Background
More than 400,000 adults and youth are released from California prisons and jails annually. Until now, due to a federal Medicaid law known as the “inmate exclusion,” inpatient hospital care was the only service that could be covered by Medicaid for individuals considered an “inmate of a public institution.” Recognizing the opportunity to improve the continuity of health care services for justice-involved individuals, California is using a Medicaid 1115 demonstration waiver to provide a targeted set of Medi-Cal services to youth and adults in state prisons, county jails, and youth correctional facilities for up to 90 days prior to release. California is the first state to be approved to provide these services. The Medi-Cal justice-involved initiative will reduce gaps in care, improve health outcomes, and prevent unnecessary admissions to inpatient hospitals, psychiatric hospitals, nursing homes, and emergency departments.
About This Toolkit
This toolkit includes turnkey communications resources to help you spread the word about the newly approved justice-involved initiative, lift up California’s broader transformation of Medi-Cal, and reinforce DHCS’ commitment to a healthier, more equitable health system for all.
Member Communications
When connecting with members and families of justice-involved individuals, please reference the Member FAQ below. It includes clear messaging on the tangible benefits for members as well as information about how this initiative ties to the broader goals of Medi-Cal transformation.
Provider Communications
When engaging with providers, please reference the Provider FAQ below for comprehensive information on eligibility criteria, available services, and more.
Social Media Posts
Below are suggested social media posts for you to share across your organization’s platforms. Please feel free to tailor for your organizational voice. We also encourage you to share and amplify DHCS social media content on Facebook and Twitter as we all work to spread the word.
Justice-Involved Waiver Approval Talking Points
- DHCS' justice-involved initiative is part of CalAIM, a broad initiative to transform Medi-Cal.
- The state's priority is to ensure all Californians have access to high-quality and timely care.
- Through the CalAIM initiative, we are creating a new standard for person-centered and equity-focused health care, including for the currently and formerly incarcerated.
- People re-entering the community after incarceration have significant physical and behavioral health needs and are at high risk of injury and death, especially in the initial period after release.
- The justice-involved initiative ensures continuity of coverage through Medi-Cal pre-release enrollment and provides key services to support a successful re-entry.
- Pre-release services will be anchored in comprehensive care management and include physical and behavioral clinical consultation, lab and radiology, Medication Assisted Treatment (MAT), community health worker services, and medications and durable medical equipment.
- For those eligible, a care manager will be assigned, either in the carceral setting or via telehealth, to establish a relationship with the individual, understand their health needs, coordinate vital services, and make a plan for community transition, including connecting the individual to a community-based care manager they can work with upon their release.
- Under the initiative, county jails, county youth correctional facilities, and state prisons will:
- Ensure all eligible individuals are enrolled in Medi-Cal before release.
- Provide targeted Medi-Cal health care services to youth and eligible adults in the 90 days prior to release to prepare them to return to the community and reduce gaps in care. Eligible adults include those who have a mental health diagnosis or suspected diagnosis, a substance use disorder or suspected diagnosis, a chronic clinical condition, a traumatic brain injury, intellectual or developmental disability, or are pregnant or postpartum. All incarcerated youth in a youth correctional facility are eligible with no clinical criteria required.
- Provide “warm handoffs" to health care providers to ensure that individuals who require behavioral and other health care services, medications, and other medical supplies (e.g., a wheelchair) have what they need upon re-entry.
- Work with community-based care managers to offer intensive, community-based care coordination for individuals at re-entry, including through Enhanced Care Management.
- Work with community-based care managers to make Community Supports (e.g., housing support or food support) available upon re-entry if offered by their managed care plan.
Member FAQ (Key Messages For Members/Families of JI Individuals)
1. When can JI individuals access services?
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DHCS expects correctional facilities to launch pre-release services between October 1, 2024
through April 2026.
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Once their facility offers pre-release services, youth and eligible adults in jails, youth correctional facilities, or prisons can begin receiving targeted Medi-Cal services 90 days before their expected release date. Anyone who is incarcerated is eligible for pre-release services, provided they meet other criteria, including those who are incarcerated for a short term
2. How do eligible individuals enroll in Medi-Cal?
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County jails, youth correctional facilities, prisons, and designated entities are responsible for identifying individuals potentially eligible for Medi-Cal, assisting them with the application, and submitting the application to County Social Services Departments (SSDs).
