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October 17, 2023
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More than half of individuals in state prison and almost two-thirds of people with jail sentences have substance use disorders (SUD), and overdose deaths are the leading cause of death among people recently released from incarceration. Despite the prevalence of SUD and overdose deaths, medications for opioid use disorder (MOUD) – methadone, buprenorphine, and naltrexone — the gold standard of care for opioid use disorder (OUD) — remain extremely limited in carceral settings. Data from 2019 show less than 1% of individuals in jails received MOUD.
While the vast majority of incarcerated individuals in Medicaid expansion states are Medicaid-eligible upon release, federal law has long prohibited Medicaid payment for health care services for people who are incarcerated, which has left the cost of care to states and local entities. Last year marked the authorization of notable expansions in Medicaid coverage for health services delivered in state prisons and county jails for certain populations. Federal legislation authorized coverage of limited Medicaid services for youth detained pretrial and reentering the community from incarceration, and the Centers for Medicare and Medicaid Services (CMS) approved requests from California and Washington to pilot coverage of some pre-release correctional health services.
Increasingly, there is interest in providing Medicaid coverage in prison and jails throughout an individual’s period of incarceration. As state and federal policymakers debate whether and how to change Medicaid’s role in these settings, our new report supported by Bloomberg Philanthropies has recommended a set of services and standards for OUD care in state prisons and county jails that could advance access to high-quality care and improve health outcomes.
We developed our recommendations by reviewing a range of existing national programmatic standards for OUD services in community and correctional systems and Medicaid policy for community OUD services. We also considered the very specific challenges that affect the provision of health care services in prisons and jails, such as security concerns, high patient population turnover, and substantial organizational variation. We recommend that states consider defining a minimum set of OUD services that prisons and jails should provide in order to participate in Medicaid, and also permit Medicaid reimbursement for additional optional services if that particular state or facility has the capacity to provide them (Table 1).
Proposed required services include screening for opioid withdrawal and OUD as part of correctional facilities’ typical intake health screening process, and an assessment by a qualified practitioner to determine whether an individual meets clinical criteria for newly initiating or continuing MOUD from a community provider. In addition, opioid withdrawal management with buprenorphine or methadone must be available. Proposed reentry services consist of case management and peer supports, arranging for recovery supports in the community, and a 30-day supply of prescription MOUD in-hand at release.
Optional but recommended services are multidimensional assessments, which determine a person’s needs across various physical and mental health domains; as well as counseling and IOP (regular, structured programming of counseling and addiction or mental health education) which have been demonstrated to improve outcomes for some individuals with OUD.
The standards that govern service provision are a crucial component of the actual services because they will help ensure that people who meet clinical criteria receive timely services in a manner that is consistent with evidence-based practices. We recommend standards that Medicaid agencies can apply to advance quality OUD services. The standards address (1) who should receive the service; (2) what should be included in the service, (3) when the service should be rendered; and (4) who should provide the service. For example, the standards specify that all individuals entering a jail or prison receive screening services performed by qualified health care personnel and health care-trained correctional personnel.
Medicaid coverage has the potential to positively transform correctional OUD care and improve patient and community outcomes through reduced emergent hospitalizations and reduced overdose deaths. With these best practices for proposed services, which are based on evidence and the standard of care in communities, Medicaid could provide not only a more consistent funding stream for services provided to eligible patients, but also an assurance of high-quality care regardless of treatment setting.
CMS and states must also develop clear goals, measurable objectives, and metrics to monitor how well states, their managed care partners, community providers, and prisons and jails are meeting program objectives and improving outcomes. Two forthcoming reports will specifically address performance measures and payment model issues.
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