By Rachel Crumpler | North Carolina Health News

Danay Burke, 43, was released from prison on Nov. 1. Among the many tasks on her to-do list for reestablishing her life was to figure out how to manage her health care needs. But she left prison without health insurance, making that a difficult and costly prospect.

“It’s slowing down the process of me helping myself,” Burke said.

She said she needs a drug assessment, medications for her anxiety and depression, birth control, a mammogram and a sleep study. However, Burke said she’s delayed all this care because she lacked medical coverage.

Burke, like many others released from incarceration, fell into a health insurance coverage gap. Historically, most people reentering society after incarceration were either uninsured or uninsurable.

But that’s poised to change in North Carolina with Medicaid expansion that took effect on Dec. 1.

The expanded eligibility rules allow people ages 19 to 64 whose incomes are up to 138 percent of the federal poverty level for their household size to gain coverage, allowing about 600,000 more low-income residents to join the state’s Medicaid rolls. Now, a single adult living in a one-person household is eligible if their annual income is $20,120 or less before taxes.

This criteria allows substantially more justice-involved individuals — people who often work in low-paying jobs or struggle to find work because of their criminal history — to enroll in Medicaid. The program can cover a variety of services, including doctor visits, behavioral health treatments and prescription drugs.

It’s a welcome change for Burke and others, who now have a path to getting health insurance that can pay for needed medical care — particularly as they shift out of a prison that was mandated to provide health care, to finding care in the community on their own.

Burke heard she newly qualified for Medicaid coverage from a staff member at Benevolence Farm — a reentry program in Alamance County offering housing and employment to women recently released from North Carolina prisons where she is staying — who helped her apply in December. Burke said she was approved for coverage, and she is eager to take advantage of the benefits to start taking care of her backlog of medical needs when she receives her Medicaid card in the mail.

However, Burke can’t help but think how much easier the path could have been without that disruption in care.

“A lot of people don’t have access,” Burke said. “They aren’t able to take care of themselves properly. Your mental health is a big thing because if you can’t take care of your mental health, a lot of people end up turning back to drugs and back to prison because we’re not able to take care of ourselves mentally and emotionally.

“It’s a big, big issue.”

The state prison system releases more than 15,000 people into the community each year, and prison officials estimate that 80 percent of them are now eligible for Medicaid.

They also recognize that inadequate access to health care can create a barrier to successful reentry into society. That’s why the N.C. Department of Adult Correction is working to ensure that fewer people are released into health care coverage gaps by helping people apply for Medicaid before they’re scheduled to leave prison.

“One of the key things with reentry is that break in service can really be detrimental,” said George Pettigrew, deputy secretary for rehabilitation and reentry at the N.C. Department of Adult Correction. “Somebody can decompensate real quick with mental health issues, substance use issues. If they don’t have that insurance ready to go where they can go and have these [health] services, that can be a problem.”

Gaining coverage

Mary Grillo, interim social work director and Medicaid expansion coordinator at the Department of Adult Correction, said the prison system has launched a department-wide effort to help people ages 19 to 64 who are within 90 days of their release date to apply for Medicaid coverage.

That effort is in line with one of the goals outlined in the state’s participation in Reentry2030, a national initiative that aims to dramatically improve reentry success. North Carolina joined the initiative through Gov. Roy Cooper’s January executive order seeking to boost reentry support.

Reaching people about 90 days ahead of time is important, Grillo said, because it can take up to 45 days for a Medicaid application to be processed and eligibility determined. The goal is to have as many people as possible covered before their release, she said.

“It’s one less thing that the individual has to do when they get out of prison,” Grillo said. “It’s one less thing to worry about.”

Grillo said prison staff, including three temporary workers hired in January to assist with the application process, are submitting about 100 Medicaid applications per week.

“The biggest challenge is getting the information out there and getting the education out there and letting people know that this is available,” Grillo said.

To spread the word about the new opportunity for Medicaid coverage upon release, the prison system has distributed a flyer through electronic tablets that are available to all incarcerated people and hung paper flyers on bulletin boards across prisons.

Several information sessions have been conducted at prisons with the largest number of people identified to be eligible for Medicaid coverage, so that incarcerated people can ask questions and get informed answers. Grillo, who has led multiple sessions, said many people are learning for the first time that they are eligible. The news has mostly been met with positive responses, she said, because justice-involved people often have higher rates of chronic diseases, mental health problems and substance use disorders. Many have expressed relief that they’ll have a way to access care in the community.

