Changes to Medicaid and Children’s Health Insurance Program (CHIP) Eligibility for Justice-Involved Youth

Many youth involved with the justice system have unmet behavioral health needs that require support.
Justice-involved youth have historically lost access to Medicaid and CHIP benefits for the duration of their incarceration due to statutory limitations on Medicaid service eligibility. This results in discontinuous coverage that increases state and local costs and creates poor outcomes for at-risk youth.
Federal legislation passed in 2022 allows Ohio to maintain Medicaid and CHIP coverage for pre-trial juveniles and requires certain Medicaid and CHIP benefits to begin up to 30 days before release from incarceration.
This statutory change goes into effect January 1, 2025, and will impact all “public institutions” which includes jails, prisons, and juvenile justice facilities.

Many young people within the justice system find themselves there due to untreated behavioral health conditions, particularly substance use disorders.

Introduction

Many young people within the justice system find themselves there due to untreated behavioral health conditions, particularly substance use disorders. Instead of receiving the appropriate care in the community, they often end up incarcerated. Correctional facilities are challenging places to provide essential care, and when these youth leave the justice systems, they often lack the connections to essential services to avoid reincarceration. This lack of coordinated care results in poor outcomes for their health and negatively impacts their educational environment, families, and community. This cycle of reincarceration results in significant costs, inefficiencies, and health disparities among justice-involved youth—undermining Ohio's efforts to improve the well-being of at-risk youth.A significant obstacle to establishing a coordinated care system wherever justice-involved youth are needed is the longstanding statutory limitation known as the "inmate exclusion" in the Medicaid and Children’s Health Insurance Program (CHIP). This restriction bars Medicaid-and-CHIP-eligible individuals from receiving benefits while incarcerated, hindering efforts to improve their health and justice outcomes. However, in response to mounting calls for change, a bipartisan provision was passed as part of the Consolidated Appropriations Act of 2023 (hereinafter called “the Act”). This provision will enable Medicaid and CHIP to cover certain services for eligible juveniles as they exit the correctional system.These changes will take effect on January 1, 2025, and they offer an opportunity to support Ohio's endeavors to enhance care for those in need while also synergizing with optional service expansions to reduce costs and improve outcomes

Legislative changes: Sections 5121 and 5122

Section 5121 of the Act mandates that each state establishes and implements a plan to provide screening or diagnostic services to eligible juveniles up to thirty days before their release from a public institution. These screenings include medical and dental screenings, and behavioral health evaluations. Beyond screenings and diagnoses, the state must provide at least thirty days of targeted case management before release and at least thirty days of targeted case management and referrals to appropriate services, ensuring they receive the appropriate care upon release.^[1]Section 5122 of the Act gives a state the option to maintain Medicaid and CHIP benefits for eligible juveniles while they are incarcerated with "pending disposition" of charges. This means that if Ohio chooses, it can maintain the entire set of Medicaid and CHIP benefits for an eligible individual, which would improve access to services and reduce the challenges with reconnecting to insurance and services upon release.^[2]Eligibility for these benefits is determined by the state’s definitions of “juvenile.” In Ohio, there are a variety of factors that determine eligibility for Medicaid and CHIP, but a beneficiary is a “juvenile” until the age of 18 in most cases. For former foster youth who have aged out of the foster system, they maintain their status as a juvenile until the age of 26.^[3] This statutory definition of juvenile may not correlate with the justice system’s definition of juvenile. Thus, an individual in an adult facility such as a jail or prison may still be considered a “juvenile” by Medicaid and CHIP eligibility criteria and would remain beneficiaries under these statutory changes.

Approximately two-thirds of justice-involved youth have diagnosable mental health or substance use disorders.

