This document is supported through a cooperative agreement 2013-DB-BX-K008 awarded by the Bureau of Justice Assistance. The Bureau of Justice

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2 This document is supported through a cooperative agreement 2013-DB-BX-K008 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. To learn more about the Bureau of Justice Assistance, please visit bja.gov. 2

3 About the Author Joan M. Shoemaker, BSN, MBA, is a Bureau of Justice Assistance fellow for the American Correctional Association. Her selection as the BJA fellow was based on more than 25 years of experience in the corrections field serving in numerous capacities. For several years, she was warden of multi-custody prisons housing both men and women. During her tenure as deputy director of prisons, she had several roles, which included supervision of wardens; supervision of department-wide programs such as education and food service; and designation as the health authority responsible for management; and delivery of all health services for all prisons. From the Author This document would not have been possible without the support and assistance from the American Correctional Association, the Coalition of Correctional Health Authorities, the staff at the Bureau of Justice Assistance and other federal partners. Special thanks to Dr. Elizabeth Gondles, director, and Doreen Efeti, manager, from the Office of Correctional Health, American Correctional Association; and Ruby Qazilbash, associate deputy director; and Danica Binkley, senior policy advisor, from BJA. Their insight and expertise have been invaluable to the development of this paper. American Correctional Association, Coalition of Correctional Health Authorities James Greer, Wisconsin Department of Corrections Bruce Herdman, Philadelphia Prison System Stuart Hudson, Ohio Department of Rehabilitation and Corrections Dr. Kathleen Maurer, Connecticut Department of Corrections Viola Riggin, Kansas Department of Corrections Dr. Ramah Singh, Louisiana Department of Corrections Kellie Wasko, Colorado Department of Corrections James Welch, Retired, Delaware Department of Corrections Bureau of Justice Assistance staff Andre Bethea, policy advisor Emily Niedzwiecki, policy advisor Office of the Assistant Attorney General Amy Solomon, senior advisor Federal Partners Linda Mellgren, senior social science analyst, Department of Health and Human Services, Office of Assistant Secretary for Planning and Evaluation Katie Green, correctional program specialist, National Institute of Corrections Charles Smith, Ph.D., SAMHSA Region VII Administrator, SAMHSA 3

4 Council of State Governments, Justice Center Alex Blandford, PMPA, CHES, deputy program director for Behavioral Health Fred Osher, M.D., director of Health Systems and Services Policy Legal Action Center Gabrielle de la Gueronniere, J.D., director of Policy TASC Inc. for Illinois Maureen McDonnell, director for Business and Health Care Strategy Development Urban Institute Jesse Jannetta, senior research associate in Justice Policy Center 4

5 Executive Summary Corrections and criminal justice professionals have continuing opportunities to utilize the Patient Protection and Affordable Care Act in reentry planning for the justice-involved populations they serve. This document will outline the successful strategies some jurisdictions have incorporated to enroll individuals in Medicaid and private health insurance to facilitate continuity of health care from incarceration to the community. The guide provides information for each step in the process of implementing health care reform for the adult population. Section 1 Knowing the Basics provides information necessary to understand health care reform, specifically the Patient Protection and Affordable Care Act. This section will provide information on Medicaid and state Medicaid plans along with how states have organized the delivery of health care services to those eligible. This includes information on presumptive eligibility and its application to the correctional environment. By understanding the beneficial implications of health reform, corrections and criminal justice systems can begin to implement enhanced enrollment procedures. These procedures will facilitate seamless transition of care as individuals move through the criminal justice system. As with any new system, it is vital to establish from the beginning the information needed to evaluate progress and success. There are suggestions about what information to gather so that correctional and criminal justice agencies will know how the efforts for enrolling justice-involved individuals are working. Establishing the right evaluation metrics will make it easier to document the impact on individuals and agency budgets. Last, this section also includes information pertaining to the benefits of Medicaid enrollment and coverage available during confinement. Strategies to maximize enrollment of individuals in Medicaid during confinement can help correctional agencies take advantage of Medicaid to cover in-patient care for some individuals. Medicaid funds are also potentially available for some enrollment and case-management functions through administrative claiming and targeted case management reimbursement. Activities must be clearly documented by the agency for any reimbursement. Section 2 Begin the Change provides information on the steps needed to make changes in procedures and processes for implementation of the Affordable Care Act. It includes information on forming and working with stakeholder groups and how to understand and analyze current procedures in order to ascertain changes necessary to move forward. There is information for each intercept within the criminal justice system. The checklists in the attachments provide action steps that correspond to the information in this section. Section 3 Conclusion provides information regarding the ongoing challenges with implementation of the Affordable Care Act. The biggest challenge remains with states that have not adapted the expansion of eligibility criteria to include adults age who fall below 133 percent of the federal poverty guidelines. The paper concludes with a summary of the lessons learned from jurisdictions that have implemented health care reform activities, providing valuable insights for others who want to begin. The attachments provide additional information and references. Attachments B through E are checklists designed to guide implementation activities. There are specific checklists for use by courts, probation/parole agencies, jails and departments of corrections. Each group of checklists contains four individual lists based on whether the state has expanded Medicaid eligibility and whether benefits are suspended or terminated when justice-involved individuals become incarcerated. 5

6 Table of Contents About the Author... 3 From the Author... 3 Executive Summary... 5 Introduction... 8 Section 1 Knowing the Basics What Is Medicaid? State Plan Eligibility Criteria Enrollment Strategies Expansion vs. Non-expansion Suspend vs. Terminate Benefits Presumptive Eligibility Structure for Delivery of Medicaid Services Within States Medically Necessary Care Health Homes What Is the Marketplace? Qualifying Life Event (QLE) Individual Shared Responsibility Payment Evaluation Establishing Metrics for Evaluation Potential Budget Implications Recovery of Hospitalization Costs Medicaid Administrative Costs Medicaid Administrative Claiming (MAC) Targeted Case Management (TCM) Correctional Agency Structure Section 2 Begin the Change Working or Stakeholder Group Process Analysis Systems Mapping Lean Information Collection and Sharing SAMHSA Gains Center Intercept 1 Community and Law Enforcement Intercept 2 Arrest and Initial Detention/Court Hearing Intercept 3 Jails/Courts Intercept 4 Reentry From Jails/Prisons to Community Intercept 5 Community Corrections