3. Who is eligible to receive services prior to release?
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All individuals incarcerated in a youth correctional facility are eligible; no clinical criteria are required.
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Eligible adults include those who have a mental health diagnosis, a substance use disorder, a chronic or significant clinical condition, a traumatic brain injury, intellectual or developmental disability, HIV/AIDS, or are pregnant or postpartum.
4. What can JI individuals expect to happen during the 90-day pre-release period? What services will be provided?
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For those eligible for pre-release services, a care manager will be assigned to establish a relationship with the individual, understand their health needs, coordinate needed services, and plan for community transition. This includes connecting the individual to a community-based care manager (i.e., ECM provider) who they can work with upon their release.
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Health care providers will ensure individuals who require behavioral and other health care services, medications and other medical supplies (e.g., a wheelchair) have what they need upon re-entry so they can continue to receive the care they need after their release.
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Members can also qualify for post-release enrollment in Enhanced Care Management and Community Supports, including housing and food supports, to help them build stability as they re-enter the community.
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ECM care managers can meet Medi-Cal members via telehealth prior to their release to establish a relationship and support their reentry into the community.
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List of Pre-Release Services
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Care management;
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Physical and behavioral health clinical consultation services;
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Laboratory/radiology;
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Community health worker services;
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Medications, consistent with the full scope of covered outpatient drugs under Medi-Cal state plans, and medication administration; and
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Medication Assisted Treatment (MAT).
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Individuals who qualify will receive covered outpatient medications and durable medical equipment (DME) in hand upon release, consistent with approved state plan authorities and policy.
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Pre-release care managers will be responsible for:
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Establishing a trusting, working relationship with the member;
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Conducting a needs assessment, as appropriate, during their initial meeting with the individual;
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Scheduling and coordinating clinical consultation services, if necessary;
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Coordinating pre-release medication including MAT;
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Developing a transitional care plan (i.e., discharge plan);
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Sharing the final transitional care plan with community-based providers (electronically, if possible);
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Coordinating post-release DME medication, including MAT;
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Coordinating with the individual's post-release providers, including specialty behavioral health providers or other community-based providers on an as-needed basis;
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Sharing relevant information and the transitional care plan with post-release support and providers (e.g., post-release care manager, MCP) to support care coordination; and,
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Conducting a warm handoff with the individual's post-release care manager (e.g., ECM provider) if different than the pre-release care manager.
5. Where can members go for more information and answers to their questions?
Provider FAQ (Key Messages For Providers)
1. What are the behavioral and physical health eligibility criteria for pre- release services for individuals who are justice-involved?
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Adults:
- Mental illness, defined as confirmed or suspected mental health diagnosis based on specified criteria;
- Substance use disorder, defined as confirmed or suspected diagnoses based on specified criteria;
- Chronic condition or significant clinical condition, defined as confirmed or suspected diagnoses based on specified criteria;
- Intellectual or developmental disability (I/DD), defined as a disability that begins before an individual turns 18 and is expected to continue indefinitely and present a substantial disability;
- Traumatic brain injury or other condition, where the condition has caused significant cognitive, behavioral, and/or functional impairment;
- Positive test or diagnosis of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS); or
- Currently pregnant or within 12 months postpartum.
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Youth:
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All youth under 21
and former foster youth between 18-26 years of age do not need to demonstrate a
health care need to qualify for pre-release services.
2. What pre-release services will healthcare providers be responsible for providing? What services will correctional facilities be responsible for facilitating?
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Care coordination and connecting individuals with the care they need;
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Physical and behavioral health clinical consultation services;
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Laboratory/Radiology;
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Community Health Worker services;
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Medications, consistent with the full scope of covered outpatient drugs under Medi-Cal State Plans, and medication administration; and
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Medication Assisted Treatment (MAT);
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Providing qualifying individuals with covered outpatient medications and Durable Medical Equipment (DME), ensuring they have these supports in- hand upon release, consistent with approved state plan authorities and policy.
