County Jails
and the
Affordable
Care Act:

Enrolling Eligible Individuals
in Health Coverage

Community Services Division
National Association of Counties

County Jails and the
Affordable Care Act:
Enrolling Eligible Individuals
in Health Coverage
Contents
Introduction.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2
ACA Coverage Expansion and Potential Effects on County Jails.  .  .  .  .  .  .  .  .  .  .  . 2
Enrollment Processes and Procedures .
 	
for Newly Eligible Individuals. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
Issues Related to Enrolling County Jail Inmates Eligible .
	
for Health Coverage. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
Potential Model Eligibility and Enrollment Systems and Processes.  .  .  .  .  .  .  .  .  . 6
Conclusion	 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8
Additional Resources.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8

For more information on NACo’s Health, Human Services and Justice programs and/or to request copies of this publication, please contact:
Maeghan Gilmore
Program Director
Community Services Division
q 202.942.4261	 E mgilmore@naco.org
This issue brief was completed in March 2012 and produced through the support of the Public Welfare Foundation.
Written by Anita Cardwell, NACo Community Services Program Manager and Maeghan Gilmore, NACo Community Services Program Director.  
Jack Hernandez performed the graphic design and layout. Any opinions in this publication are those of the contributors and do not necessarily
reflect the views of the Public Welfare Foundation or NACo.
NACo wishes to thank the following individuals for their time and contributions to the development of this publication:
• Those who contributed from Alameda County, CA, with special thanks to Rachel Metz, Alameda County Health Care Services Agency and Lori
Jones, Director, Alameda County Social Services Agency
• Those who contributed from Allegheny County, PA, with special thanks to Mary Jo Dickson, Administrator, Allegheny County Bureau of Adult
Mental Health Services
• Those who contributed from New York City, NY, with special thanks to Cecilia Flaherty and Cynthia Summers, NYC Department of Health & Mental
Hygiene
• Those who contributed from Salt Lake County, UT, with special thanks to Patrick Fleming, Director, Salt Lake County Substance Abuse
• Paul Beddoe, NACo Associate Legislative Director
• Tom Joseph, Waterman & Associates
• Cathy Senderling, California Welfare Directors Association

About the National Association of Counties
The National Association of Counties (NACo) is the only national organization that represents county governments in the United States. Founded
in 1935, NACo provides essential services to the nation’s 3,068 counties. NACo advances issues with a unified voice before the federal government,
improves the public’s understanding of county government, assists counties in finding and sharing innovative solutions through education and
research, and provides value-added services to save counties and taxpayers money. For more information about NACo, visit www.naco.org.

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

Introduction
In 2014 the Patient Protection and Affordable Care Act (ACA) will
provide new health insurance coverage options for millions of
individuals through an expansion of Medicaid eligibility and the
establishment of state-based health insurance exchanges.  This
brief will examine ways that counties may be involved in eligibility
determination and enrollment processes for these newly eligible
individuals, focusing particularly on issues related to enrolling
qualified individuals held in county jails as pre-adjudicated detainees and inmates preparing to reenter the community.  
Specifically the brief will assess some of the potential issues and
challenges county jail and human services staff may face in terms
of enrollment procedures.  The brief will also highlight examples
of existing county-based enrollment strategies that may be able
to serve as models for developing processes to enroll individuals
in county jails who become newly eligible for health insurance
coverage in 2014.

ACA Coverage Expansion and
Potential Effects on County
Jails
The ACA’s significant expansion of health insurance coverage has
many important implications for counties, as county governments
provide the local health care safety net infrastructure, public
health functions and other health care services, as well as often
govern, finance and operate local coverage and enrollment programs.  Counties also run and finance local jails, which are responsible for providing health care coverage for the approximately 13
million individuals who are booked into these facilities each year.1
By 2014 the ACA requires that health insurance exchanges be established in each state, and states can either opt to create and run
their own exchange or allow the federal government to develop
and operate the exchange in the state.  Exchanges are intended to
be regulated insurance marketplaces where individuals without
employer-sponsored health insurance will be able to obtain coverage or small businesses can obtain coverage for their employees.2
Premium credits will be available for individuals and families with
incomes between 133-400% FPL based on a sliding income scale
to help them purchase coverage through the exchanges.  

1  Bureau of Justice Statistics, Prison and Jail Inmates at Midyear Series: Jail
Inmates at Midyear 2009—Statistical Tables, http://bjs.ojp.usdoj.gov/index.
cfm?ty=pbdetail&iid=2195.
2  Initially the exchanges will primarily serve individuals purchasing coverage on their own and small employers; in 2017 states will have the option to
allow businesses with more than 100 employees to purchase insurance from
an exchange.

