Revisiting Pending Medicaid 1115 Re-Entry Demonstration Waivers and Where They Stand
Last spring, Health Policy News highlighted the major components of California’s Section 1115 Re-Entry Demonstration Waiver, the first waiver of its kind to be approved by the Centers for Medicare and Medicaid Services (CMS). Following the approval of California’s waiver, CMS published a State Medicaid Director Letter (SMDL) to provide guidance to states wishing to similarly offer Medicaid reimbursable re-entry services under a Demonstration Waiver (Health Policy News’ also shared an in-depth overview). Since then, CMS has approved Washington’s Reentry Demonstration Initiative as part of the Washington Medicaid Transformation Project Waiver, which in large part mirrors California’s waiver.
Despite these important milestones, 15 states continue to wait for approval from the agency on their pending waiver applications. Several of these states (AZ, MT, NJ, NM, NY, OR, VT) have received partial approval of their Demonstration Waivers from CMS, but the re-entry service bundle within those waivers has not been approved for implementation. A couple of states (KY, MA) have submitted amendments to their initial applications, acknowledging the SMDL and bringing their proposed services into better alignment with CMS guidance. CMS has indicated in the feedback it has provided to states that it is “supportive of increasing pre-release services for justice-involved populations” and remains committed to working with states to provide re-entry services that are consistent with the agency’s goals.
This article provides a deeper dive into the pending waiver applications and amendments to provide re-entry services to individuals who are incarcerated, how they compare to the SMDL, as well as lessons learned from California’s and Washington’s approvals and recommendations for states moving forward.
How Pending Waivers Compare to State Medicaid Director Letter
Broadly, CMS’ SMDL provides states with high-level expectations and required components for Re-Entry Demonstration Waiver applications. Specifically, the SMDL offers guidance to states with respect to defining eligible populations, pre-release timeframes, minimum covered services, goals for the demonstration projects, infrastructure investment, and stakeholder engagement. Because most states submitted their waiver applications before CMS published its guidance, there is quite a range of state approaches to these topics.
Eligible Population and Implementation Approach:
CMS left this very open-ended for states, encouraging states to very broadly define the demonstration population to include soon-to-be formerly incarcerated individuals (see more about what qualifies as “soon-to be” below). California also requires participants to meet at least one additional health-related criteria (e.g., mental illness, SUD, chronic condition), whereas Washington leaves its waiver open to all Medicaid-eligible adults and youth incarcerated in state prisons, jails, or youth correctional facilities. States with pending applications have taken a variety of approaches when defining their eligible populations.
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- Several states (IL, KY, MA, MT, NC, OR, RI, VT) have defined their eligible populations broadly to include incarcerated individuals who are transitioning out of the system and are otherwise Medicaid-eligible.
- Several states (NH, NJ, UT, WV) have specifically included additional behavioral health (mental health disorder, substance use disorder, or both) diagnosis requirements for their eligible populations.
- A couple states (NM, NY) have included additional “high-risk” health criteria for their eligible populations.
- One state (AZ) has specifically included additional behavioral and physical health requirements and social determinants of health for their eligible population.
Kentucky limits re-entry service eligibility to individuals in state Department of Corrections (DOC) facilities and Youth Development Centers, New York limits re-entry service eligibility to individuals in jails and prisons, and New Hampshire, Oregon, and West Virginia limit re-entry service eligibility to individuals in state prisons. Every other pending application proposes to offer re-entry services to all Medicaid-eligible incarcerated individuals, or more specifically to adults and youth incarcerated in state prisons, jails, or youth correctional facilities, which is consistent with how California and Washington have structured their eligibility criteria.
CMS also indicated in the SMDL that states should consider whether to implement their waivers using a phased-in or pilot approach or offer these services statewide immediately. Both California and Washington will implement a phased-in approach and will assess each facility for readiness to provide re-entry services prior to their participation in the reentry initiatives. Massachusetts’ and North Carolina’s applications indicate a similar approach. Illinois’ application illustrates a plan to pilot its reentry initiative within a single county jail in order to establish best practices and evidence-based policies and programming prior to expanding to other counties and carceral settings across the state.
Pre-release Timeframe:
CMS clarified that states may provide services “aiming to improve care transitions” for incarcerated individuals up to 30 days pre-release, but states seeking to provide services that go above and beyond simply improving care transitions can do so up to 90 days pre-release. Both California and Washington will provide reentry services up to 90 days pre-release.
States considering providing services more than 30 days pre-release should keep in mind that CMS is requiring California and Washington to specifically evaluate whether providing services earlier pre-release leads to better diagnosis and treatment of chronic conditions, fewer emergency department visits and less acute care use post-release, and more robust engagement and retention in medication-assisted treatment (MAT) and other appropriate treatment for substance use and mental health disorders.
