Medicaid and CHIP coverage for incarcerated youth
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Federal guidance describing requirements and options under the Consolidated Appropriations Act, 2023 for Medicaid and CHIP coverage, screenings, and case management for youth who are incarcerated or pending disposition; affects state Medicaid and CHIP programs and incarcerated juveniles.
Section 5121 of the CAA, 2023 adds section 2102(d) to the Act effective January 1, 2025, modifying how incarceration impacts a child's CHIP eligibility and prohibiting termination solely for incarceration at CE end.
States must complete a redetermination prior to release for eligible juveniles who were eligible immediately before incarceration and restore coverage upon release if eligible.
Section 5122 of the CAA, 2023 provides a state option to lift inmate payment and CHIP eligibility exclusions to cover full Medicaid/CHIP benefits during pre-release period pending disposition of charges.
Coverage requirements and service criteria for incarcerated juveniles
Coverage requirements and options for incarcerated juveniles
Mandated and optional coverage provisions under sections 5121 and 5122 of the CAA, 2023 effective January 1, 2025.
ALL of the following
- Screenings and diagnostic services that meet reasonable standards of medical and dental practice or are otherwise medically necessary, including behavioral health screening/diagnostic services; timing: within 30 days prior to release or, if not possible, not later than one week or as soon as practicable after release.
- Targeted case management (TCM) services, including referrals to appropriate local care and services, provided in the 30 days prior to release and for at least 30 days following release.
Mandatory coverage and service criteria for eligible juveniles
Coverage and service provision requirements for eligible juveniles post-adjudication:
ALL of the following
- Individual must meet the 'eligible juvenile' definition (under 21 who was eligible for Medicaid immediately before or while an inmate, including certain former foster care youth up to age 26); includes incarcerated youth under age 19 for CHIP per section 2102(d)(2).
ALL of the following
- Provide screenings and diagnostic services (medical, dental, behavioral health) meeting state reasonable standards or EPSDT where applicable; timing within 30 days prior to release or, if not possible, not later than one week or as soon as practicable after release.
ALL of the following
- Provide TCM, including comprehensive assessment, person-centered care planning, referrals and scheduling, monitoring and follow-up; timing: in the 30 days prior to release and for at least 30 days post-release.
ALL of the following
- States must accept and promptly process Medicaid applications submitted while incarcerated and may place juveniles in suspended eligibility or benefits status rather than terminating coverage; someone 'acting responsibly' may sign for a minor when required.
Coverage and operational criteria for pre-release services
Mandatory coverage elements and timing for eligible juveniles within scope of section 5121/1902(a)(84)(D) and 2102(d)(2):
ALL of the following
- Provide screening services that meet EPSDT intervals and include appropriate immunizations per ACIP for under-21s; timing within 30 days prior to release or, if pre-release provision is not possible, not later than one week or as soon as practicable after release.
ALL of the following
- Provide diagnostic services when screening indicates need and when medically necessary; timing aligned with the screening timeframes above (30 days prior to release or the alternative timeframes).
ALL of the following
- Provide TCM including assessment, person-centered care plan, referrals (including scheduling), monitoring and follow-up; timing: in the 30 days prior to release and for at least 30 days post-release; include warm handoff if another case manager takes over.
ANY of the following
- CHIP must provide screening, diagnostic, and case management services for children within 30 days of release in the same manner as described in section 1902(a)(84)(D); CMS interprets the alternative timeframes (not later than one week or as soon as practicable) to apply when pre-release provision is not possible; children are entitled to full CHIP benefits upon release.
ALL of the following
- States must have internal operational plans by Jan 1, 2025 to address data exchange, eligibility/enrollment/claims processes, policies to avoid delaying release, provider enrollment and training, and other operations required to implement pre-release services.
ALL of the following
- Services may be delivered in-person or via telehealth; community provider in-reach is preferred where feasible; carceral health providers may be used but must be enrolled as Medicaid/CHIP providers if the state recognizes their provider type.
ANY of the following
- If states use managed care for pre-release services, they must ensure managed care authority, adjust plans/waivers/contracts as needed, and develop distinct capitation rates and base data for the incarcerated juvenile population separate from traditional populations.
ALL of the following
- States must provide language access and disability-related auxiliary aids and reasonable accommodations, plain-language materials, interpretation and translation in accordance with federal civil rights and Medicaid/CHIP requirements.
ALL of the following
- Children who become incarcerated during a CE period remain eligible through CE; states may suspend or continue CHIP services not provided by the carceral facility during CE but must terminate eligibility if CE ends while still incarcerated unless another eligibility reason exists.
CHIP and Medicaid coverage rules for incarcerated juveniles
Coverage stance and specific provisions for juveniles who are incarcerated or pending disposition of charges.
ALL of the following
- States shall not terminate CHIP eligibility for a targeted low-income child solely because the child is an inmate of a public institution at the end of a CE period; states may instead suspend coverage during incarceration.
