Justice-involved youth tend to have more significant health care needs compared to other youth, and an estimated two-thirds have a behavioral health condition. These youth also face unique barriers to accessing care and coverage disruptions as they transition between correctional settings and the community. To better support this population, states are developing and advancing cross-system strategies to improve continuity of care, including by leveraging new federal opportunities.
Attendees of NASHP’s 37th annual conference in September 2024 had the opportunity to hear about approaches in Arizona and Washington during the session “Climbing Ol’ Rocky Top: Strengthening Systems to Help Justice-Involved Youth Ascend.” State officials discussed leveraging cross-system collaborations, maintaining and increasing Medicaid enrollment, implementing pre- and post-release services, and assessing capacity and gaps for justice-involved youth.
Federal Requirements and Opportunities for States to Improve Medicaid Coverage Continuity for Justice-Involved Youth
While over half of justice-involved youth are covered by Medicaid or CHIP, federal law has historically prohibited states from receiving federal financial participation for services provided while youth are in correctional settings due to the “inmate payment exclusion.” By implementing policies to meet recent federal requirements and opportunities, states can reduce Medicaid coverage disruptions and improve continuity of care for justice-involved youth. Requirements and opportunities include:
- The 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) prohibits states from terminating Medicaid eligibility for youth incarcerated after October 24, 2019. Instead, states must suspend their eligibility, allowing youth to stay enrolled in Medicaid while their coverage is temporarily deactivated during incarceration.
- The Medicaid Reentry 1115 Demonstration opportunity, described in the Centers for Medicare & Medicaid Services (CMS) guidance from April 2023, allows states to cover certain pre-release services for individuals leaving correctional settings, waiving the inmate payment exclusion. As of September 2024, 11 states’ demonstrations have been approved by CMS, and many include justice-involved youth, such as California, Illinois, Kentucky, Massachusetts, New Mexico, Oregon, Utah, and Washington.
- The Consolidated Appropriations Act of 2023 includes two key provisions that waive the inmate payment exclusion for justice-involved youth. Beginning January 1, 2025, state Medicaid and CHIP agencies will be required to cover certain pre- and post-release services for justice-involved youth who are incarcerated post-adjudication. These services include screening and diagnostic services, in alignment with Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards, as well as targeted case management. States also have the option to cover all state plan-covered services for youth who are incarcerated pending disposition.
Leveraging Cross-System Collaborations
Justice-involved youth are often engaged with multiple systems, including juvenile justice, child welfare, Medicaid, public health, and behavioral health. States are collaborating across a range of partners to improve continuity of care and streamline access to services across these agencies and systems for this population. State officials also described leveraging longstanding partnerships and the importance of leadership to advance policies that support justice-involved youth.
In Washington, state agencies (e.g., Medicaid, child welfare, juvenile justice, developmental disability), providers, managed care organizations (MCO), and families partnered to implement Wraparound with Intensive Services (WISe) in response to a 2013 class action lawsuit. State officials highlighted the importance of engaging families and people with lived experience to support justice-involved youth. The state identified justice-involved youth as a priority population for WISe, which supports children and youth with intensive behavioral health needs. The state worked with regional and statewide Family, Youth, System Partner Round Tables to engage families, youth, and system partners in the design and implementation of this service.
State Medicaid and juvenile justice officials in Washington have also formed a strong partnership following a 2016 Governor’s Executive Order that mandates the agencies work together to support Medicaid enrollment and suspension for justice-involved youth. State officials have built on this existing partnership to engage in planning and implementation of the state’s Medicaid Reentry 1115 Demonstration, which was approved in June 2023, through the state’s Reentry Advisory Workgroup. This workgroup includes representatives from the state juvenile justice agency, among other partners, and includes a subcommittee focused on reentry for youth. Similarly, Arizona, which has a pending Medicaid 1115 Reentry Demonstration, has longstanding collaborations between the state Medicaid and juvenile justice agencies, and local detention facilities, to support pre-release planning for justice-involved youth. Officials from Arizona also described a focus on engaging partners in rural and frontier areas, including Tribal populations.
Maintaining and Increasing Medicaid Enrollment
Gaps in Medicaid coverage may negatively impact continuity of care, health outcomes, and recidivism for justice-involved youth. States have implemented strategies to maintain and increase Medicaid enrollment for justice-involved youth through processes and staffing that support pre-release Medicaid applications and prevent termination of Medicaid coverage. These strategies can be built upon as states leverage new federal opportunities to improve continuity of care for justice-involved youth.