7 Section 3 Conclusion Challenges for the Future Lessons Learned Glossary of Terms Attachment A References & Resources Attachment B Evaluation Metrics Implementation Checklists Attachment C Checklist Courts C-1 Courts in Expansion State That Suspend Benefits C-2 Courts in Expansion State That Terminate Benefits C-3 Courts in Non-Expansion State That Suspend Benefits C-4 Courts in Non-Expansion State That Terminate Benefits Attachment D Checklist Probation/Parole D-1 Probation/Parole in Expansion State That Suspend Benefits D-2 Probation/Parole in Expansion State That Terminate Benefits D-3 Probation/Parole in Non-Expansion State That Suspend Benefits D-4 Probation/Parole in Non-Expansion State That Terminate Benefits Attachment E Checklist Jails E-1 Jails in Expansion State That Suspend Benefits E-2 Jails in Expansion State that Terminate Benefits E-3 Jails in Non-Expansion State That Suspend Benefits E-4 Jails in Non-Expansion State That Terminate Benefits Attachment F Checklist Department of Corrections F-1 Department of Corrections in Expansion State That Suspend Benefits F-2 Department of Corrections in Expansion State That Terminate Benefits F-3 Department of Corrections in Non-Expansion State That Suspend Benefits F-4 Department of Corrections in Non-Expansion State That Terminate Benefits

8 Introduction The Bureau of Justice Statistics Bulletin on Correctional Populations in the United States, 2014, shows that an estimated 6,851,000 persons were under the supervision of adult correctional systems, a decline of 52,200 from About one in 36 adults (2.8 percent) were under some form of correctional supervision. These figures are not surprising to corrections and criminal justice professionals. The National Reentry Resource Center (NRRC) estimated that 95 percent of all state prisoners will eventually be released back to their communities. The incidence of serious mental illness is two to four times higher among prisoners than the general population, and three-quarters of those returning to prison have a history of substance use disorders; additionally, 70 percent of prisoners with serious mental illness also have a co-occurring substance use disorder. 1 At the American Correctional Association Winter Conference in 2014, Director Gary Mohr from the Ohio Department of Rehabilitation and Correction stated that, in his 40 years of working in corrections, the Patient Protection and Affordable Care Act will be the largest catalyst that has been seen in corrections in terms of having the ability to change lives of justice-involved individuals. Prior to Medicaid expansion in Ohio, less than 10 percent of individuals left prison with health insurance. After the state expanded Medicaid, it is estimated that more than 90 percent of the released prison population will leave with Medicaid and be able to access health care services, including mental health and substance use disorders treatment. Director Mohr stated that the Affordable Care Act will positively affect incarcerated individuals and their families, which will influence the next generation. The change in Medicaid coverage, he said, is more than an opportunity to link individuals with health care services in the community; it is the responsibility of professionals working with justice-involved populations. 2 There are projects throughout the country focused on Medicaid enrollment as part of reentry efforts to combat recidivism and provide justice-involved individuals with the best possible chance for successful returns to the community. These programs are working at every intercept in criminal justice systems, from courts to jails and prisons through the transition to communities. The Laura and John Arnold Foundation sponsored efforts by Harvard Medical School and Johns Hopkins Bloomberg School of Public Health to inventory the state and local initiatives for enrolling individuals in Medicaid. 3 The inventory includes a brief description of initiatives in many states and local jurisdictions. Reentry efforts at the federal level are spearheaded by the Federal Interagency Reentry Council (Reentry Council) established by former Attorney General Holder in January This represents the Reentry Council a significant executive branch commitment to coordinating reentry efforts and advancing effective reentry policies. It is premised on the recognition that many federal agencies have a major stake in prisoner reentry. Twenty-three federal agencies, working toward a mission to make communities safer by reducing recidivism and victimization, assist those who return from prison and jail in becoming productive citizens and save taxpayer dollars by lowering the direct and collateral costs of incarceration. 4 All of these initiatives have the common goal of changing the way justice-involved populations access health care in the community. Being able to secure public health insurance coverage (Medicaid) or private health insurance coverage (through the Marketplace or employment) increases access to health care, including behavioral health programs that will improve health outcomes and reduce recidivism rates. Having public or private health insurance coverage will augment the chance of successful reentry, which is why efforts to enhance access to health insurance and community based services should be an integral part of reentry programs. 8

9 Introduction There is no one right time to enroll justice-involved individuals in health coverage. Access to coverage can impact decisions about diversion, pretrial confinement, and care during confinement and release. For example, when coverage is available, it can decrease the use of jail confinement for individuals who need mental health treatment. Because there can be different strategies for increasing access to health care at the various points of involvement with the criminal justice system, this document uses the GAINS sequential intercept model 5 as part of its organizational framework. This model was developed through grant funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and identifies points of opportunity in the justice system to intervene improving outcomes for individuals with mental health needs. This model easily adapts to providing opportunities for increasing health care access. This document will provide examples of jurisdictions that have been successful in increasing access to health care coverage; however, there is no single solution that will work for every jurisdiction. Each jurisdiction will need to identify processes and procedures that will work within their system. Implementation will be a process with multiple steps that may require criminal justice and social services partners to make changes in current practices. The Affordable Care Act creates the expectation that, in order to benefit from the new opportunities, the criminal justice system s approach to health care access will have to change. As with most system changes, planning will be critical for success; implementation will take time and focus to ensure that new procedures meet the needs of the entire system and, most importantly, make a difference in the lives of justice-involved populations. Change to any system is process-driven and requires focus and attention from multiple sources. It will take a group of dedicated individuals who are willing to take on the challenges of implementing new ways of doing business. Ensuring that everyone begins with the same knowledge and understanding of both health care reform and the criminal justice system will be vital in making the appropriate system changes. This document will provide information about the necessary steps for implementing health care reform for adult populations within corrections and criminal justice agencies. Each part of the document will describe the information that will be needed to complete the checklists at the end of the document. There are separate checklists for each intercept: courts, probation/parole, jails, and prisons (Attachments C F). Each intercept has separate checklist for states that have expanded Medicaid, and non-expansion states that have maintained eligibility criteria pre-dating the passage of the Affordable Care Act. Checklists also accommodate state policy differences on the suspension or termination of Medicaid benefits when justice-involved individuals are incarcerated. Endnotes 1 NRRC Facts and Trends, National Reentry Resource Center, Retrieved July 2015, 2 American Correctional Association, webcast ACA The Patient Protection and Affordable Care Act, uploaded March 10, 2014, State and Local Initiatives to Enroll Individuals in Medicaid in Criminal Justice Settings, John Hopkins Bloomberg School of Public Health, Center for Mental Health and Addiction Policy Research, 4 Federal Interagency Reentry Council, webpage available at 5 Munetz, Mark R., and Griffin, Patricia A. GAINS Center for Behavioral Health & Justice Transformation, funded by Substance Abuse and Mental Health Administration (SAMHSA), Center for Mental Health Services 9

