Reminder on Medicaid Beneficiaries and Incarceration
Individuals enrolled in NC Medicaid do not lose eligibility when they become incarcerated (exception: beneficiaries incarcerated in a federal prison will have Medicaid terminated if they are age 21 and over, unless they are between the ages of 18 and 26 on Medicaid for Former Foster Care).
During a period of incarceration, Medicaid benefits are suspended, meaning the beneficiary is only eligible for coverage of inpatient hospital stays over 24 hours (if eligible for full Medicaid benefits). Note that this changed as of Jan. 1, 2025, for the youth population in the 30-day pre-release period (see details on CAA 5121 below).
Once released from incarceration, the full scope of benefits available to the beneficiary based on their category of eligibility will be reinstated as of the date of release. Eligibility will not be reevaluated unless the individual reports a change in circumstance to their local Division of Social Services (DSS).
The beneficiary’s release status may not be immediately reflected in NCTracks (e.g., the release has yet to be reported to the DSS or a caseworker needs to take action to update the case) however, once the release date is added to the Medicaid case the full scope of benefits are unsuspended (reinstated) retroactively to the date of release.
The beneficiary’s Managed Care (MC) Status will also change from “Excluded – Incarcerated” to an “FI” (Formerly Incarcerated) Managed Care status as of the date of release. All “FI” Managed Care Statuses are enrolled in NC Medicaid Direct (or the Eastern Band of Cherokee Indians (EBCI) Tribal Option, if applicable).
CAA Section 5121: Per the Centers for Medicare and Medicaid Services (CMS) State Health Official Letter SHO# 24-004:
Starting Jan. 1, 2025, state Medicaid and CHIP programs are required to have a plan in place and to provide for the following for an eligible youth who is within 30 days of their scheduled date of release from a public institution following adjudication:
In the 30 days prior to release (or not later than one week, or as soon as practicable after release from the public institution), and in coordination with the public institution, the state must provide any screenings and diagnostic services which meet reasonable standards of medical and dental practice, as determined by the state, or as otherwise indicated as medically necessary, and for youth under the age of 21, in accordance with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements, including a behavioral health screening or diagnostic service.
In the 30 days prior to release and for at least 30 days following release, the state must provide targeted case management services, including referrals to appropriate care and services available in the geographic region of the home or residence of the eligible youth, where feasible, under the Medicaid state plan (or waiver of such plan).
Note: Targeted Case Management is not to be confused with NC Medicaid’s Tailored Care Management model. Post-release, eligible individuals will receive reentry care management via Tailored Care Management. Other individuals not eligible for Tailored Care Management will obtain reentry care management at a similar level of intensity to Tailored Care Management.
An eligible youth is defined as a Medicaid enrolled beneficiary who is:
- Under 21 years of age or age 18 up to age 26 under the mandatory former foster care eligibility group; and,
- Being held in a correctional facility post-adjudication (e.g., youth who are incarcerated after conviction).
These requirements only apply to individuals who are being held post adjudication as inmates of a public institution.
CAA 5121 allows for the reimbursement of screening and diagnostic services for eligible youth, as noted above. That means, all preventive health check screenings for eligible youth under the age of 21 should be conducted per the North Carolina Periodicity Schedule and should include all required screenings for that age group, as defined by the Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule.
Providing these screening and diagnostic services to eligible youth pre-release will help identify necessary treatment services so that medical and behavioral health appointments can be scheduled prior to release and occur as soon as possible after an eligible youth is released.
While CAA 5121 allows for the reimbursement of screening and diagnostic services, it does not allow for the reimbursement of treatment services while the eligible youth is still incarcerated. In the event an eligible youth needs treatment services that do not require a referral for additional treatment to be received after their release, (i.e. sick visit, evaluation and management services), they should be referred to the carceral facility to meet their care needs. After the eligible youth is released from the carceral facility, they are eligible to receive any treatment services found to be medically necessary.
Reentry care management will be phased-in at a later date in 2025.
All CAA 5121-required services will be billed to NCTracks.
For more information on NC Medicaid’s phased implementation plan for CAA 5121 requirements, please reference the Medicaid Services for Justice-Involved Youth Per Section 5121 of the 2023 Consolidated Appropriations Act Fact Sheet.