3. What will pre-release care managers be responsible for?
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Establishing a trusting, working relationship with the member;
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Conducting a needs assessment using a DHCS-provided template during their initial meeting with the individual;
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Scheduling and coordinating clinical consultation services, if necessary;
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Coordinating pre-release medication, including MAT;
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Developing a transitional care plan (i.e., discharge plan);
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Sharing the final transitional care plan with community-based providers (electronically, if possible);
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Coordinating post-release DME medication, including MAT;
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Coordinating with the individual's post-release providers, including specialty behavioral health providers or other community-based providers on an as-needed basis;
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Sharing relevant information and the transitional care plan with post-release support and providers (e.g., post-release care manager, MCP) to support care coordination; and,
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Conducting a warm handoff with the individual's post-release care manager (e.g., ECM provider) if different than the pre-release care manager.
4. How will this initiative increase access to MAT?
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To increase access to MAT in carceral settings and improve the standard of care in delivering these services to justice-involved populations, the provision of MAT will be a required pre-release service.
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DHCS will work with correctional facilities to build off their current progress in providing MAT and provide technical assistance to CDCR, jails, and youth correctional facilities to ensure all facilities are able to provide MAT.
5. How do eligible individuals enroll in Medi-Cal?
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County jails, youth correctional facilities, prisons, and designated entities (DHCS/MCED's preferred term for application assisters) such as county offices will be responsible for identifying individuals potentially eligible for Medi-Cal, assisting them with the application, and submitting the application with County Social Services Departments.
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County jails, youth correctional facilities, and designated entities should submit Medi-Cal applications at intake or as close to intake as possible. Prisons will start this process, at an appropriate time closer to the release date.
6. Where can providers go for more information and answers to their questions?
Outpatient Pharmacy Benefits and Medi-Cal Rx FAQ
The Department of Health Care Services (DHCS) Pharmacy Benefits Division (PBD) has prepared the following Questions and Answers (Q&A) based upon stakeholder feedback received during meetings and via email. The intent is to provide additional support for correctional facilities and pharmacies as they prepare for implementation of the Justice-Involved (JI) Reentry Initiative. This information is specific to Medi-Cal outpatient pharmacy benefits administered under Medi-Cal Rx. For information about medical and durable medical equipment benefits covered by Medi-Cal, please refer to Justice-Involved (JI) Pre-Release Services.
For purpose of reconciling terminology that may differ across DHCS resources, the following definitions have been applied to this document:
Individual: Use of the term “individual" applies to the incarcerated individual who is JI-eligible 90-days prior to release and receiving, or eligible to receive outpatient pharmacy benefits covered by Medi-Cal. This term is used synonymously with “patient" when the individual is receiving pharmacy services.
Member: Use of the term “member" refers to the individual enrolled in Medi-Cal. While incarcerated, they may be referred to as a patient or JI-eligible individual. Once released, they are referred to as a Medi-Cal member.
For Eligibility, refer to Questions 1-2.
For Billing, refer to Questions 3-20.
For Prior Authorization, refer to Questions 21-23.
For Policy, refer to Questions 24-25.
1. If the individual is eligible for Medi-Cal JI medical coverage, is the individual automatically eligible for pharmacy benefits via Medi-Cal Rx?
- Yes, if the individual is eligible for Medi-Cal JI medical coverage, they are automatically eligible for (Medi-Cal Rx) JI pharmacy benefits. The DHCS Medi-Cal Eligibility Division (MCED) provides the eligibility information to Medi-Cal Rx for pharmacy claims and to CA-MMIS for medical claims.
2. Are the Subscriber ID and JI effective dates the same for both Medi-Cal and Medi-Cal Rx?
- Yes, the same Subscriber (member) ID and JI aid code effective dates are used by Medi-Cal and Medi-Cal Rx. The DHCS Medi-Cal Eligibility Division (MCED) provides the eligibility information to Medi-Cal Rx for pharmacy claims and to CA-MMIS for medical claims.
3. Do we need to bill pre-release and discharge medications from a single site or single NPI?
- Billing for pre-release and discharge medications does not need to be from a single site/NPI. If different sites will be submitting pharmacy claims to Medi-Cal Rx, each site will need to submit a Medi-Cal provider enrollment application to DHCS Provider Enrollment Division (PED) via PAVE - Provider Application and Validation for Enrollment.
4. When a primary (mail order) pharmacy bills Medi-Cal Rx
for the 90-days prior to release medications and the individual gets released early
(e.g., at day 67), how will the local community pharmacy be able to bill
Medi-Cal for the medications, as the refills will be ordered too
soon? In this event, would the local community pharmacy fill the
release medications prior to discharge? What is the modifier that the
pharmacy should use for the upon release medications? With the modifier,
will Medi-Cal Rx approve the early fill of release medications?