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11 Section1 Knowing the Basics The information presented will be essential for understanding health care reform. Parts of the information may be familiar to some; to others, the information will be new. However, ensuring that everyone involved begins with the same knowledge will be important. For additional reference, this document provides links to resources that have been developed by federal agencies, state and local governmental entities, national associations and nonprofit groups. The Patient Protection and Affordable Care Act (Public Law ) (hereafter the Affordable Care Act ) created changes in the availability of health insurance by expanding coverage, holding insurance companies accountable, and guaranteeing more coverage choices for consumers. It lowers health care costs for some individuals and expands the Medicaid program in the states that opted for expansion. The Medicaid expansion removes the categorical exclusions and bases eligibility solely on income (e.g. adults without dependent children). People who are below the federal poverty guideline of 133 percent are eligible. In 2015, that is an individual income less than $15,654 annually or $1,304 monthly. This group was targeted because many were uninsured or underinsured, which has an impact on the cost of health care. In addition to Medicaid expansion, the Affordable Care Act contains state requirements, like streamlining the Medicaid application to make it easier for individuals to apply, using the tax code definition of income for determining eligibility, and creating Marketplace sites for purchasing private health insurance. The Marketplace created ways to compare health insurance plans and pricing. There are plans that offer catastrophic coverage only or plans that have small co-pay amounts with higher premiums. These different types of plans allow the consumer to select a plan that meets their individual needs. Some states have created their own Marketplace sites, and other states are utilizing the federal site. Based on the income guidelines, individuals or families with incomes between 100 percent and 400 percent of the federal poverty level could qualify for a tax credit that would lower the cost of their premiums. Additionally, individuals with incomes between 100 percent and 250 percent of the federal poverty level could be eligible for additional cost sharing to help subsidize deductibles and co-payments. Important to the discussion about the Affordable Care Act is mental health parity. Parity began as a result of the Mental Health Parity and Addiction Equity Act of This act prevented group health plans and health insurance carriers from setting limitations on behavioral health benefits lower than medical/surgical benefits. This concept of parity was also included in the Health Care and Education Reconciliation Act of 2010 and the Affordable Care Act. As individuals transition from incarceration to communities, they may be referred to community-based providers to continue treatment. Increasing the number of individuals who have health insurance coverage through Medicaid or Marketplace plans, the parity requirement increases the possibility that behavioral health care treatment will be available to those who need it. There have been several challenges to the Affordable Care Act; however, not all of them will be discussed in this document. A significant challenge was presented in National Federation of Independent Business v. Sebelius, a Supreme Court case that resulted in allowing states to choose whether or not to expand Medicaid benefits. Currently, 31 states and the District of Columbia have expanded benefits and have adapted the new eligibility criteria. As allowed in the Affordable Care Act, the federal government pays a higher proportion of the cost for newly eligible individuals into 11

12 Section 1: Knowing the Basics the expanded Medicaid programs. The proportion that the federal government pays for individuals is called the Federal Medicaid Assistance Percentage (FMAP). In expansion states, the FMAP rate paid to the state Medicaid agency for the newly eligible population is 100 percent through FY 2016 and will decrease to 90 percent by 2020, but not go lower than 90 percent. This higher Medicaid rate has assisted states in increasing the number of people on Medicaid without comparable increases in the state share of their Medicaid budgets. States that did not expand are not receiving the increase in dollars but still get the FMAP of at least 50 percent for their existing Medicaid populations. These changes have positive results for the justice-involved populations. High percentages of this population are likely to qualify for Medicaid or for affordable private health insurance coverage through the Marketplace. While there are various limitations and exclusions during incarceration, those limitations do not apply to individuals on pretrial release or who are on probation or parole. Additionally, Medicaid may be available for in-patient care during incarceration and states can determine whether an individual is Medicaid eligible while incarcerated so that Medicaid payments are available on release from incarceration. Beginning in January of 2017, enrollment 60 days prior to release will also be available through the Marketplace. For justice-involved individuals, access to health services may mean the difference between staying in the community and returning to jail or prison. Treatment that began in incarceration will more easily be continued in the community, providing stabilization for behavioral health and other conditions. This continuity of care is critical, especially for those with mental health and substance use disorders. What Is Medicaid? Medicaid is a state-federal partnership to meet the health needs of vulnerable populations. It was created in 1965 through the Social Security Act. The Affordable Care Act has increased the ability of the Medicaid program to provide health coverage for most low-income adults. Previously, it primarily covered children, pregnant women, parents, seniors and individuals with disabilities. The federal guidelines for Medicaid are determined by the Centers for Medicare and Medicaid (CMS), part of the U.S. Department of Health and Human Services. The federal guidelines allow significant state flexibility in determining benefits that will be covered, eligibility and enrollment procedures, and benefit delivery systems. State Plan Eligibility Criteria Each state has a State Medicaid Plan that governs what and how benefits will be provided and to whom they will be provided. State plans are changed by submitting a State Plan Amendment (SPA) that must be approved by CMS. All states must provide Medicaid to children, pregnant women and parents either through Medicaid or a combination of Medicaid and the Children s Health Insurance Program (CHIP). States must also provide coverage for elderly adults and disabled individuals. Eligibility criteria for coverage of the disabled differ from state to state. For example, some states link eligibility for Medicaid coverage to receipt of Supplemental Security Income (SSI), a means-tested Social Security program for low-income adults with disabilities. Other states determine eligibility based on disability that is not linked to SSI payments. Because every state establishes its own eligibility criteria, it is vital that all correctional professionals understand what eligibility categories or criteria their state is using. States must maintain their pre-affordable Care Act eligibility criteria for mandatory Medicaid populations. For the adults newly covered by the Medicaid expansion authorized in the Affordable Care Act, eligibility is based on federal established income guidelines plus federal and state requirements regarding residency, immigration status and documentation of U.S. citizenship. 12

