where Medicaid eligibility is put in suspended status upon entry into prison due to that long-standing exclusion and then reinstated upon release. NC Medicaid cannot yet do that for people entering jails — a tougher task due to the decentralized jail system. This can result in Medicaid being terminated when someone goes to jail, requiring them to reapply after their release.
Bush said a data feed has been identified that will allow NC Medicaid to gain this ability and that work is underway to get it up and running.
“I think that the justice-involved work is a lot bigger than we anticipated, and we really are trying to knit together a bunch of systems that don’t necessarily — and were never designed to — talk to each other,” Bush said.
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