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1 1 (May 12, 2021)

handle is hein.crs/govedhd0001 and id is 1 raw text is: Medicaid and Incarcerated Individuals 9 May 12, 2021 Medicaid is ajoint federal-s tate means-tested entitlement programthat finances the delivery of primary and acute medical services, as well as long-termservices and supports, for a diverse low-income population. States that operate their programs within broad federal rules are entitled to federal Medicaid matching funds. (For more information about Medicaid, see CRS Report R43357, Medicaid: An Overview.) The Patient Protection and Affordable Care Act (ACA; P.L. 111-48, as amended), and a subsequent Supreme Court decision (National Federation ofIndependentBusiness v. Sebelius), made it optional for states to expand Medicaid coverage to non-elderly adults with income up to 133% of the federalpoverty level beginning in 2014. This created a new eligibility pathway for such adults based solely on income rather than on other categorical criteria, such as dis ability, being a parent of dependent children, or being a pregnant woman. In states thatexpandedMedicaid, many individuals transitioning into and out of incarceration-a population that tends to have higher rates of substance use disorder, mentalillnes s, and chronic disease than the general population-were eligible for Medicaid for the first time. This In Focus describes how incarcerationcan impact the availability of federal Medicaid payment and an individual's Medicaid coverage. Medicaid Inmate Payment Exclusion Historically, Medicaid has notbeen a major source of funding for the health care of incarcerated individuals. This is mainly because federal Medicaid statute generally prohibits the use of federal Medicaid funds to pay for the health care of an inmate of a public institution (hereinafter referred to as the inmate paymentexclusion) except when the individual is a patient in a medical institution that is organized for the primary purpose of providing medical care. Additionally, pre-ACA, many incarcerated individuals did not meet Medicaid eligibility criteria, so when theinmate was a patient in a medical institution, the stays were not billable to Medicaid (see Medicaid Payment During Incarceration). Inmates of Public Institutions Generally, an individual detained in a localjail, state or federal prison, detention facility, or others etting that is organized for the primary purpose ofinvoluntary confinement is an inmate ofa public institution for the purposes of Medicaid. Public institution is defined in federalregulation as an institutionthatis the responsibility of a governmental unit or over which a governmentalunit exercises administrative control, with exceptions fortypes of settings such as medical institutions, among others. Federal regulations define inmate as someone living in a public institution, with certain exceptions for individuals living in public educational/vocationalinstitutions to secure education or vocational training or individuals residing in a public institution temporarily (e.g., pending arrangements for community residence). In a 2016 State Health Official (SHO) letter (SHO # 16- 007), the Centers for Medicare and Medicaid Services (CMS) provided additional guidance on the definition of inmate, stating, CMS considers an individualof any age to be an inmate if the individual is in custody and held involuntarily through operation of law enforcement authorities in a public institution. Thus, for the purposes of Medicaid, CMS does not dis tinguishbetween individuals who are detained in a public institution pending disposition of charges and those who are incarcerated post-sentencing. Individuals are not considered inmates for the purposes of Medicaid ifthey have freedomofmovement (e.g., ability to work outside a facility, to seekhealth treatment in a community setting). Therefore, individuals on probation or parole, underhome confinement, residing in halfway houses under the jurisdiction of state or local governments, etc., are not considered inmates. Medicaid Payment During Incarceration Public institutions are required to provide medicalcare to inmates as a consequenceof the 1972 Supreme Court ruling Estelle v. Gamble, which found that deliberate indifference to a prisoner's serious injury or illnes s constitutes cruel and unusualpunishment. Inmate healthcare canbe costly for state andlocalgovernments, and billing Medicaid can offset a portion of these expenses for coverable services when eligible inmates are inpatient for 24hours or longer in a medicalinstitution(fordetails oninmate eligibility and enrollment, see Medicaid Eligibility for Inmates). CMS provides guidance on which settings qualify as medical institutions in its 2016 SHO letter, stating that medical institutions can include hospitals, nursing facilities, and intermediate care facilities for individuals with an intellectual dis ability that are certified Medicaid providers, also serve members of the generalpublic, and house and provide treatment based on medical need rather than incarceration status, among other criteria. Services providedto inmates in medical institutions on an outpatient basis still are subject to the inmate p ayment exclusion. Similarly, any inpatient and outpatient medical services provided in settings that primarily or exclusively treat inmates are subject to the inmate payment exclusion because they are considered correctional (not medical) settings. Separate 2016guidance (S&C: 16-21-ALL) from CMS provides that such settings can, among other things, limit personalprivacy, restrict choice ofphysician, and use nonmedical restraint, allof which would disqualify them from obtaining certification as a Medicaid provider. https://crs rept

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