13 Section 1: Knowing the Basics In states that did not expand Medicaid as a result of the Affordable Care Act, it is still possible to enroll justice-involved individuals in Medicaid under the existing state plan. The number of individuals covered will be much lower and it may be more challenging; however, the reward will be worth the effort. For example, documenting that an individual has a disabling condition could result in a determination of eligibility for Medicaid coverage and approval by Social Security for SSI. This could greatly benefit the justice-involved individual as they return to the community in that they will not only have health care, but also income to meet their basic needs. When individuals qualify for Medicaid, the coverage remains in place for a specific period of time, within the federal requirement of a yearly redetermination of eligibility. States can require more frequent eligibility redeterminations but CMS is encouraging states to use a 12-month eligibility determination period. States also have to be cognizant that there are some additional rules that govern when individuals are incarcerated. Once a person is incarcerated the federal government cannot reimburse for Medicaid eligible costs for out-patient services. The issue of suspending or terminating benefits is discussed later in this section. This information is especially relevant for justice-involved individuals who frequently move from the community to jail and back to the community. If, when arrested, an individual is allowed to remain in the community, their Medicaid coverage remains active. Enrollment Strategies The Kaiser Commission on Medicaid and the Uninsured has published an issue brief that provides insight on enrollment strategies. 6 The purpose of the commission is to provide information and analysis on health care coverage and access for the low-income population, with special focus on Medicaid s role and coverage of the uninsured. The five key lessons for developing enrollment strategies can help correctional and criminal justice agencies develop their enrollment approaches. First, the commission found that the majority of individuals believe that health coverage is important and would enroll in Medicaid if they were eligible. The coverage that Medicaid offers provides services, peace of mind and protection from large medical bills. Being able to access health care before the need for care becomes a crisis is important and another reason why individuals would benefit from enrolling in Medicaid. These factors are the same for justice-involved populations and potentially their family members. The second and third key lessons combine broad and targeted outreach strategies, making enrollment more accessible for individuals by reducing barriers. Targeting justice-involved individuals with high health care needs is an example of a specific group for enrollment. Making posters and educational materials visible and available in courts, probation/parole offices and throughout jails and prisons would be examples of broad outreach. Jails and prisons may engage multiple staff in outreach efforts, including correctional staff, teachers and health care providers. Probation and parole offices need to coordinate with community health care providers to reinforce the importance of enrolling in Medicaid coverage. Ensuring that information is available in English and other primary languages spoken by justice-involved individuals would assist in reducing barriers to the application process. Most Medicaid agencies have information available in English and Spanish. The fourth lesson validates the importance of one-on-one assistance. Utilizing volunteer groups may be part of the process and could provide the one-on-one contact. Local Medicaid offices have staff that provides assistance through face-to-face contact with individuals. It is important to consider cultural competency and the availability of bilingual staff or volunteers for this type of assistance. 13

14 Section 1: Knowing the Basics The final key lesson focuses on renewals of coverage. Probation and parole offices may have more contact with justice-involved individuals and need to understand the importance of re-enrollment. However, this information should be included in any health literacy programs that are provided in jails and prisons so justice-involved individuals have an understanding of the renewal requirement and will be prepared to keep their enrollment current after they return to the community. Expansion vs. Non-expansion Under the Affordable Care Act, 31 states and the District of Columbia have removed the previous categorical exclusions and expanded their Medicaid program. This coverage is available for individuals with incomes under 133 percent of the federal poverty guidelines. Many justice-involved individuals are newly eligible under Medicaid expansion. In July 2012, BJA reported that New York City estimated that 80 percent of individuals in jails are either enrolled or eligible to enroll, and Illinois estimated that 300,000 of the 500,000 to 800,000 new Medicaid enrollees would have justice involvement. 7 Regardless of whether states have expanded to include single adults, there are changes to all Medicaid programs that will have positive impacts for correctional systems: 1. The simplified application form will make it easier for justice-involved individuals to complete an application. 2. Streamlined income guidelines for determining eligibility known as Modified Adjusted Gross Income (MAGI) will make it quicker and more efficient to determine eligibility. Guidelines are based on income tax definitions. 3. Increased use of presumptive eligibility (see explanation below) by hospitals and other entities will provide more opportunities for payment of care in the community for justice-involved individuals. Figure 1 shows the current listing of Medicaid expansion and non-expansion states. States continue to evaluate whether to expand. The following graphic illustrates expansion and non-expansion states. 14

15 Section 1: Knowing the Basics Figure 1. Expansion states Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, West Virginia and the District of Columbia Non-Expansion states Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming States are continuing to evaluate expansion decisions. Below are two websites with interactive maps showing the most current and accurate information. CMS State Medicaid and CHIP Profiles: by-state/by-state.html. The Legal Action Center web tool is State Profiles of Health Care Information for the Criminal Justice System. The site has information about Medicaid, health systems and health insurance options: 15

16 Section 1: Knowing the Basics Suspend vs. Terminate Benefits CMS recommends that states suspend rather than terminate benefits when individuals enter jails/prisons but states have the flexibility to make that determination for themselves. All state plans specify whether Medicaid benefits are suspended or terminated when individuals enter jails/prisons. This decision is independent of whether states expanded Medicaid. Research conducted by the American Correctional Association shows that there are 14 states (Arizona, California, Colorado, Connecticut, Florida, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, New York, North Carolina, Ohio, and Oregon) that currently suspend benefits, and one state, Texas, that suspends benefits for 30 days and then terminates. The decision to use suspension instead of termination is within the authority of the state and can be changed by submitting a State Plan Amendment (SPA) to CMS. If the state has chosen to suspend benefits, reactivation is much easier and benefits can be reactivated anytime within the one-year eligibility period. If benefits are terminated, a new Medicaid application must be completed and approved. If benefits are suspended instead of terminated, it reduces the workload involved for both correctional agencies and state Medicaid offices because benefits are reactivated upon release from incarceration and applications do not have to be completed. Since Medicaid coverage generally remains in place up to one year, this could be especially valuable for jail populations that generally have sentences of one year or less. Arizona (Expansion State) The state Medicaid agency made a decision to put a procedure in place for suspension rather than termination. They have intergovernmental agreements with counties and exchange information electronically. California (Expansion State) In 2013, the state legislature passed a bill to suspend Medicaid during incarceration and has a process for enrolling eligible individuals prior to release. Texas (Non-Expansion State) For the first 30 days of incarceration, Medicaid benefits are suspended. After 30 days, benefits are terminated. This is to prevent loss of benefits for those with short stays. States that terminate benefits when justice-involved individuals are incarcerated should consider evaluating a change to suspending benefits. The workload would be comparable for terminating or suspending benefits on initial incarceration whether it is done manually or through some electronic process. However, other aspects of managing eligibility would be reduced with suspension. For example, the number of new applications that need to be filled-out and processed would be reduced with suspension, gaining efficiencies for both the corrections and Medicaid work forces. Even when focused on short term stays, such as the Texas 30-day suspension model, there would be a reduction in duplicated efforts, especially for the jail population. The outcome for every agency involved has the potential to remove redundancy and will likely increase the probability of successful reentry for justice-involved individuals. 16

