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Fraud Waste & Abuse

Balancing public trust with Medicaid for prisoners

State and local Medicaid agencies have to balance on a tightrope of trust from their constituents. The general public who fund their program trust that their tax dollars will not be wasted on faulty or misplaced payments, while those who rely on Medicaid are trusting that they will receive the help they need quickly. Maintaining this balance is especially challenging when managing aid for those who are serving jail time. To adequately protect the trust of the greater public, Medicaid managers must find ways to actively monitor the incarceration status of their program beneficiaries.

“Poverty is the parent of crime.” – Aristotle

For centuries, it has been known that there are close ties between high crime rates and population poverty levels. So, it should not be surprising that many of those who rely on Medicaid in the U.S. also have complicated relationships with the law. But the inmate exclusion policy of the Social Security Act prohibits federal Medicaid funds from being used to pay for services for inmates of public institutions. This ensures that the tax money dedicated to Medicaid is not given to those whose medical needs are already covered by inmate healthcare provisions.

Managing Medicaid is a high-wire balancing act

If someone who receives Medicaid is incarcerated, their benefits must be halted to avoid wasteful spending. And once they complete their sentence, they will need to have their financial help reactivated quickly to get back on their feet. This is especially important because many people who are released from prison rely on consistent medical prescriptions to help them manage underlying issues. Those prescriptions tend to be expensive and difficult for former inmates to pay for without assistance. State Medicaid providers have to carefully monitor the legal status of all of their program participants to protect the financial interests of the many, while also meeting the needs of the few.

Why is it so hard to keep track of everyone on Medicaid?

According to data from the Centers for Medicare & Medicaid Services (CMS), there were 72,204,587 individuals enrolled in Medicaid in the U.S. as of November 2020. Each state agency manages millions of payments every week. It’s simply impossible for them to manually check the criminal status of every one of their beneficiaries.

On the other hand, there were 2.19 million prisoners in the U.S. in 2019, and correctional facilities are not obligated to inform local Medicaid agencies every time someone is released. It is typically up to the individual to do that, which is unreliable at best. This leaves a wide information gap between the criminal justice system and the social security system. So, it is up to state Medicaid teams to string a wire across that gap.

Walk the line

The good news is that much of the public records information needed to pause and resume Medicaid payments for the incarcerated is readily available if you know how to find it. State social security agencies often request updates on the legal status of beneficiaries who they know will see changes soon. But this can take days or even weeks to receive, and the information can be inconsistent. The faster they can get that information, the better they will be at managing their funds and serving those in need.

By using a live gateway for criminal records like Thomson Reuters CLEAR, Medicaid agencies can get nearly instant updates and alerts when their program recipients are incarcerated or released. Then the agency can move quickly to handle their payments however is necessary. Learn more about our public records solutions for Medicaid.

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