Arizona has implemented data-sharing agreements between the state’s juvenile justice, criminal justice, and Medicaid agencies to suspend and reinstate Medicaid benefits as people transition in or out of correctional settings. For youth, the suspension process is currently completed manually, but the state is moving toward an automated process. The state has also established processes to submit pre-release Medicaid applications up to 30 days prior to release and to expedite the Medicaid application process for incarcerated youth. While Medicaid eligibility determinations are typically made within 45 days, expedited determinations for justice-involved populations can be made within 72 hours.
In Washington, the state Medicaid and juvenile justice agencies jointly fund a staff position that serves as a liaison between the two systems. The liaison reviews correctional facility admissions reports and identifies coverage status for individual youth. Upon entry into a correctional facility, coverage is suspended for those who are enrolled in Medicaid, while others are screened for eligibility and enrolled, as appropriate. The liaison then meets with each youth to discuss their Medicaid coverage and managed care enrollment, which will be activated upon release. Additionally, in 2021, the legislature mandated that the juvenile justice agency notify MCOs at least 30 days prior to an individual’s release from a facility.
Implementing Pre- and Post-Release Services
Pre-release and post-release services, such as case management, can support youth as they transition in and out of correctional settings and provide a connection to community-based services. States are focused on providing these services, as well as diverting youth from justice system involvement when possible. States’ existing services can provide a foundation for implementing Reentry 1115 Demonstrations and meeting 2023 Consolidated Appropriations Act (CAA) requirements.
Washington has focused on improving services and supports for youth and families with the goal of diverting youth from the juvenile justice system earlier on. For example, the Community Transition Services program provides youth with the opportunity to return home and access services in the community, with monitoring and support from the juvenile justice system. This program, among others, has led to the closure of multiple juvenile justice facilities over the past several years.
In Arizona, each Medicaid managed care health plan is required to have a justice system liaison who provides pre-release services. These services are available to all youth, as well as some adults who have complex health or behavioral health needs. The liaison is notified within 72 hours of an individual’s admission to a facility and often works with the youth as part of a multidisciplinary child and family team that may include the guardian, probation staff, case managers, community-based providers, attorneys, and others. The liaison generates referrals, secures appointments, and ensures that appointments are maintained within seven days of release.
Assessing Capacity and Gaps
State officials described assessing their current capacity and gaps to prepare for implementation of Reentry 1115 Demonstrations and to meet 2023 CAA requirements that support transitions for justice-involved youth. This process can support states in strategically planning for operationalizing these policies in correctional settings.
State officials from Arizona described reviewing their current policies to determine their status toward meeting 2023 CAA requirements. For example, the state assessed that it partially meets the requirement that youth receive screening and diagnostic services 30 days prior to release, or within one week or as soon as practicable after release, because the state Medicaid agency’s current policy is that youth must receive appropriate appointments within seven days of release from a correctional facility. The state has also identified required next steps, such as establishing separate capitation rates for justice-involved youth, updating their provider enrollment system to include corrections providers, and submitting a state plan amendment for targeted case management to the Centers for Medicare & Medicaid Services.
Arizona has also reached out to youth correctional facilities to inquire about their current services to determine their capacity and needs. One area of focus for the state is working with agencies and providers in rural and frontier areas to meet their unique needs and ensure that youth across the state receive the same services.
In Washington, the state Medicaid agency has distributed a capacity-based assessment to correctional facilities to gather information for Reentry 1115 Demonstration implementation. This assessment will inform the state about the pre-release services correctional facilities currently provide and help identify gaps in services. Additionally, facilities can choose to join one of three cohorts based on whether they will launch the initiative in July 2025, January 2026, or July 2026. The state juvenile justice agency has opted for its facilities to participate in the first cohort.
As of 2022, nearly 80 percent of justice-involved youth in Washington had a behavioral health need prior to incarceration, yet only 32 percent received mental health service and 14 percent received a substance use service covered by Medicaid within 90 days of release. Washington officials described plans to continue tracking these and other data to identify improvements and needs as their state advances strategies to improve continuity of care for justice-involved youth.
NASHP will continue to work with states and track developments as they plan and implement policies that improve continuity of coverage and care for justice-involved youth. This includes NASHP’s work with seven states seeking to implement Medicaid Reentry 1115 Demonstrations through its State Reentry Learning Collaborative, as well as work with a broader network of states through NASHP’s State Reentry Learning and Action Network, in collaboration with the Health and Reentry Project (HARP). Interested states may request to join the reentry learning and action network meetings and listserv.