17 Presumptive Eligibility Section 1: Knowing the Basics Presumptive eligibility allows non-medicaid agencies to determine temporary eligibility for Medicaid on the presumption that the client most likely meets the eligibility criteria. Prior to the passage of the Affordable Care Act, presumptive eligibility was mostly used by hospitals to obtain coverage for individuals who did not have other health insurance. Its use has been expanded to other agencies administrating programs that serve individuals who are likely eligible for Medicaid, such as SNAP and TANF. Some correctional agencies have worked with their state Medicaid office to utilize presumptive eligibility as part of reentry programming. Advantages to presumptive eligibility include the ability of hospitals and other agencies to immediately enroll patients who are likely to be eligible under the state Medicaid eligibility guidelines. It is based on income, household size and, depending on the state, information regarding citizenship, immigration status and residency. Presumptive eligibility is a temporary Medicaid status, pending final determination by the state Medicaid agency. Depending on the setting and how presumptive eligibility was determined, it may be necessary to complete and submit an application to obtain ongoing Medicaid coverage. For correctional agencies, the dissension to apply presumptive eligibility needs to be carefully thought out. It may create duplication of applications and approval processes. For example, if someone leaving jail/prison has presumptive eligibility, it remains in place for a limited timeframe. Prior to the end of the limited timeframe, that individual must apply, utilizing the regular Medicaid application, generally within 60 to 90 days. If the individual does not complete the application, Medicaid coverage ceases, and the individual could not reapply for one year. For presumptive eligibility to be successful, it is critical that mechanisms be in place to ensure completion of the application, as well as, close follow-up to prevent a lapse in coverage. This step could be completed by local Medicaid agencies or volunteer enrollment groups in the community, but it is imperative that the process happens. The process for enrollment may be streamlined by using the standard Medicaid application and working out mechanisms for approval or denial prior to leaving jail/prison. This process requires a single application and approval rather than layering and potentially duplicating steps. Structure for Delivery of Medicaid Services Within States Medicaid has contracts for health services through mechanisms similar to other health insurance programs. There are managed care options, traditional fee-for-service delivery models, and combination models. The trend is for states to move to a system of managed care. Thirty-nine states contract with comprehensive managed care organizations (MCOs) for services to some Medicaid clients; nationally, however, more than half of all Medicaid clients are receiving their care through these plans. 8 Managed care models differ from state to state, with most having the enrollee select which MCO they want to participate in. Regionally based MCOs are assigned depending on the enrollee s geographic location. It will be important to understand how enrollees are assigned within a state s MCO structure as part of any enrollment strategies. Each MCO has a network of health care providers that represent all aspects of health care, including specific hospitals or hospital systems with which they contract for services. They generally focus on preventive care as well as encouraging clients to utilize appropriate services. For example, often MCOs will have a call center staffed by registered nurses who will answer questions and help clients make decisions about health care needs. This might result in being seen in an office visit the following day instead of going to the emergency room. Understanding how to navigate the health care system can be challenging, especially for justice-involved individuals. Health literacy programs can assist in understanding how to access primary health care providers and behavioral health services. Discussions might include the use of office visits versus the emergency room and how to locate pharmacies in the network. The basic structures of MCOs and how they contract and manage care would be useful information to include. 17

18 Section 1: Knowing the Basics Medically Necessary Care Medicaid, like commercial health insurance plans, uses criteria to determine that the health care being provided is necessary to prevent, restore or treat illness in a clinical manner consistent among community providers. The definitions of medically necessary care for Medicaid are set by each state. It is important to understand this concept when dealing with treatments that are part of a court order or included as conditions of probation/parole. Treatment must meet the state s definition of medical necessity for Medicaid to cover the costs. While court-ordered treatment for substance use disorders is certainly within the range of services that could be paid for by Medicaid, it will be important to ensure that treatment providers have input into the types of treatment that the justice-involved individual needs. Treatment providers must document in health care records how the treatment is medically necessary care for payment through Medicaid. Treatment programs or providers must be approved Medicaid providers to receive payment from the Medicaid system. Criminal justice agencies will want to ensure programs they utilize for services, either existing or new programs, are Medicaid approved treatment providers. For those new programs, it will be important to establish relationships prior to referring the first new clients. Meeting with the new providers will begin the process of understanding the needs of the criminal justice agency as well as the treatment program requirements. Discussion about documentation requirements should be part of the conversation, including any release of information that the treatment program might request. Participation by the justice-involved individual will need to be documented for reports back to the courts or probation and parole. Some criminal justice information may be helpful to the treatment program, including risk/need assessments. Establishing a memorandum of understanding may facilitate the flow of information between the treatment providers and the criminal justice agency. Health Homes Included in the Affordable Care Act was the opportunity for states to improve care coordination and care management for Medicaid beneficiaries with complex needs through health homes. Health homes do not involve a physical location where services are obtained rather they have staff who help clients manage their care to ensure that the appropriate services are provided. As of May 2015, 19 states, both expansion and non-expansion, had developed plans for health homes. Health homes integrate coordination of physical and behavioral health, long-term services, and support for highneed, high-cost populations. Health homes are designed to improve quality of care while reducing costs. Individuals who have two chronic conditions, or one chronic condition and are at risk for a second chronic condition or have serious mental illness, are targeted for health homes. The chronic conditions dictated for inclusion in health homes per Medicaid include mental disorders, substance use disorders, asthma, diabetes, heart disease, and obesity. States may choose to include other conditions in the health home plans as well. 18