Health status of justice-involved youth

Justice-involved youth often face significant health challenges, with a high prevalence of adverse childhood experiences and trauma.^[4]These adverse events often lead to higher risk of sexual and physical abuse, as well as behavioral health disorders.^[5] Approximately two-thirds of justice-involved youth have diagnosable mental health or substance use disorders.^[6] Unsurprisingly, there is also substantial overlap between youth in foster care and those in the juvenile justice system. In at least one jurisdiction studied, fifty percent of justice-involved youth were also foster youth.^[7]These youth also experience high rates of various health issues, including tuberculosis, dental problems, and sexually transmitted infections.^[8] Many of them are Medicaid or CHIP eligible, but as noted above, the inmate exclusion disrupts continuity of care for these youth the moment they are booked into a juvenile justice facility or jail.^[9]Despite the health status of these youth, their charges rarely demonstrate violence or criminality. Their justice involvement is often driven by a lack of support as evidenced by the fact that the majority of children between 10 and 17 are charged with delinquency or non-criminal status offenses such as truancy or running away.^[10] Despite the lack of seriousness in charges, a short stay in a carceral setting can lead to disenrollment from health insurance that would be essential for enhancing the vulnerable young person’s wellbeing.Most juveniles involved with the justice system are placed on community probation, and only a small fraction end up in residential treatment facilities. In such facilities, there is a clear gender and racial disparity, with 87 percent being male and two-thirds being minorities.^[11]Loss of access to health insurance due to incarceration would exacerbate the disparities in both health and justice systems.

Fewer than half of the facilities provide mental health evaluations to all youth

The opportunity to improve access to services before, during, and after incarceration is crucial. Although significant efforts have been made to improve care for incarcerated young people, there are still significant gaps in access to mental health evaluations in juvenile and adult correctional facilities. One survey showed that fewer than half of the juvenile correctional facilities provide mental health evaluations to all youth.^[12]That same report said that fifty-three percent of in-custody youth have personally met with a counselor at their current facility.^[13] The failure to identify the needs of youth who are incarcerated perpetuates their justice involvement into adulthood. By providing screenings and facilitating the transition to community-based care, young people can be supported in their successful integration into society.^[14]

Fewer than half of the juvenile correctional facilities provide mental health evaluations to all youth

While these statutory changes will create new challenges for correctional facilities, they also provide a significant opportunity to expand the number and quality of screening and referral services offered through the support of the Medicaid and CHIP systems. Many correctional facilities have attempted to create improved linkages to community services, but without the support of consistent revenue to support the programs, it is a challenge to ensure long-term survival of these programs. Connecting with Medicaid and CHIP systems in the community will provide an influx of financing, quality assurance frameworks, and support for reimagining the relationship between unmet health needs and the justice systems.These opportunities arrive as federal lawmakers and regulators are reexamining inmate exclusion and the challenges it creates for creating coordinated health systems that can reduce engagement with emergency departments and the criminal legal systems. The federal government has invited states to create Medicaid 1115 waivers that can vastly expand the services offered to people who are incarcerated, regardless of their age. By synergizing the mandates of the Consolidate Appropriations Act with these 1115 waiver opportunities, Ohio can reimagine the relationship between health and justice systems in a way that can improve the health status of justice-involved individuals, reduce our reliance on justice systems for untreated behavioral health needs, and decrease the costs created by out disjointed health and justice systems.

The federal government has invited states to create Medicaid 1115 waivers that can vastly expand the services offered to people who are incarcerated, regardless of their age.

Eligibility and implementation

With the opportunities created by the statutory changes, there will be significant implementation hurdles. As mentioned above, the statutory changes impact every “public institution,” including jails, prisons, and juvenile justice facilities. Identifying who is eligible for these benefits will require close collaboration between justice agencies and Medicaid agencies. Beyond determining eligibility, correctional facilities will need to provide opportunities for providers to offer the required screening, diagnosis, and case management benefits. This may require significant changes to workflow and staffing. Some jurisdictions may have already created relationships with community providers outside of Medicaid and CHIP programs, and it will be essential to support these providers as they begin offering services in alignment with the expectations of the Medicaid and CHIP programs. Leveraged appropriately, these challenges can enhance the relationship between the community and the facility and improve public trust in the institutions serving some of our most vulnerable citizens.

