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1 1 (August 24, 2023)

handle is hein.crs/govemqo0001 and id is 1 raw text is: Con gressionl Research Service Informning Ih legis19tive debate sin ce 1914 Medicaid and Incarcerated Individuals Medicaid is a joint federal-state means-tested entitlement program that finances the delivery of primary and acute medical services, as well as long-term services and supports, for a diverse low-income population. States that operate their programs within broad federal rules are entitled to federal Medicaid matching funds. (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 of Independent Business v. Sebelius), made it optional for states to expand Medicaid coverage to non-elderly adults with income up to 133% of the federal poverty level beginning in 2014. In states that expanded Medicaid, many individuals transitioning into and out of incarceration-a population that tends to have higher rates of substance use disorder, mental illness, and chronic disease than the general population-were eligible for Medicaid for the first time. This In Focus describes how incarceration can impact the availability of federal Medicaid payment and an individual's Medicaid coverage. Medicaid Inmate Payment Exclusion Historically, Medicaid has not been 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 payment exclusion) 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 the inmate was a patient in a medical institution, the stays were not billable to Medicaid (see Medicaid Payment During Incarceration). Inrmates of Public Institutions Generally, an individual detained in a local jail, state or federal prison, detention facility, or other setting that is organized for the primary purpose of involuntary confinement is an inmate of a public institution for the purposes of Medicaid. Public institution is defined in federal regulation as an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, with exceptions for types 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/vocational institutions to secure education or vocational training or individuals residing in a public institution temporarily (e.g., pending arrangements for community residence). Updated August 24, 2023 In a 2016 State Health Official (SHO) letter, the Centers for Medicare and Medicaid Services (CMS) provided additional guidance on the definition of inmate, stating, CMS considers an individual of 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 generally does not distinguish between individuals who are detained in a public institution pending disposition of charges and those who are incarcerated post-sentencing (for an exception, see Special Rules for Eligible Juveniles). Individuals are not considered inmates for the purposes of Medicaid if they have freedom of movement (e.g., ability to work outside a facility, to seek health treatment in a community setting). Therefore, individuals on probation or parole, under home confinement, residing in halfway houses under the jurisdiction of state or local governments, etc., are generally not considered inmates. Medicaid Payment During Incarceration Public institutions are required to provide medical care to inmates as a consequence of the 1972 Supreme Court ruling Estelle v. Gamble, which found that deliberate indifference to a prisoner's serious injury or illness constitutes cruel and unusual punishment. Inmate health care can be costly for state and local governments, and billing Medicaid can offset a portion of these expenses for coverable services when eligible inmates are inpatient for 24 hours or longer in a medical institution. 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 disability that are certified Medicaid providers, also serve members of the general public, and house and provide treatment based on medical need rather than incarceration status, among other criteria. Services provided to inmates in medical institutions on an outpatient basis still are subject to the inmate payment 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 2016 CMS guidance provides that such settings can, among other things, limit personal privacy, restrict choice of physician, and use nonmedical restraint, all of which would disqualify them from obtaining certification as a Medicaid provider. Medicaid's patient in a medical institution exception applies to federal inmates, but the Bureau of Prisons chooses to retain responsibility for the payment of health care services for its inmates, so in practice, the policy is not applied to inmates in federal prisons.

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