19 Section 1: Knowing the Basics According to CMS: The goal of the Medicaid health home state plan option is to promote access to and coordination of care. States have flexibility to define the core health home services, but they must provide all six core services, linked as appropriate and feasible by health information technology: Comprehensive care management; Care coordination; Health promotion; Comprehensive transitional care and follow-up; Individual and family support; and Referral to community and social support services. 9 In the state plan amendments, health homes do not have to be available to all Medicaid beneficiaries; however, selective criteria cannot be utilized to isolate certain populations (such as the justice involved). As states establish health homes for beneficiaries with chronic conditions, the justice-involved population should be included since they experience a high incidence of chronic conditions. For example, many of these justice-involved individuals have mental health and substance use disorders as well as a high need of medical care and would benefit from comprehensive care management through a health home. When justice-involved individuals are linked to health homes, they should receive enhanced case management services from the MCO that ensures the right health care is being provided. The intense level of case management assists in coordination between physical and behavioral health care. In Ohio, once a justice-involved individual chooses a managed care organization (MCO) and they have two or more health conditions, they participate in a health home and are targeted for at least one in-reach visit from the MCO to develop a health care transition plan. In Ohio, this is known as the Critical Risk Indicator Program. MCOs use the Ohio Department of Rehabilitation and Correction s telemedicine system to communicate with the individual prior to their release. This coordination of care improves the transition from incarceration to community; justice-involved individuals have an increased understanding of where they will be receiving health care services in the community before they leave the correctional facility. What Is the Marketplace? Each state has made a decision whether to create a web-based system for obtaining private health insurance, known as the Health Insurance Marketplace ( Marketplace ). States either manage their own state-run Marketplace or rely on the federal site to house their state Marketplace. These sites have numerous health insurance plans available that can compare the types of coverage offered, and the cost for premiums, and health care insurance can be purchased. For individuals who qualify, there may be assistance with premium costs and reducing out-of-pocket costs. The majority of justice-involved individuals will meet the financial guidelines for Medicaid; however, if they do not qualify for Medicaid, they may apply and be found eligible for reduced premiums through the Marketplace. Premiums are subsidized through tax credits, which require filing individual tax returns even when no payment may be owed. Typically, there will be a separate application for obtaining health care insurance through the Marketplace. If possible, corrections should consider how to facilitate the submission of a Marketplace application as part of their health care reform planning. 19

20 Section 1: Knowing the Basics Qualifying Life Event (QLE) There are two circumstances in which people can make changes in their Marketplace health insurance coverage. The first way is during open enrollment periods. Open enrollment takes place annually and is usually publicized broadly in mailings and through newspaper and television advertising. Individuals who are in jail pending disposition of charges are eligible to enroll in Marketplace coverage as individuals or as part of their family s coverage. The second way changes can be made to health insurance enrollment is through Qualifying Life Events (QLE). Tribal members are exempt from needing a QLE and can apply any time for health insurance. Listings on the Marketplace websites and in health insurance information explain the kinds of circumstance that are QLEs. Commonly understood examples are the birth of a child or changes in family status, such as divorce. Moving from one geographic location to another or being released from jail or prison are also examples. QLEs allow for justice-involved individuals to sign up for health insurance within a specific time after release. Any post-release enrollment process should include this information, since the time-frame for making changes is usually within 60 days. Individual Shared Responsibility Payment Beginning in 2014, the Affordable Care Act requires each individual to maintain a minimum level of health care coverage, and if coverage is not maintained, it requires an individual to make a shared responsibility payment when filing federal income tax returns. Most people who had insurance coverage for the entire year whether government sponsored, employer-based, or purchased through the Marketplace will not need to make a payment. There are several exemptions to the required payment including incarceration. Other types of exemptions include when coverage is considered unaffordable, there are short coverage gaps, or they are not eligible for Medicaid in non-expansion states. More information on payments and exemptions are available through the Internal Revenue Service and state or federal Marketplace websites. Evaluation Evaluation strategies should be developed by first considering the desired end result. Any component or metrics for evaluation should provide answers and information about how new procedures and processes are working. Evaluation metrics will indicate whether the program has been successfully implemented or will point to areas that need improvement. Putting the plan in writing helps ensure that the process is transparent and that all stakeholders agree on the goals of both the program and the evaluation. It serves as a reference when questions arise about priorities, supports requests for program and evaluation funding, and informs new staff. 10 Enrollment in Medicaid is one of the foundational goals of implementation of the Affordable Care Act. Some of the evaluation criteria may include the number of enrollments in correlation to the number of justice-involved individuals who qualify for Medicaid or some other form of health insurance. Both financial and staffing resources are limited and may be maximized by conducting a cost-benefit analysis. A costbenefit analysis offers a comprehensive, realistic way to understand all of the costs associated with doing business. This analysis captures the usual cost of staffing and resources but also helps to compare the investment dollars and the long- 20

21 Section 1: Knowing the Basics term benefits. For example, long-term benefits could be a reduction in recidivism rates. The Vera Institute of Justice s Cost-Benefit Analysis and Justice Policy Toolkit 11 is one resource that can be used in conducting a cost-benefit analysis. The toolkit outlines detailed steps necessary to complete the analysis. Establishing Metrics for Evaluation When establishing an evaluation plan, it is vital to first identify the measures and targets for measuring the outcomes of the project. The evaluation should help define what success looks like and how stakeholders and working group members will know when it is accomplished. The evaluation components should be structured to show both short- and long-term accomplishments. Data that is meaningful and accurate will justify the continuation or expansion of the program. Costbenefit analysis is one aspect of evaluation, but there will also be other factors to consider. Time studies, as discussed in the Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM) section will need to be part of any evaluation metrics. MAC and TCM are discussed in detail beginning on page 23 of this section. It is important to understand the data already being collected within the agency or system. This will assist in understanding the current functions and may provide measures to gauge the success of the proposed changes. This data may be utilized to establish a baseline. If the data points needed for future evaluations are not being collected, sampling may need to be completed prior to implementation of new programs. As the review of data collection is conducted, some elements may not be needed in the future. However, there are some data points that will continue for other informational purposes. If, after thoughtful analysis, the data is not needed, consider not collecting in the future, reducing the agency s workload. Whenever possible, data collection should be conducted through electronic means. The next table contains evaluation metrics that may be easy to implement and will provide information about the program s success. This information is the minimum needed for an evaluation and could provide the baseline for more complex evaluations. Attachment B has more extensive metrics and it should be the goal to gradually integrate into the data collection. The long-term goal would be implementation of all the metrics in attachment B. Agencies will need to determine whether the sample metrics will provide the needed information or whether there are different metrics that would be more meaningful for evaluation purposes. Table 1 Basic Metrics (Minimum Needed) New Admissions Eligible Enrolled Any health care coverage Total Number Number Number Of those, how many have Medicaid coverage Number Number Releases Eligible Enrolled Any health care coverage Total Number Number Number Of those, how many have Medicaid coverage Number Number 21