2

There is a specific ACA provision related to the exchanges that
could significantly impact county jails, which states that “…an individual shall not be treated as a qualified individual, if at the time of
enrollment; the individual is incarcerated, other than incarceration
pending disposition of charges.” 3 This provision will likely allow
eligible individuals in custody pending disposition of charges to
enroll in a health insurance plan offered through an exchange prior to conviction, or maintain coverage if they are already enrolled.  
A substantial number of individuals that enter into county jail
custody have serious medical and behavioral health needs4 and
would benefit greatly from treatment to address these conditions.  
Additionally, as counties are responsible for providing health care
services for county jail inmates and the overwhelming majority of
individuals in jails lack any type of health insurance coverage,5 this
provision could potentially reduce county jail health costs.  
In 2014 the ACA also expands Medicaid eligibility to include all
individuals under age 65—including adults without children—
who have incomes up to 133% of the federal poverty level (FPL).6  
Many individuals involved in the criminal justice system will fall
into this category of adults who will be newly eligible for Medicaid,
because a large majority of jail inmates are young, low-income
males7 who did not previously qualify for the program.  However,
unless future administrative actions change existing federal rules,
while these individuals will be eligible to enroll in the program
they will not be able to receive Medicaid benefits in 2014.  
Presently some county jail inmates meet Medicaid’s eligibility
requirements and are eligible to enroll in the program, but they
are not covered by Medicaid.  This is because federal law does not
allow for federal Medicaid funding—Federal Financial Participation (FFP)—to pay for medical care provided to individuals who
are “inmates of a public institution,” which is commonly referred to
as the “inmate exception.”  This results in counties covering the full
cost of jail inmates’ health care services rather than eligible detainees receiving coverage through Medicaid.    

3  PPACA §1312(f)(1)(B).
4  National Commission on Correctional Health Care, The Health Status of
Soon-To-Be-Released Inmates: A Report to Congress, Volume 2 (2004).
5  McDonnell, Maureen, Laura Brookes, Arthur Lurigio and Daphne Baille.
“Realizing the Potential of National Health Care Reform to Reduce Criminal
Justice Expenditures and Recidivism Among Jail Populations.”  Community
Oriented Correctional Health Services Issue Paper.  January 2011.
6  In 2014 states will be allowed the option to create a Basic Health Plan for
uninsured individuals who have incomes between 133-200% FPL, who would
otherwise be eligible for premium tax credits on the exchange. The Basic
Health Plan will offer individuals Standard Health Plans and benefits for these
plans must be at least equivalent to the essential health benefits package
determined by the Secretary of the U.S. Department of Health and Human
Services and that premiums do not exceed those in the exchanges.
7  “The Implications of Expanded Medicaid Eligibility for the Criminal Justice
Population: Frequently Asked Questions.” Community Oriented Correctional
Health Services.  May 2011.

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

When an individual enrolled in Medicaid is detained, the majority
of states terminate Medicaid benefits, despite federal guidance
that allows for the suspension of Medicaid for individuals involved
in the criminal justice system whose eligibility for the program is
not linked to Supplemental Security Income (SSI). 8 This benefit
termination occurs primarily because of the inmate exception, as
well as because some states’ information management systems
may not be designed to accommodate benefit suspension.  
Of particular issue for counties are pre-adjudicated individuals, because benefit termination often occurs prior to official conviction
and even though many individuals are in jail for very short periods
of time. Upon their release from jail, individuals whose benefits are
terminated must reapply for Medicaid, and the process of regaining benefits may take many months.  Particularly for individuals
with chronic medical or behavioral health issues, this unnecessary
disruption of benefits can cause serious delays in their ability to
access needed care and treatment.  Additionally, lack of access to
medical and behavioral health care services can also potentially
increase recidivism rates for these individuals. 
However unlike the provision allowing eligible pre-adjudicated
inmates to obtain health insurance coverage through plans on
the exchanges, the ACA does not provide further clarity regarding
Medicaid and the pre-adjudicated population.9 This means that
while many individuals in jail pending disposition of charges will
meet the new Medicaid income requirements in 2014 and will be
able to enroll in Medicaid, any medical services they receive will
not be covered through the program while they are incarcerated
(barring an existing exception mentioned in Box 1). 