For most medications/products, the local community pharmacy may override the claim. Pharmacy claims that are denied for Medi-Cal Rx Drug Utilization Review (DUR) will receive a NCPDP Reject Code 88 (DUR Reject Error) along with an additional message indicating the specific reason (early refill, high dose, etc.). DUR-related pharmacy claim denials/rejects can be resolved via pharmacy point of sale (POS) or via web claims submitted through the Medi-Cal Rx Provider Portal. To resolve the pharmacy claim, refer to:
For additional information on Medi-Cal Rx DUR program, refer to the following resources:
If the claim denied for additional or other NCPDP reject codes, the local community pharmacy may provide an emergency fill. Refer to the Medi-Cal Rx Provider Manual, Emergency Fills section (currently section 15.7) for more information.
In this scenario, it is assumed that the upon release medications that may have been dispensed/in transit (already billed) by the mail order pharmacy will be returned and the mail order pharmacy will reverse the associated claim(s).
5. When the pharmacy receives claim NCPDP Reject Code 88
with a DUR error code of ER: Overutilization (Early Refill) for release
medications, what does the pharmacy enter when resubmitting the claim to
complete the override?
6. In the outpatient setting, pharmacies have proprietary software that allow for them to bill and submit claims to Medi-Cal Rx (using a point-of-sale system). Would the web and batch approach to submitting pharmacy claims require us to have outpatient software to submit claims or can that still be done without having software?
Batch- and web-submitted pharmacy claims must also adhere to the NCPDP format; refer to Medi-Cal Rx NCPDP Payer Specification Sheet.
In the Medi-Cal Rx Provider Manual, refer to the following sections for more information:
- Secured Provider Portal (section 3.6.1.2)
- Web Claims Submission/Direct Data Entry (section 3.6.1.2.1)
- Claims (section 4.0) and subsections
- For more information on web-submitted pharmacy claims, refer to:
For additional available training, guides, and information refer to:
7. Can we utilize paper claims (Pharmacy Claim Form 30 - 1)
for billing Medication Upon Release (30-day supply)?
8. When a claim is submitted for adjudication, is the date
of birth (DOB) used as part of the member validation? If the BIC or CIN is validated, but the DOB
does not match to the Medi-Cal Rx member details, will the claim reject?
In addition to the CIN/BIC, the first/last name and date of birth are used to validate the member. If the first/last name and/or date of birth does not match DHCS/Medi-Cal Rx records, an NCPDP Reject 52 (Non-Matched Cardholder ID) is provided in the response, along with a supplemental message to identify what is not matching. To learn more, refer to Claim Submission Reminders on the Medi-Cal Providers | Forms and Information.
9. Can you clarify if prescriptions dispensed during the in-custody stay are billed through Medi-Cal Rx or if Medi-Cal Rx is limited to discharge medication/product prescriptions?
- Prescriptions dispensed during the 90-day JI pre-release period and those provided in-hand at the time of release, should be billed to Medi-Cal. Refer to the Policy and Operation Guide for what type of dispensing is billed to Medi-Cal Rx on a pharmacy claim versus to CA-MMIS on a medical claim.
10. How should a pharmacy claim for an individual single dose of medication be submitted? Would that be per dispense or per administration?
- Individual doses of a medication may be billed by the pharmacy at the time of each dispense. If the pharmacy is aggregating administrations and billing retroactively, these pharmacy claims should be submitted to encompass the entire 90-day JI pre-release in the fewest claims possible following existing Medi-Cal Rx pharmacy utilization management controls.
11. How are prescriptions billed when a facility uses stock model dispensing/administration, and the medication/pharmacy supply is not individual-specific?
12. If a medication is dispensed to a nurse to give to the JI individual, should it be billed at the time of dispense or upon administration?
- If the pharmacy is submitting the pharmacy claim to Medi-Cal Rx, the medication/product should be billed for the time/date of dispense. If the correctional facility's Electronic Health Record (EHR) is deriving and submitting the pharmacy claim to Medi-Cal Rx once the individual is released, the EHR-derived pharmacy claim (for a given medication/product) is to encompass the entire 90-day JI pre-release period for the administered prescription and submit the fewest claims possible under existing Medi-Cal Rx pharmacy benefit utilization management controls.