Covered Services:
CMS will require states to provide, at a minimum, case management services, clinically appropriate MAT services, and a 30-day supply of all prescribed medications. In addition to these minimum services, California and Washington are providing physical and behavioral health clinical consultation services, laboratory and radiology services, and services provided by community health works with lived experience. States looking to submit Re-Entry Waiver Demonstration applications should at least seek to provide the minimum services required by CMS as specified in its SMDL.
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- A couple of states (KY, NM, NC) are seeking to provide only the minimum pre-release services described by CMS, some with plans to add additional services over the course of the demonstration period, as well as services post-release.
- Many states are seeking to provide a more diverse bundle of services, including:
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- Housing screening (NJ) and housing support services upon release (AZ, OR)
- Clinical consultation services (in-person or via telehealth) (IL, MA, MT, NY, WV)
- Peer support services (MA, NH, NY) and CHW/community navigator services (IL, MA)
- Laboratory and radiology services (IL, MA)
- Medicaid program enrollment education and information (NJ)
- Sexual and reproductive health information and connectivity (NY)
- Infectious disease (HIV/HCV) screening and treatment (MT, WV)
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- A handful of states are seeking to provide comprehensive Medicaid benefits pre-release: Rhode Island is trying to provide access to state Medicaid covered services, Vermont wants to provide access to its complete Medicaid State Plan benefits, and Utah hopes to provide Medicaid State Plan benefits appropriate to the eligible individual (e.g., pregnant individual versus medically frail individual).
Demonstration Goals:
CMS indicated in its SMDL that it expects to see the following goals addressed in states’ reentry demonstration applications:
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- Increase coverage, continuity of coverage, and appropriate service uptake through assessment of eligibility and availability of coverage for benefits in carceral settings just prior to release;
- Improve access to services prior to release and improve transitions and continuity of care into the community upon release and during reentry;
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- Improve coordination and communication between correctional systems, Medicaid systems, managed care plans, and community-based providers;
- Increase additional investments in health care and related services, aimed at improving the quality of care for beneficiaries in carceral settings and in the community to maximize successful reentry post-release;
- Improve connections between carceral settings and community services upon release to address physical health, behavioral health, and health-related social needs (HRSN);
- Reduce all-cause deaths in the near-term post-release; and
- Reduce number of ED visits and inpatient hospitalizations among recently incarcerated Medicaid beneficiaries through increased receipt of preventive and routine physical and behavioral health care.
Both California and Washington included goals nearly identical to these in their approved waiver applications. A few pending waiver applications include similar, albeit less comprehensive goals, including Kentucky, Montana, Oregon, Utah, and West Virginia. States considering submitting a reentry demonstration waiver application should use CMS’s enumerated goals to guide the development of their own programmatic objectives. Both California and Washington included goals nearly identical to these in their approved waiver applications. A few pending waiver applications include similar, albeit less comprehensive goals, including Kentucky, Montana, Oregon, Utah, and West Virginia. States considering submitting a reentry demonstration waiver application should use CMS’s enumerated goals to guide the development of their own programmatic objectives.
Infrastructure:
In its SMDL, CMS suggests that state Medicaid agencies may use enhanced administrative matching funds to support the implementation of Re-Entry Demonstration Waivers for a variety of purposes, including:
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- To improve data sharing and integration
- To create new systems to serve both state Medicaid agencies and departments of correction
- To support communication between Medicaid providers and DOC staff.
California’s and Washington’s approved waivers include language around developing
infrastructure to support data exchange, IT systems, and communication and care coordination.
Both waivers also discuss using funds to hire and train additional staff to support service
provision, as well as for purchase or upgrade of electronic health record (EHR) technology.
A few pending waivers include language around developing infrastructure to support data sharing, care coordination, capacity building, and stakeholder engagement (IL, KY, MA, NC, and WV). Many waiver applications also propose providing clinical consultation services via telehealth, which would likely require additional infrastructure investments. States looking to submit Re-Entry Demonstration Waiver applications should consider where further support and capacity is needed and for what purposes they should request expenditure authority.
Stakeholder Engagement:
In its SMDL, CMS “strongly encourages” states wishing to submit a Re-Entry Demonstration Waiver application to work with stakeholders with lived experience with the criminal legal system as they develop and implement their waivers. The agency also noted in its approval letter to CA that the state had invested substantial time and resources in stakeholder engagement, including stakeholders with lived experience.
In its amended application, Kentucky indicates that it spent significant time “conducting key informant interviews and focus groups to identify the current state of reentry policies and processes, discover challenges and barriers, recognize the needs and wants of the stakeholders, and gain a clear understanding of existing infrastructure and opportunities.” Massachusetts convened an interagency Coordinating Council to support and inform the development of its waiver application and noted that it will “continue to identify opportunities to engage with stakeholders, including people with lived and living experience.” States considering submitting Re-Entry Demonstration Waiver applications or updating pending applications can strengthen their applications by engaging with people with relevant lived experience and incorporating their perspectives and insight.
Health Policy News continues to monitor developments with state Medicaid Re-Entry 1115 Waivers and will share more information as there are further developments.