Provision of Medicaid and CHIP Services to Incarcerated Youth - FAQs
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Guidance interpreting section 5121 of the CAA, 2023 on state obligations to provide screening, diagnostic, and targeted case management services to Medicaid- and CHIP-eligible juveniles within 30 days before release from public institutions (including federal custody) and related implementation items for states and carceral facilities.
No material clinical or coverage changes in this revision.
State obligations and timing for required services
State coverage and implementation criteria
State obligations and permissible implementation approaches for providing required screening, diagnostic, and targeted case management services to eligible juveniles in relation to the pre-release and post-release periods.
Codes, timing recommendations, and authorization-sensitive items
| Note that certain benefits require prescriptions/orders from enrolled providers (e.g., PT/OT) per 42 C.F.R. 440.110; lack of enrolled provider may affect FFP. |
Enrollment, authorization, and facility-level alternatives
Enroll ordering/referring providers to preserve FFP
Providers who order, refer, prescribe, or certify eligibility for Medicaid and CHIP services must be enrolled in the program for claims to be payable; if an unenrolled carceral provider furnishes pre-release services and then orders/refers/prescribes post-release care, Medicaid FFP may be unavailable for those post-release services. Certain benefits (e.g., physical and occupational therapy) require prescriptions/orders from enrolled providers per existing benefit rules (see 42 C.F.R. 440.110).
- Enrollment is required for providers who order, refer, prescribe, or certify eligibility in order for related claims to be payable.
- If an unenrolled carceral provider orders/refers/prescribes post-release services, Medicaid federal financial participation (FFP) may be unavailable for those services.
- Benefit-specific authorization rules (for example, PT/OT) require prescriptions/orders from enrolled providers (42 C.F.R. 440.110).
Allow facility-provided services without facility enrollment (state alternative)
States may meet the statutory obligation by ensuring carceral facilities furnish required screening, diagnostic, and targeted case management services even if those facilities do not enroll in and bill Medicaid/CHIP; however, states should assess and document impacts on post-release access and FFP when facilities remain unenrolled.
- A carceral facility’s furnishing of required services can satisfy sections 1902(a)(84)(D) and 2102(d)(2) even if the facility does not enroll or submit claims to Medicaid/CHIP.
- States should consider and document potential downstream effects on post-release claims eligibility and FFP when unenrolled facilities provide orders/referrals/prescriptions that community providers rely on.
Key term clarifications used in the policy
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