13. What happens if during the pre-release period the medication is refused by the individual? Can the prescription be billed?
- If the medication/product (in full or partial) is returned to stock, submit a pharmacy claim to Medi-Cal Rx for reimbursement for the used portion. If a pharmacy claim was submitted to Medi-Cal Rx at the time of dispense for the returned medication/product, that pharmacy claim should be reversed, and if applicable, submit a pharmacy claim for the used portion.
14. Prior to incarceration the individual had their prescription filled and needs this same medication/product during their 90-day JI pre-release period, but the pharmacy claim is denying for a Drug Utilization Review (DUR) reason. Can this be resolved without having to call Medi-Cal Rx Customer Service?
- Pharmacy claims that are denied for Medi-Cal Rx Drug Utilization Review (DUR) will receive a NCPDP reject code 88 (DUR Reject Error) along with an additional message indicating the specific reason (early refill, high dose, etc.). DUR-related pharmacy claim denials/rejects can be resolved via pharmacy point of sale (POS) or via web claims submitted through the Medi-Cal Rx Provider Portal. To resolve the pharmacy claim, refer to:
- For additional information on Medi-Cal Rx DUR program, refer to the following resources
Note: This resolution method can also be used in the scenario of 90-day pre-release prescriptions overlapping with upon release prescriptions.
15. Are in-hand, upon release prescriptions billed under Medi-Cal JI or Medi-Cal non-JI?
- The individual's Medi-Cal aid code is not included on the pharmacy claim submission. During claim adjudication, Medi-Cal Rx performs member eligibility look-up based on date of service and the appropriate aid code is selected/determined. If the individual is Medi-Cal JI eligible on the day of release, then the Medi-Cal JI aid code is selected.
16. What is the allowable time frame for submitting retrospective medication JI pharmacy claims due to implementation delays?
- For full reimbursement, pharmacy claims must be submitted to Medi-Cal Rx within 6 months following the month of the date of service of the claim. This requirement is referred to as the six-month billing limit.
- Pharmacy claims that are not received within the six-month billing limit and do not have an approved exception will be reimbursed at a reduced rate or will be denied as follows:
- Claims received during the 7th through the 9th month after the month of service will be reimbursed at 75 percent of the payable amount.
- Claims received during the 10th through 12th month after the month of service will be reimbursed at 50 percent of the payable amount.
- Claims received after the 12th month following the month of service will be denied.
Note: County-specific questions can be directed to DHCS at CalAimjusticeadvisorygroup@dhcs.ca.gov.
17. Can a discharge prescription that is processed before/on the release date be billed as a JI pharmacy claim at time of release, although it is picked up after the day of release? How would a pharmacy know to cancel what was already billed?
- A minimum requirement of JI is for the individual to leave with a full supply of medications in hand upon release. Refer to Section 8.6 of the Policy and Operation Guide. If the date filled (i.e., date of service) is within the JI eligibility period, there should be no issue with the member obtaining their discharge medications any time within 15 days from the date of service. Pursuant to CCR, Title 22, Section 51172, if a prescription has not been received by the member or the member's representative within 15 days of the fill date, the pharmacy must reverse the claim and refund the payment to DHCS.
18. How will correctional facilities be paid for daily pill packs, pre-release?
- Pharmacies will be reimbursed an ingredient cost and dispensing fee for each prescription regardless of how they are packaged. Refer to Section 4.6 of the Medi-Cal Rx Provider Manual for reimbursement methodology.
19. For JI pharmacy claims, what value ('1' [Home] or '15' [Correctional Institution]) is appropriate for the 384-4X (Patient Residence) field for pre-release prescriptions? For upon release discharge prescriptions?
- The residence value (NCPDP 384-4X [Patient Residence] field) is not a required field on the pharmacy claim. If the provider opts to include this information, it should be reflective of the member's residence at the time of dispensing. It would be appropriate to populate with '15' (Correctional Institution) for pre-release and upon release discharge prescriptions.
