Section 5121: New Medicaid Coverage Rules for Incarcerated Youth

December 15, 2024
in Blog, Medicaid in Jails Initiative, Medicaid Suspension

Effective January 1, 2025, provisions in the Consolidated Appropriations Act (CAA) of 2023 take effect, removing portions of the Medicaid Inmate Exclusion Policy (MIEP) and modifying CHIP eligibility for “eligible juveniles” who are incarcerated. State Medicaid agencies will be required to provide mandatory screening, diagnosis, and case management services for Medicaid-eligible incarcerated youth during the 30 days prior to their release, to be reimbursed through standard federal financial participation (FFP). (State Medicaid programs may also opt to cover the full range of Medicaid and CHIP services for these incarcerated youth when held pending disposition of their charges.)

“Eligible juveniles” are defined as incarcerated individuals under 21 years of age and/or former foster youth up to the age of 26, who are enrolled in Medicaid or CHIP or who are determined eligible for Medicaid or CHIP while incarcerated. “Incarcerated” refers to placement in a public institution such as state prisons, local jails, tribal jails and prisons, and all juvenile detention and youth correctional facilities.

Required Services

For eligible juveniles incarcerated post-adjudication, the state Medicaid agency must provide early and periodic screening, diagnostic, and treatment (EPSDT) services in the 30 days prior to release. This includes medically appropriate medical, dental, behavioral health, and diagnostic services as needed, as well as targeted case management services. Targeted case management services must continue for at least 30-days post release. (For eligible juveniles held pending disposition of their charges, states have the option to cover full Medicaid and CHIP coverage and receive FFP). Additionally, eligible juveniles must be screened for Medicaid or CHIP eligibility and assisted with applications while incarcerated. This service can be provided by correctional facilities themselves or in partnership with Medicaid Managed Care Organizations (MCOs).

State Medicaid Agency Responsibilities

The state Medicaid agency will need to file a State Plan Amendment (SPA) to implement the new mandatory coverage for these youth. CMS is currently developing a SPA template for states to use. The state agency may also opt to file a state plan amendment to cover optional services newly eligible for FFP for incarcerated youth. The state must have in place an internal operational plan for mandatory pre-release services for eligible juveniles which includes policies, procedures, and processes for such things as data exchange; eligibility, enrollment, and claims processing; timely provision of screens and services; staff workflows; linkages with managed care; and ensuring that pre-release services to no delay release or result in increased involvement with the justice system.

The CAA makes state Medicaid agencies responsible for providing these newly covered Medicaid and CHIP services. However, state agencies will need to partner with state and local correctional agencies for data sharing and enrollment services, and will also need to engage with MCOs and community-based providers to ensure eligible juveniles have safe and medically-appropriate transitions from incarceration into the community.

State agencies will need to decide whether to use “in-reach” pre-release services or rely upon correctional health care providers to furnish the screening, diagnosis, and case management services during the 30-day pre-release period. CMS recommends that community-based Medicaid providers complete “in-reach” pre-release services in order to build trust with incarcerated juveniles and strengthen juveniles’ connection to the community before their release. However, CMS recognizes that states may face provider shortages or other exigencies and so provides guidance on working with MCOs and correctional health care providers to provide these services. If correctional providers are used, they must be enrolled as Medicaid providers.