Policy and Process Changes
Taking into consideration the needs of the justice-involved population newly eligible for Medicaid following passage of the ACA, the state negotiated new contracts with their Medicaid health plans and implemented certain changes to the benefit packages for these plans. For example, many behavioral health services that had previously been separately administered were integrated into the health plans to help improve connections to mental health and substance abuse services for these individuals. Also, the Executive Office of Health and Human Services specifically required certain care management protocols, making it a contractual requirement of the health plans that they conduct outreach and health risk assessments for individuals being released from incarceration. Currently, health plan representatives are providing corrections staff with information about how individuals reentering the community can contact plans for further assistance. This policy change has the potential to improve care coordination for individuals needing mental health and substance abuse treatment.
Application Process Changes
The DOC integrated the Medicaid application process into existing discharge planning services. Due to the DOC’s security concerns regarding incarcerated individuals using computers, individuals complete paper Medicaid applications that are then hand-carried by DOC staff to the Executive Office of Health and Human Services (EOHHS). Current practice is to submit the paper applications two weeks prior to individuals’ release dates to allow time for their information to be entered into the system. However, the actual Medicaid eligibility determination process does not occur until the individual’s incarceration release date. Individuals being released from incarceration are provided a phone number to initiate the activation of their benefits.
Rhode Island’s EOHHS worked closely with the DOC to increase the accuracy of incarceration status data and to address challenges related to identity and income verification. One of the issues the departments encountered was that federal data sources did not have information about an individual’s incarceration release date and the system often indicated an individual was still incarcerated even though s/he had been released. After discussions between the two agencies, the DOC and EOHHS revised processes and implemented system changes so that the DOC’s databases could be more easily accessed to obtain real-time data on incarceration status.
Also recognizing the need to address the issue of income verification, EOHHS developed a self-attestation form for individuals to indicate lack of income, and then informed exchange contact center staff and Navigators to accept this as a valid document. In terms of identification, the DOC provides each individual released to the community with two forms of photo identification—one form of general identification and a copy of a page from the DOC database that indicates their release date. This information can be provided to assisters who might be working with these individuals to enroll them in coverage.
Enrollment as Part of Pre-Release Planning
Medicaid Enrollment Education/Training for Incarcerated Individuals
Within Rhode Island’s unified prison-jail system, there are two discharge planning tracks. On the first track, incarcerated individuals attend group education classes and participate in individual discharge planning that occurs closer to the release date. A community agency conducts the education for the pre-release groups, providing information about Medicaid enrollment and distributing paper applications. Discharge planners also give incarcerated individuals information about how to access local offices if they wish to enroll after being released. On the second track, individuals being released are given a form, and Department of Corrections (DOC) staff assists in filling out the form with identifying characteristics. This form can be given to Navigators outside of the facility to confirm that the person is no longer incarcerated (even if internal systems have not yet been updated to reflect their release). Then, enrollment can take place at that Navigator Center.
Correctional facilities provide application assistance in three different ways and at varying points in the pre-release planning process. Interns from Brown University’s Center for Prisoner Health and Human Rights directly assist incarcerated individuals awaiting trial with completing Medicaid applications, or follow up to ensure that an application has been completed. Additionally, pre-release planners assist incarcerated individuals, especially those going into residential treatment upon release, in completing paper applications. The Executive Office of Health and Human Services (EOHHS) temporarily allocated funding from their Navigator Program to staff corrections facilities with mobile navigators to answer questions and assist incarcerated individuals visiting the Exit Resource Center, although this service is no longer available.
Health insurance is a requirement for individuals to participate in certain parole programs, and former inmates must be in parole programs to remain in the community. Although the program is no longer funded, the DOC contracted with an application assister working with the Rhode Island Parent Information Network to provide application assistance to individuals on parole who needed health insurance. The DOC had two staff members also helping with applications: one in the DOC office and another that helped individuals checking in on probation. There are plans in the future to involve interns from Brown University with enrollment efforts at parole programs.
Beyond Eligibility and Enrollment Strategies
Health Literacy Materials
In partnership with the Center for Prisoner Health and Human Rights at Brown University, state officials from the Executive Office of Health and Human Services (EOHHS) are working on a health literacy initiative for the justice-involved population. Students from the university’s medical school provide information to individuals nearing release from incarceration about what to expect when calling for appointments with providers and how to access care appropriately in the community.
Access to Care
The DOC uses the same electronic health record system as the state’s Federally Qualified Health Centers (FQHCs). State officials recognize the potential of this shared system to better coordinate care, and are in the initial stages of planning for a more effective care transfer process, particularly for individuals with complex physical and/or behavioral health needs.
Cross-Agency Coordination and Partnerships
Officials from the DOC indicated that prior to the ACA their office of transitional services had established efforts to enroll individuals reentering the community who had intense medical and behavioral health needs in health coverage. Recognizing that with their state taking up the Medicaid expansion option there would be a significant number of justice-involved individuals eligible for coverage upon release from incarceration, the DOC and the Medicaid agency held a series of joint meetings to begin planning for how to coordinate these enrollment efforts. Both the DOC and the Medicaid agency indicated that there has been very effective communication between the two departments, and that this strong partnership was crucial to implementation efforts.
During the initial planning phases, the state’s health agency also initiated weekly face-to-face meetings with parole workers, unified jail-prison system discharge planners, and DOC nurses to provide greater support to them, understand what was working and what was not working in terms of providing application assistance and outreach.
Additionally, representatives of insurance plans attended some of the meetings between the DOC and the Medicaid department to discuss issues such as promoting continuity of care for the newly enrolled justice-involved population and potential challenges associated with the plans in terms of handling a larger volume of clients. Both departments indicated that it was very helpful to include the insurance companies in some of the initial planning meetings. Connections with the insurance companies are still continuing to some degree, with some attending discharge planning services to talk about substance abuse issues.
Rhode Island has also included the Center for Prisoner Health and Human Rights at Brown University as a partner in these enrollment efforts. The DOC is working with the Center to train university students to assist with applications and conduct post-release follow up in terms of accessing services upon release from incarceration. The DOC also emphasized the importance of having developed partnerships with local mental health agencies and other community-based organizations that work with the justice-involved population, as these entities are able to assist with follow-up enrollment efforts.
Looking Forward: Future Issues to Address
According to current state procedures, the Medicaid eligibility determination process does not occur until the individual’s incarceration release date, which results in individuals generally not being able to leave the correctional facility with their Medicaid card unless their release date is postponed. This leads to a number of challenges because some individuals leaving incarceration do not have addresses where the cards can be mailed. The Department of Corrections staff indicated that this is a significant barrier and that it would be very helpful to be able to include the Medicaid eligibility cards in the individuals’ exit packages.
Policy and Process Changes