8  States such as NY, OR, MN and FL have adopted policies to suspend rather
than terminate federal benefits; additionally, in OH a memorandum of understanding allows for the suspension of benefits..
9  NACo submitted comments in response to the proposed regulations
related to Medicaid eligibility changes and eligibility determination for the
exchanges advocating that the Centers for Medicare and Medicaid Services
(CMS) should explicitly prohibit states from terminating Medicaid eligibility
solely due to incarceration, that individuals pending disposition of charges
should not be considered as inmates of a public institution and that incarcerated individuals should have the opportunity to apply for coverage either
through plans on the exchanges or Medicaid.  NACo’s comments can be found
at www.naco.org/healthreformimplement. However in response to these
comments published with the new federal rules related to Medicaid eligibility
changes on 3/16/12 CMS stated that issues related to FFP not being available
to incarcerated individuals were beyond the scope of their rulemaking, and
asserted that: “An individual is considered an inmate when serving time for
a criminal offense or confined involuntarily in State or Federal prisons, jails,
detention facilities, or other penal facilities, regardless of adjudication status.”
Similarly, in response to NACo’s comments published with the new federal
rules related to the exchanges on 3/12/12 CMS stated that the term “incarcerated, pending disposition of charges” will be clarified in future guidance. At
the time of publication of this brief, no other administrative actions related to
this topic had been issued.

Box1: Medicaid Inpatient Billing
for Incarcerated Individuals
While federal law does not allow for the reimbursement of
inmate medical care under Medicaid, there is an important
exception to this rule.  Specifically, the exception states that
federal financial participation (FFP) is permitted “during that
part of the month in which the individual is not an inmate of
a public institution.” 1 The Centers for Medicare and Medicaid
Services has verified through guidance letters issued in 1997
and 1998 that this exception applies to incarcerated individuals once they are admitted as an inpatient in a hospital,
nursing facility, juvenile psychiatric facility or intermediate
care facility that is not part of the state or local correctional
system.  Therefore, if an inmate is eligible for Medicaid and is
transported out of a correctional facility to receive inpatient
hospital services, Medicaid can be billed to cover the cost of
these services. 
1  42 CFR 435.1009

Enrollment Processes and
Procedures for Newly Eligible
Individuals
Through the ACA’s expansion of health coverage, many individuals incarcerated in county jails will become eligible to enroll in
either Medicaid or plans available through the exchanges.  This
expansion poses both opportunities and challenges in terms of
eligibility determination and enrollment of individuals who newly
qualify for coverage.  
The ACA requires a coordinated eligibility determination and
enrollment process for both Medicaid and plans offered on the
exchanges. This means that determining individuals’ eligibility for
either Medicaid or a product on the exchange is intended to be a
one-time streamlined screening conducted through a single application that is consumer-friendly and that minimizes administrative
burdens.  To facilitate the eligibility determination process, the U.S. 
Department of Health and Human Services (HHS) will operate a
data services hub to provide functions for the exchanges such as
verifying citizenship and tax information.10

10  Also, in September 2011 the U.S. Department of Health and Human Services proposed a partnership model for the health insurance exchanges
called for in the ACA.  The partnership model is intended to provide states
with additional exchange design options and will allow for states to perform some of the exchange functions and have the federal government
operate other functions.  For more information, see www.healthcare.gov/
news/factsheets/2011/09/exchanges09192011a.html

3

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

Particularly in states where county human services agencies currently determine whether families are eligible for Medicaid, counties will likely continue to help certain individuals with enrollment
in some way because of the ACA’s requirement of a “no wrong
door” approach for individuals applying for coverage.  However,
how county jails may be involved in the enrollment process remains a question, and their role has likely not yet been considered
much in state-level exchange planning efforts.

Issues Related to Enrolling
County Jail Inmates Eligible for
Health Coverage
Conducting eligibility determination and enrollment is outside
of the traditional scope of the core function of jails.  While some
jails already help enroll eligible individuals into public assistance
programs such as Medicaid as part of their pre-release planning
services, it is important to recognize that jails must focus on their
primary purpose and direct the majority of their resources on
inmate population management and public safety concerns. 
However, many county jails experience a substantial number of
individuals that cycle in and out of detention due to untreated
mental health and substance abuse problems. Although health
coverage does not guarantee access to services, enrolling these
individuals into appropriate health plans may increase the likelihood that they will be able to obtain more consistent physical and
behavioral health care.  Increased access to appropriate treatment
also has the potential to reduce the re-arrest rates of these individuals and consequently lessen the overall burden on county jails.
Considering these factors, counties may want to take the initiative
in beginning to plan for the development of processes to enroll
individuals in jail pending disposition of charges who fall into
the eligibility category for exchange plan coverage.  Additionally, regarding Medicaid, even though recently issued federal
regulations state that current rules regarding FFP and inmates
are not changed through the ACA, county jails can continue to
enroll those who are Medicaid-eligible into the program to help
expedite access to treatment and maintain continuity of care upon
their release from incarceration.
The following paragraphs outline some of the potential key issues
related to enrolling eligible individuals involved in the criminal
justice system into the new health coverage options that will
become available beginning in 2014. There are a number of other
challenges not addressed here related to ensuring that the ACA’s
expansion of health coverage translates into meaningful access to
medical and behavioral care for the unique needs of this population, such as having an adequate and qualified health provider
workforce as well as potential complications associated with
handling medical records and billing.  
4