22 Section 1: Knowing the Basics Agencies may want to consider contracting for evaluation services. The decision to contract for the evaluation should be made early in the process so they can assist with defining measures and other aspects of the evaluation. Colleges and universities would be another resource to explore for assistance. They may need student projects or internships that could assist with evaluation methods. Their services do not have to be limited to research, although that would be highly valuable. Colleges and universities might also be appropriate for working group membership, if they are available. Potential Budget Implications There are costs associated with any project, and understanding the budget implications of implementation of certain provisions of the Affordable Care Act will be important. Utilization of existing funded staff may reduce some costs of health care reform implementation; for instance, staff in the booking center of a jail may be asked to add more questions to screening tools or intake forms. Although this would increase workload, it should not require new or additional staff. Volunteers are another resource that may be used to conduct enrollment activities, which would not impact the budget and could help to relieve existing workload issues. Linking justice-involved individuals to health care services, including treatment programs, may contribute to reductions in the number of individuals returning to confinement and, consequently, budgetary reductions. However, identifying the costs associated with the revolving door of justice-involved individuals may be difficult to capture. Reducing recidivism may translate to fewer occupied beds in jails and prisons or may translate to fewer community supervision staff needed to monitor individuals, potentially generating considerable savings. In addition to reducing recidivism, there are at least two ways that Medicaid dollars can have a positive impact on criminal justice budgets. For jails and prisons, recovery of hospitalization costs will be essential. Courts, probation and parole as well as jails and prisons may be able to access Medicaid Administrative Claiming (MAC). (See page 23 of this section for a further discussion.) Recovery of Hospitalization Costs When authorized in 1965, the Medicaid program was prohibited from covering the cost of health care provided to individuals incarcerated in public institutions, like jails or prisons. The law provided an exception for justice-involved individuals hospitalized in health care facilities not controlled by the correctional system for more than 24 hours. 12 The justice-involved individual must meet state plan eligibility criteria for enrollment into Medicaid for this cost to be recovered. Numerous hospitals have the ability to complete Medicaid applications for their patients, and this same system could be utilized with justice-involved individuals. If justice-involved individuals qualify by using either presumptive eligibility or Medicaid determinations, then the hospitalization costs could be billed to Medicaid for payment instead of to the correctional agency. This would generate a significant savings for jail and prison budgets. Enrollment of justice-involved individuals during intake processes in jails/prison could positively impact the jail s ability to obtain Medicaid coverage during hospitalizations. If this information is identified and tracked, and if justiceinvolved individuals are hospitalized, the hospital would submit billing to Medicaid instead of to the jail or prison. Denver County Jail, Colorado (Expansion State) In the fall of 2013, the Denver County Jail began a process of enrollment for justice-involved individuals. They worked closely with their local Medicaid agency and community hospital. During the first three to four months of 22

23 Section 1: Knowing the Basics implementation, Denver County Sheriff s Department saved approximately $600,000 in outside medical costs. 13 This savings was for hospitalizations longer than 24 hours. North Carolina (Non-Expansion State) North Carolina Department of Public Safety and the state Medicaid office were directed by the state legislature to establish a process for determining Medicaid eligibility for the DOC population. In 2012, the first year of implementation, 45 percent of hospitalizations were longer than 24 hours and were billed to Medicaid. This resulted in savings of approximately $13 million in 2012, and savings continue to be over $1.0 million each month. Wisconsin (Non-Expansion State) Wisconsin Department of Corrections worked with the state Medicaid office to implement a procedure for hospitalizations longer than 24 hours in April During fiscal year 2014, the savings were $2.4 million and in fiscal year 2015 totaled $9.1 million. Wisconsin is a non-expansion state; however, there is a waiver to cover single adults who are at or below 100 percent of the federal poverty threshold. Louisiana (Non-Expansion State) Louisiana Department of Public Safety and Corrections has collaborated extensively with the state Medicaid office; during fiscal year , 60 percent of all inpatient admissions were covered using the existing state Medicaid plan criteria. In fiscal year , Medicaid has already paid approximately $10 million and has $11.4 M in claims pending. Medicaid Administrative Costs It is possible to obtain up to 50 percent reimbursement for administrative activities directly related to obtaining Medicaid coverage or assisting beneficiaries in obtaining care. This mechanism for reimbursement is often used by school systems, and states have developed written guidance regarding schools. Criminal justice agencies will need to have a discussion with the state Medicaid office and complete several pieces of documentation before billing for administrative costs can occur. Reimbursement will require a written plan and documentation of time spent on the administrative activities. The two specific types of reimbursement are Medicaid Administrative Claiming (MAC) and Targeted Case Management (TCM). Documentation of time spent on administrative activities will require either a perpetual time study or random moment time study. Both require activity records of types and time to complete each activity. This will determine how much staff time is used to complete the administrative activities. There may be more than one staff member who would be included in any time study. The goal is to establish how much staff time could be included for billing purposes. If an agency is completing only one activity, then it could be done using direct billing while maintaining the records of the time spent on the activity. Accurate accounting for activities will be essential for successful billing. a. Medicaid Administrative Claiming (MAC) is a joint federal-state program that provides reimbursement for the costs of administrative activities that directly support efforts to identify and/or enroll individuals in Medicaid or assist individuals gaining access to needed health care services. Some activity codes are reimbursed at rates up to 50 percent of costs for salary, benefits and other associated costs. 23

