Revised July 25, 2017
Prior to July, 2017, Washington Apple Health (Medicaid) was closed when a person receiving coverage became incarcerated. Following the passage of SSB 6430 Medicaid Suspension, the Health Care Authority (HCA) was directed to suspend, not terminate Medicaid coverage for individuals in a correctional setting. The bill also directed HCA to accept applications from justice involved (JI) individuals in these settings during their incarceration period. While a JI individual’s Medicaid is suspended, the scope of coverage is limited to inpatient hospitalizations lasting longer than 24 hours.
To be eligible for Apple Health, the JI individual must meet program requirements, including income. For individuals in Department of Corrections (DOC) facilities (state prisons), the facility will complete a Medicaid application. For individuals in a city/county jail, the facility may allow individuals to apply depending upon its available resources (staffing, etc.).
HCA receives a daily interface from DOC and the statewide Jail Booking and Reporting System (JBRS) to facilitate the suspension of Medicaid coverage for the incarcerated. Suspended coverage means the individual is eligible for Medicaid, but all claims payment and managed care assignment is suspended while the individual is in custody. For claims payment, suspension means only inpatient claims can be paid. Once an individual is released, full scope Medicaid coverage is reinstated. Justice involved individuals with Medicaid coverage will simultaneously show both a Medicaid and a jail suspension coverage group in ProviderOne. This means the individual is incarcerated and only has coverage for inpatient hospitalization.
DSHS continues to process applications for 1290 related individuals as well as other ‘Classic’ SSI-related cases (aged, or disabled and entitled to Medicare). An individual who is not age 65 or older, or not eligible for SSI or Medicare, should apply for Apple Health through Healthplanfinder (HPF). There are organizations with staff helping people apply throughout the state, but the level of services to support this varies depending upon local area resources.
Applications for the Justice-Involved Individual
Applications for Medicaid generally fall into two groups: individuals currently incarcerated and applications for an inpatient hospitalization. Depending on whether the applicant is related MAGI or non-MAGI, the applications go to either DSHS or Healthplanfinder (HPF). Clients who are 65 years of age or older, or receive SSI or Medicare need to apply through DSHS. Others need to apply for MAGI-based coverage in HPF.
In some instances applications are processed prior to the date of release. In the past this was possible due to a signed Memorandum of Understating (MOU) between the Medicaid agency and the facility. The MOU defines roles and responsibilities of the facility and HCA. The MOU also defines the timeline for when applications can be submitted prior to release. Now that the agency has the capability to suspend Medicaid coverage for those incarcerated in a city, county, or state correctional facility the need for MOUs is diminished. Facilities can now submit an application for Apple Health while the individual is incarcerated. For those who are eligible, coverage is suspended based on incarceration data received nightly. When the individual is released from custody, suspension is lifted automatically and full scope coverage is reinstated.
Medicaid Eligibility while Incarcerated - Suspension
The federal rule for Apple Health does not prohibit having an individual open/active on Apple Health while residing in a correctional facility, but it does prohibit HCA from receiving federal match while the individual is incarcerated. Under current policy, an incarcerated individual can retain their Apple Health eligibility indefinitely, however, their scope of coverage will change. When an individual is incarcerated HCA suspends full scope coverage and limits it to inpatient hospitalization only. While incarcerated the agency also suspends any payments to managed care organizations, behavioral health organizations, and any other Medicaid-related service authorizations.
Apple Health coverage for inmates of a public institution (i.e. jail or prison) that are admitted for an inpatient hospitalization or to a chemical dependency treatment facility
Inmates of public institutions, such as a prison or jail, may be Apple Health eligible if they are categorically relatable and income/resource eligible for an Apple Health program. There is no need to have an inpatient event to be program relatable. Individuals can be determined Medicaid eligible at any time and the system will suspend coverage overnight if incarcerated.
Applications for individuals in a correctional facility or public institution
Prior to release from a public institution, individuals may apply for public assistance and/or Medicaid. The CSO needs to accept these applications.
- Expedited medical assistance for people with mental disorders before release from public institutions.
The enactment of House Bill 1290 in 2005 requires the department to perform expedited eligibility determinations and provide timely access to medical assistance for individuals with mental disorders being released from confinement. The goal is to provide eligible people with a medical assistance identification card on the date they are released, whenever possible. MAGI-related individuals will most likely apply for Apple Health with the assistance of an IPA or corrections staff. Individuals entitled to Medicare must apply through Washington Connections or use the paper application HCA 18-005.
- Chemical dependency treatment
Individuals may apply for a determination of financial eligibility to allow the institution to arrange for chemical dependency assessment and treatment placement. Accept applications from individuals whose situation is described above and determine eligibility or notify the individual of necessary verification and follow-up.
- Program options for inmates
The Department of Corrections (DOC) and county and city jails have a variety of programs that may be used in placing offenders outside public institutions. The Program options for the justice involved matrix is intended to clarify how placement in a correctional program affects a person's eligibility for public assistance or Apple Health benefits.
SSI/SSDI suspended by SSA for JI Individuals
Title XVI clients (SSI)
The Social Security Administration stops an SSI cash benefit, if an individual is incarcerated for more than 30 days, and reduces it to $30 if an individual goes into a medical facility for more than 30 days. SSA suspends eligibility for the cash benefit, if the stay continues for up to 12 months. It terminates eligibility for the benefit after 12 months. If an individual discharges while still in suspense, Medicaid can be reinstated. SSA will need to do a ‘technical review’ of their living arrangement, income, and resources; a new disability determination is not needed. The individual must go to SSA in person, however, to get the cash benefit reinstated.
SSI terminated prior to discharge. If SSI is terminated while the individual is at the state hospital, then SSA will require a new SSI application and a new disability determination, with the exception of concurrently entitled clients detailed below (i.e., Title XVI and Title II). SSA will accept a new application up to 90 days in advance of an individual’s release date.
Title II clients (SSDI)
Individuals who are admitted to the state hospital or prison after conviction of a crime will have their Title II benefits suspended.
SSDI suspended due to IMD stay
An individual continues to have disability status even if the diary date has passed while they were in the hospital or jail. For Medicaid purposes, SSI related Medicaid can be approved without a new disability decision. There is no ‘technical review’ for a Title II claim as it is not considered a needs-based payment. For someone who was receiving Title II, but has not yet turned 65 or become eligible for Medicare, an application through Healthplanfinder (HPF) should be made first, to see if the person will income eligible for MAGI coverage.
For both SSI and SSDI clients, the individual must be discharged/released from the incarceration setting or hospital before a suspended benefit can be put back into payment status.
Medicare – When Title II closes, Medicare entitlement often continues. However the Part B benefit usually closes for nonpayment of premiums.