20. Is the JI Aid Code required in the Medi-Cal Rx NCPDP Payer Sheet? If yes, which Field?
- The aid code is not a field submitted on the NCPDP pharmacy transactions (claim, prior authorization, or eligibility). The member's eligibility and aid code (JI or non-JI) are validated and determined by Medi-Cal Rx based upon the date of service. Medi-Cal Rx uses DHCS Medi-Cal Eligibility Division (MCED)-provided information for the validation and determination.
21. Medication X was prescribed under two separate orders (orders A and B) for a JI active custody individual with NDC 1 and NDC 2 dispensed accordingly. Can we combine the quantities from both orders into a single charge (resulting in one charge with different NDCs), or can we separate them into two charges by NDC, which could lead to two dispensing fees?
- Separate pharmacy claims should be submitted for each of the orders (prescriptions) and associated NDC.
22. We allocate space in a correctional facility to provide acute psychiatric services to patients. Are medications provided to JI patients within the 90 days pre-release period billable to Medi-Cal Rx?
- Yes, medications provided in the acute psychiatric setting of the correctional facility within the 90-day pre-release period are billable to Medi-Cal Rx if billed as an outpatient prescription(s). These can also be submitted as medical claims to CA-MMIS. If the acute psychiatric services are part of a hospital stay, they would be considered part of the inpatient benefit, and the medications would not be separately billable on a Medi-Cal Rx pharmacy claim. For more information, refer to Medi-Cal Inmate Program.
23. An opioid dispense, per Medi-Cal Rx restriction, is a 7-day supply for the first dispense, 30 tablets/capsules or 240 mL. How is "dosage unit" defined? Are we required to combine all medications into "as fewest claims as possible?" How do we reconcile the difference between these variations/intervals?
- New start opioid pharmacy claims will be restricted to a 7-day supply or a maximum quantity of 30 solid dosage units (each) or 240 mL for liquids – meaning the first opioid claim on this member's profile is limited to a 7-day supply or 30 tablets/capsules. If this opioid order is a liquid, the initial claim is limited to 240 mL.
24. Can a PA be submitted retroactively?
- Yes, the PA will need to be submitted requesting a retroactive date of service for the correctional facility to receive Medi-Cal Rx reimbursement.
25. If a PA was submitted by another prescriber for the individual prior to incarceration, is that PA still active? Can the correctional facility see which PAs are active?
- Prior authorizations approved by Medi-Cal Rx prior to incarceration remain active for the duration of approval. The length of prior authorization varies depending on multiple factors and is determined at time of review. Incarceration does not affect the status of active prior authorizations on file. Since prior authorizations are associated with the NPI of the original submitter, they are not visible to other NPIs. Prescribers and pharmacies can call the Medi-Cal Rx Call Center to inquire if a PA is on file for a member (after passing verification for PHI access).
26. For an individual that had Medi-Cal eligibility prior to custody and was undergoing opioid treatment, how do we define "new" or lookback period? When does the new start begin?
- For continuations of care with no paid pharmacy claim history for the medication in the last 90 calendar days, a prior authorization will have to be submitted. For more detailed information, please refer to Medi-Cal Rx Provider Manual, Section 15.1.3.
27. If a correctional facility releases an individual with the remaining medication in their current prescription, does that meet the meds in hand requirement?
- No, correctional facilities must ensure that individuals are released with a full supply of medications in hand upon release, as described in Section 8.8.A of the Policy and Operation Guide. “Full supply" is defined as the maximum amount that is medically appropriate and allowed by the Medi-Cal State Plan which under most circumstances is up to a 35 days' supply for controlled substances and 100 days' supply for other prescription drugs.
- If the individual's remaining medication on their current prescription is not a “full supply," the correctional facility must ensure that they are given a full supply upon release.
- In addition to providing the medications in hand upon release, the correctional facility should submit a prescription for any active medication, formula, or medical supply to a community pharmacy as appropriate and feasible so that the individual has access to refills.
28. Are long-acting injectables covered? If someone is receiving long-acting injectables, is a prescription required at the time of discharge?
- All medications and biological products utilized to treat substance use disorders (SUDs), including long-acting injectables (LAI), are included as pre-release services and continue to be available through the Medi-Cal pharmacy benefit without prior authorization. For individuals who received LAIs while incarcerated, prescriptions should be provided if clinically appropriate. For example, if it is not clinically appropriate to provide a script (e.g. monitoring is needed) then a visit with a provider to continue treatment must be scheduled prior to needing another injection.