24 Section 1: Knowing the Basics 24 Reimbursement could be for work that is already being done by existing staff. These activities could be billed through the following codes: 1. Medicaid Eligibility Intake Applicable to most agencies and occurs when assisting individuals in completing a Medicaid application. 2. Medicaid Outreach Applicable to agencies outside of jails/prisons; assisting justice-involved individuals to determine where services can be obtained and assisting in scheduling appointments. 3. Referral, Coordination and Monitoring Applicable to agencies outside of jails/prison; may include activities monitoring justice-involved individual s progress in treatment programs. 4. Arranging Transportation to a Medicaid-Covered Service Applicable to agencies outside of jails/prisons; may include driving or arranging transportation to health care appointments, including behavioral health services. b. Targeted Case Management (TCM) services are designed to help Medicaid clients access needed medical, social, education and other services. Some of these services include accessing non-health care-related support, such as emergency housing, SNAP benefits, and energy bill assistance. TCM must include four areas: assessment, development of a care plan, referrals/scheduling and monitoring/follow-up. Most probation and parole staff currently include these four components in their casement of justice-involved individuals. All four components must be present in order to obtain reimbursement for the administrative activity. Appropriate documentation will be critical. Correctional Agency Structure There might be multiple stakeholder groups involved in the planning and implementation process for increased access to health care that may not understand corrections or criminal justice systems and how they are organized. Providing an overview may be very useful as a baseline for developing potential solutions for implementing health care reform strategies. Remember to include information about the different levels of the court system, how they are connected and differences between city, county, and regional jail and prison systems. The information should describe jail/prison management, including topics like risk/need assessments and programing. Discussion should include community supervision, such as probation, parole and community corrections (halfway houses). Another topic to include in the discussion will be how health care services are structured within jails and prisons. There are four primary staffing models for delivery of health care. Health care staff is often employed by the corrections agency and have a reporting structure within the system. Some corrections agencies employ some health care staff and have contracts for physicians, nurse practitioners, psychiatrists, mental health and substance use disorders treatment providers. Other agencies contract for the entire health care staff through vendors who specialize in correctional health care. The final model involves contracts with universities who provide the health care staff. Regardless of the model for delivery, health care staff, including contract administrators who might be external to the agency, will need to be involved in the implementation process and should be part of the stakeholder or working group to assist with implementation strategies. They will be integral to the management of hospitalizations longer than 24 hours for possible Medicaid billing. The health information of the justice-involved individuals will be important for both prioritizing enrollment activities and linkages to health homes for reentry.

25 Endnotes Section 1: Knowing the Basics 6 The Kaiser Commission on Medicaid and the Uninsured, Key Lessons from Medicaid and CHIP for Outreach and Enrollment under the Affordable Care Act, June 2013, Issue Brief, The commission is part of the Henry J. Kaiser Family Foundation. 7 Bainbridge, Andrea A., July 2012, The Affordable Care Act and Criminal Justice: Intersections and Implications, Washington D.C.: Bureau of Justice Assistance, U.S. Department of Justice. 8 Medicaid Moving Forward Issue Brief, March 2015, The Kaiser Commission on Medicaid and the Uninsured, attachment/issue-brief-medicaid-moving-forward. 9 medicaid-health-homes-overview.pdf. 10 Brooks-Martin, A. (2015) Plan for Program Evaluation from the Start, National Institute of Justice Journal 275 (June), gov/journals/275/pages/plan-for-program-evaluation.aspx?utm_campaign=eblast-ncjrs&utm_medium=eblast&utm_campaign=jnl275- progeval Vera Cost-Benefit Analysis and Justice Policy Toolkit, December 2014, 12 The Council of State Governments, December 2013, Medicaid and Financing Health Care for Individuals Involved with the Criminal Justice System, 13 Video of Gary Wilson, Division Chief, Denver County Sheriff Department, 2014, Take Care Health Matters, Colorado Criminal Justice Reform Coalition, at 25

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27 Section2 Begin the Change Working or Stakeholder Group This group will be instrumental in designing, implementing and ensuring that new processes are successful. When considering the appropriate members of the group, think about who will be champions of change. Looking at current structures may identify people who have been early adapters in other projects. The goal is to create an environment where creative solutions are welcomed, it is safe to institute new processes and change will take place. The following considerations may be helpful in assembling a working or stakeholder group: 1. Utilize an existing group(s) There may be working groups already in existence within a jurisdiction that may be effective for this purpose. These groups generally have structure and working relationships that would provide a forum for implementation of the new process. Because of the existing relationships, there may already be a degree of trust within the group that could be capitalized on to build momentum for a new program. However, the existing group membership may need to be modified. If members are added or removed, dynamics within the group will be different and may be more like a new group. 2. Establish working group Whether you utilize an existing group or form a new one, refrain from making assumptions that community partners have worked together just because they are in the same community. The working group will need to spend some time establishing ground rules for working together. Membership in the group needs to be consistent, especially at the beginning of the project. This will reduce the re-education of members and allow the project to move forward more rapidly. 3. Consideration of potential stakeholders Some stakeholders may be critical to developing the process, whereas others might be messengers for getting out the word on the process. There may be agencies/groups that will not have a role in implementing the process, but may still add value to the group. After an initial meeting, there may be groups who will opt out of the process. However, it may be important to continue to include them in documentation and educational processes. The stakeholder group would likely consist of top-level administrators; however, working group membership might also include lower-level staff in the organizational structure. 27

28 Section 2: Begin the Change Stakeholders selected for participation in designing and planning for implementation should represent all aspects needed for implementation. This will include individuals from the correctional or criminal justice agency as well as other agencies and groups. The following table identifies potential stakeholders who should be considered for membership in the stakeholder group. They are listed in the appropriate SAMHSA Gains Center sequential intercept. Table 2 Dispatch 911 Intercept 1 Intercept 2 Intercept 3 Intercept 4 Intercept 5 Police Chief Crisis Intervention Team Leaders *Staff involved with this Intercept may participate in working groups in Intercept Two and Three Judges Pretrial Services District Attorney/ Prosecutor Public Defender Probation Office Law Enforcement/Police Chief Local Medical Agency Information/Data Specialist Local Safety Net Providers Food Bank Housing Federally Qualified Health Clinic Behavioral Health Clinic Local Hospital(s) Nonprofit Organizations Faith-based Organizations Sheriff Jail Administrator Correctional Health Administrator County Governmental Officials Commissioners Health Department Local Medicaid Agency Probation/Parole Office Information/Data Specialist Safety Net Providers Food Bank Housing Federally Qualified Health Clinic Behavioral Health Clinic Local Hospital(s) Nonprofit Organizations Faith-based Organizations Medicaid MCO Department of Corrections Executive State Medicaid Agency State Budget Office Governor s Office Prison Wardens Probation/Parole Office Information/Data Specialist Local/Regional Hospitals Safety Net Providers Federally Qualified Health Clinic Behavioral Health Clinic Nonprofit Organizations Faith-based Organizations Support Groups for Justice-involved individuals Medicaid MCO *If Jail may have members from Intercept Three Probation/Parole Office Chief Judge Department of Corrections Executive or Jail Administrator Community Corrections Director/Staff Information/Data Specialist Local/Regional Hospital(s) Safety Net Providers Food Bank Housing Federally Qualified Health Clinics Behavioral Health Clinics Nonprofit Organizations Faith-based Organizations Support Groups for Justice-involved Individuals Medicaid MCO 28