To apply for Medicaid while incarcerated, prison staff help people fill out paper applications and send them to local department of social services offices. In the community, the most common and efficient way to apply for Medicaid is through the state’s ePass website, but that option isn’t available to incarcerated people who don’t have email addresses for security reasons, Grillo said.

If they’re deemed eligible for Medicaid, benefits will take effect after their release from prison, as federal law prohibits Medicaid funds from paying for most health care during incarceration. A person’s Medicaid will be activated automatically upon release; the Department of Adult Correction’s data system and North Carolina Medicaid’s data system communicate nightly with each other.

What happens to Medicaid coverage in prison:

• If someone enters prison with Medicaid coverage, it’s automatically suspended until the person is released. Upon release, coverage is resumed automatically.
• If there is an annual recertification period while someone with Medicaid is incarcerated, the Medicaid coverage is terminated. A person will need to reapply for Medicaid within 90 days of their release date to regain coverage.
• If someone is determined to be eligible for Medicaid while incarcerated, their coverage will be put in suspended status until they’re released.

Determining someone’s health coverage before they’re released also gives prison social workers and case managers more options to schedule appointments and find placements for people to get care in the community before they leave.

“It can be very difficult to find a nursing home or a group home or an assisted living placement for somebody who’s returning to the community,” Grillo said. “Being able to have a payer source for a person and being able to activate — or at least get their Medicaid enrollment going — before they leave prison makes it easier.”

Prison system savings

Expanded Medicaid eligibility also is poised to save the prison system millions of dollars. That’s because the one medical expense Medicaid can pay for is when an eligible incarcerated person receives inpatient care lasting more than 24 hours at a community hospital.

In past years, only a small portion of hospital placements have been paid by Medicaid because so few people were eligible for Medicaid, said Doug Holbrook, the prison system’s chief deputy secretary for administration.

Now, that breakdown will shift tremendously. Holbrook said that he expects over 80 percent of hospital placements will now be able to be covered by Medicaid, which he estimates will save the Department of Adult Correction an excess of $10 million annually — funds that can be allocated elsewhere.

These savings to the prison system will require no change in process, Holbrook explained. Anytime someone is sent to the hospital for more than 24 hours, the prison system applies for Medicaid. That will continue to occur, but hereafter, far fewer cases will be denied coverage.

Holbrook added that long term, there could be even greater savings to the prison system from Medicaid expansion — savings stemming from people not reaching the prison system in the first place because they can get care in the community.

“It’s entirely possible that people who have access to mental health services may not end up with us at all,” Holbrook said. “Some of the people that get to us are because they are dealing with mental illness. If they’re getting treated, they may be diverted out of the court system and out of our system.”

Fostering smoother reentry experiences

Pettigrew, deputy secretary for rehabilitation and reentry, hopes that increased Medicaid coverage will help improve people’s reentry success.

States that have had Medicaid expansion in effect for years are showing positive results. Research shows that people with serious mental illness who are enrolled in Medicaid are more likely to use community health services and are less likely to wind up back in jail than those without health insurance. Another study found that expanded Medicaid coverage resulted in reductions in the rate of rearrest for multi-time offenders. Additionally, research shows that states with Medicaid expansion reported fewer violent crime and drug arrests within the first three years of enactment.

Pettigrew said the prison system will be watching to see if there are similar improved reentry outcomes from greater Medicaid coverage in North Carolina. For example, he said he expects the show-rate for behavioral appointments in the community after release will increase because people will no longer have to fret about how they can pay.

Angela Wright, 52, said she’s had health insurance since her release from prison in May. It made returning to the community after over seven years spent incarcerated less stressful, she said. It took one expense off her plate as she navigated a new world of affording groceries, a vehicle and other necessities from her part-time wages.

“If I ever had to pay health insurance premiums, that could take a paycheck and a half,” Wright said.

In January, Wright said she got approved for Medicaid under expansion, and she said she’s already taken advantage of the coverage to go to doctor’s appointments and pick up prescriptions — all at no out-of-pocket costs thus far.

Wright said she hopes more people leaving prison will have her experience of uninterrupted health care.

“It’s a peace of mind having Medicaid,” Wright said. “It’s just the expense, I really don’t have to worry about it. And with Medicaid, if something happens, and I don’t have a vehicle I can call and schedule to have them come pick me up and take me.”

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.