Conclusion

Sections 5121 and 5122 of the Consolidated Appropriations Act of 2023 offer a critical step forward in addressing the systemic challenges faced by justice-involved youth with behavioral health conditions. By allowing Medicaid and CHIP coverage for essential screenings, diagnoses, and case management, as well as the opportunity to maintain benefits during incarceration, these provisions can improve outcomes, reduce disparities, and support the well-being of Ohio's at-risk youth.[1] Consolidated Appropriations Act, 2023, Pub. L. No. 117-328 (2022), https://www.govinfo.gov/app/details/PLAW-117publ328.[2] Id. at § 5122.[3] Ohio Administrative Code Rule 5160:1-4-03.[4] Baglivio M, Epps N, Swartz K, Huq M, Sheer A, Hardt N. The prevalence of adverse childhood experiences (ACE) in the lives of juvenile offenders. Journal of Juvenile Justice, 2014; 3(2):1-23.[5] Underwood L.A., Washington A. Mental Illness and Juvenile Offenders. International Journal of Environmental Research and Public Health, 2016 Feb 18; 13(2):228[6] National Center for Mental Health and Juvenile Justice. 2015. Caring for youth with mental health needs in the juvenile justice system: Improving knowledge and skills. Laurel, MD: U.S. Department of Justice. https://www.ncmhjj.com/wp-content/uploads/2015/05/OJJDP-508-050415-FINAL.pdf).[7] Thomas D., Siegel G., Wachter A., Deal T., Rackow A., Vessels L., Halemba G., Hurst H. When Systems Collaborate: How Three Jurisdictions Improved their Handling of Dual-Status Cases. Pittsburgh, PA. National Center for Juvenile Justice; 2016. Available at: http://www.ncjj.org/pdf/Juvenile%20Justice%20Geography,%20Policy,%20Practice%20and%20Statistics%202015/WhenSystemsCollaborateJJGPSCaseStudyFinal042015.pdf [8] Teplin, L.A., K.M. Abram, J.J. Washburn, et al. 2013. The northwestern juvenile project: Overview. In OJJDP Juvenile Justice Bulletin. Washington, DC: Department of Justice. http://www.ojjdp.gov/pubs/234522.pdf).[9] Zemel, S. and N. Kaye. 2009. Findings from a survey of juvenile justice and Medicaid policies affecting children in the juvenile justice system: Inter-agency collaboration. Washington, DC: National Academy for State Health Policy. https://nashp.org/findings-survey-juvenile-justice-and-medicaid-policies-affecting-children-juvenile/[10] National Center for Juvenile Justice. 2017. Easy access to the census of juveniles in residential placement. Pittsburgh, PA: NCJJ. https://www.ojjdp.gov/ojstatbb/ezacjrp/[11] Acoca, L., J. Stephens, and A. Van Vleet. 2014. Health coverage and care for youth in the juvenile justice system: The role of Medicaid and CHIP. Washington, DC: Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/health-coverageand-care-for-youth-in-the-juvenile-justice-system-the-role-of-medicaid-and-chip/[12] Sedlak, A.J., and K. McPherson. 2010. Survey of youth in residential placement: youth’s needs and services. Unpublished report. Rockville, MD: Westat. https://www.ncjrs.gov/pdffiles1/ojjdp/grants/227660.pdf[13] Sedlak, A.J., and K. McPherson. 2010. Survey of youth in residential placement: youth’s needs and services. Unpublished report. Rockville, MD: Westat. https://www.ncjrs.gov/pdffiles1/ojjdp/grants/227660.pdf [14] American Academy of Pediatrics. Health Care for Youth in the Juvenile Justice System. Pediatrics, 2011; 128(6):1219–1235. Available at: https://publications.aap.org/pediatrics/article/128/6/1219/31060/Health-Care-forYouth-in-the-Juvenile-Justice.