ANY of the following
- States may elect a benefits suspension (child remains eligible but coverage limited to CHIP services not provided by the carceral facility) or an eligibility suspension (pause renewals) while the child is incarcerated; if suspended, states must follow renewal/redetermination rules and complete redetermination prior to release when required.
ALL of the following
- Children who apply for CHIP within 30 days prior to release may be found eligible for screening, diagnostic, and case management services; states must process applications and make eligibility determinations upon release.
ANY of the following
- If a state elects section 5122, it must provide all mandatory and optional Medicaid/CHIP services under the applicable state plan, waivers, or section 1115 demonstrations to eligible juveniles pending disposition of charges, effectively lifting the Medicaid inmate payment exclusion and CHIP eligibility exclusion for that pre-disposition period; states cannot provide a limited subset of services under this option.
ALL of the following
- States must complete a redetermination prior to release for eligible juveniles who were eligible immediately before incarceration and restore coverage upon release if eligible; if the juvenile is within an ongoing CE period and released before CE end, redetermination is not required unless a permissible exception occurred.
ALL of the following
- States electing options or implementing required changes must submit Medicaid and/or CHIP State Plan Amendments (SPAs) as applicable by specified deadlines and follow CMS guidance and templates to effectuate coverage and eligibility changes for incarcerated youth.
Definitions, codes, and service scope
| No codes listed |
| EPSDT | Early and Periodic Screening, Diagnostic, and Treatment services — required medically necessary screening and diagnostic services for eligible juveniles under 21 |
| No codes listed |
| No codes listed |
State and provider operational requirements and actions
Pre-release and post-release screenings, diagnostics, and TCM (30-day window)
Provide medically appropriate screenings and diagnostic services (including behavioral health) during the 30 days prior to release (or not later than one week/as soon as practicable after release) and furnish targeted case management beginning in the 30 days prior to release and continuing for at least 30 days following release, in coordination with the public institution and consistent with EPSDT when applicable.
- Screenings and diagnostic services must meet state reasonable standards of medical and dental practice and be provided in accordance with EPSDT where applicable.
- Targeted case management must include referrals to appropriate regional care and services and continue for a minimum of 30 days post-release.
Optional Medicaid/CHIP coverage while pending disposition (state option)
States may elect, beginning January 1, 2025, to provide Medicaid (with FFP) or consider children eligible for CHIP for juveniles who are inmates pending disposition of charges, covering services provided during the pre-disposition period.
- If a child is already enrolled in CHIP during a continuous eligibility period, that coverage may not be discontinued during the CE period.
Accept/process applications and use suspension rather than termination
Accept and promptly process Medicaid applications from or on behalf of inmates at any time during incarceration in accordance with 42 C.F.R. § 435.912; place individuals determined eligible while incarcerated into suspended eligibility or benefits status rather than terminating their coverage.
- States should conduct prerelease outreach and aim to submit applications no later than 90 days before expected release to allow processing time.
- Someone 'acting responsibly' may sign and submit an application on behalf of a minor who is incarcerated per 42 C.F.R. § 435.907(a).
Provider enrollment and billing for carceral providers
Ensure carceral health care providers furnishing pre-release screenings, diagnostics, or case management enroll as Medicaid/CHIP providers if their provider type is recognized by the state; enrolled practitioners may bill directly or reassign payment consistent with 42 C.F.R. § 447.10(g).
- Individual practitioners (e.g., physicians) who will furnish, order, refer, or render services must enroll when their provider type is eligible to enroll in the state program.
- Providers may reassign payment to the carceral facility or contracted agency consistent with federal reassignment rules.
Managed care authority, contracting, and distinct rate development
If states use managed care to deliver pre-release services, they must ensure they have the necessary managed care authority and develop distinct capitation rates and base data for the incarcerated juvenile population separate from traditional populations.
- May require revisions to state plans, waivers, managed care contracts, and consultation with actuaries.
- Final capitation rates must be based only on state plan services per 42 C.F.R. § 438.3(c)(1)(ii) and 457.1201(c); develop separate rates for this population.
Medicaid and CHIP SPA submissions and internal operational plan attestations
Submit required SPAs: a Medicaid SPA attesting the state has an internal operational plan (due to CMS by March 31, 2025, for an effective date no later than Jan 1, 2025) and any additional payment or benefit SPAs if existing plan coverage or payment methodologies do not already authorize screening, diagnostic, or TCM services; CHIP SPAs must be submitted by the end of the state fiscal year containing Jan 1, 2025, to be effective Jan 1, 2025.
- A payment SPA is required if the state does not have an approved payment methodology for these services (submission by March 31, 2025, effective no later than Jan 1, 2025).
- States may need a SPA to add a TCM target group if not already in the state plan.
Key definitions and distinctions
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