Community Health Initiatives Unit

The Community Health Initiatives Unit with the Office of Programs, Treatment & Re-Entry Services is responsible for the development and implementation of services under the 1115 Reentry Demonstration Waiver granted by the Centers for Medicare and Medicaid Services (CMS). This new initiative allows eligible, incarcerated individuals to enroll in Medicaid 90 days prior to release in addition to receiving coordinated care, medication assisted treatment, and counseling, as needed. Selected correctional facilities will fully execute the goals and objectives of the Re-entry Waiver by meeting specific measures. These measures include the facility's ability to execute the Medicaid enrollment process; identify behavioral health needs as determined by the Waiver; and provide reentry support services.

Facility-based, community care coordinators will work closely with correctional facilities, providers, and case managers to assist eligible incarcerated individuals with the Medicaid enrollment process. In addition, they will coordinate the development of person-centered care plans that identify community-based providers who will continue to address both behavioral health concerns and health related service needs. Individuals will remain enrolled in Medicaid when he or she returns to the community and may renew as long as they continue to meet the criteria.

Primary Goals and Objectives:

Increase coverage, continuity of care, and appropriate service uptake through assessment of eligibility and availability of coverage for benefits in correctional facility settings prior to release;
Increase receipt of preventive and routine physical and behavioral health care for the justice- involved population through identification of SUD and SMI and providing transitional supports;
Improve access to services prior to release and improve transitions and continuity of care into the community upon release and during reentry;
Improve coordination and communication between correctional systems, Medicaid systems, managed care plans (as applicable), and community-based providers;
Increase additional investments in health care and related services, aimed at improving the quality of care for individuals in correctional facility settings, and in the community to maximize successful reentry post-release;
Improve connections between correctional facility settings and community services upon release to address physical and behavioral health needs, and health-related social needs;
Reduce all-cause deaths in the near-term post-release;
Reduce the number of emergency department visits and inpatient hospitalizations among recently incarcerated Medicaid individuals through increased receipt of preventive and routine physical and behavioral health care;
Provide interventions for certain behavioral health conditions, including use of stabilizing medications like long-acting injectable antipsychotics and medication for addiction treatment for substance use disorders where appropriate, with the goal of reducing overdose and overdose-related death in the near-term post-release.