• Ensuring county jails are considered as
a point of contact with newly eligible
individuals
The ACA specifically requires states to provide targeted outreach
to facilitate the enrollment of underserved and vulnerable populations in Medicaid or the Children’s Health Insurance Program.11 To
fulfill the intention of this provision, exchange planning by state
administrators should include consultation with a wide range of
local level stakeholders, such as county officials, community providers, as well as criminal justice authorities.12
For example in Massachusetts, which established a state-based
health insurance exchange in 2006, evaluations of enrollment data
show that a substantial portion of low-income young adults with
behavioral health issues were not receiving substance abuse treatment and were much less likely to be enrolled in health programs
than the general population.13 Since a large portion of jail detainees
have many of these same population characteristics, evidence from
Massachusetts’ experience appears to demonstrate the importance
of including the criminal justice system in enrollment efforts.  
Also some of the individuals who will be newly eligible in 2014
may not be aware that they qualify for health coverage. A number
of these individuals will have interactions with the criminal justice
system, and their time in custody could be an important opportunity to provide them with information about health coverage
options. As states develop their overarching enrollment outreach
strategies, they should recognize that it will be important to connect with staff at local jails and the wider justice system, such as
public defenders, probation officers and others. 

• Lack of staff capacity at jails to assist
with/conduct screening and enrollment
A number of jail inmates will require assistance in applying for health
coverage, as they may have limited literacy skills and/or lack experience using computers,14 or correctional authorities may determine
that all enrollment activities should be conducted specifically by jail
staff.  However many jails have staffing constraints and may have limited personnel available to engage in the additional work associated
with conducting the enrollment of eligible inmates.  

11  PPACA §2201(b)(1)(F)
12  McDonnell, Maureen, Laura Brookes, Arthur Lurigio and Daphne Baille.
“Realizing the Potential of National Health Care Reform to Reduce Criminal
Justice Expenditures and Recidivism Among Jail Populations.”  Community
Oriented Correctional Health Services Issue Paper.  January 2011.
13  Executive Report of the Working Group on Health Reform and Criminal
Justice: Implications for the Delivery of Behavioral Health Services to the
Criminal Justice Population Cycling through Jails.  Community Oriented Correctional Health Services. September 2011.
14  Ibid. and “The Implications of Health Reform for the 9 Million People
Who Cycle Through U.S. Jails Each Year: Frequently Asked Questions.”  Community Oriented Correctional Health Services.  May 2011.

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

The ACA does establish a Navigator program to provide funding
to entities that have the capacity to provide outreach and application assistance.  Entities with experience enrolling individuals into
federal programs—such as county human services agency staff—
may opt to participate in the program and could potentially assist
with enrolling eligible individuals in jails. Yet it will be important to
remember that some county human service agencies, nonprofit
organizations and other entities serving as Navigators may lack
experience working with jail populations and there may be challenges associated with establishing better connections between
these agencies and correctional authorities.   

• Barriers related to jail environment and
jail population characteristics
While jails may serve as an important place of interaction with
a substantial portion of the newly eligible individuals, there will
be enrollment challenges due to the nature and constraints
of the jail setting. First, high turnover rates are common in jail
populations—a substantial portion of jail detainees are released
within 48 hours, although the average length of detention varies
from two weeks to two months.15  Since a significant number of
individuals are released in a matter of days, for a large portion of
the justice-involved population there may not be sufficient time
during their stay in custody to conduct eligibility determination
and enrollment in Medicaid or an appropriate health plan on the
exchange.  Also, some county jails that currently conduct Medicaid
enrollment just prior to an inmate’s release have encountered
complications associated with inmates’ scheduled release dates
frequently changing, making it difficult to track individuals and
connect them to coverage in a timely way.
Another challenge is that some inmates will not have the appropriate documentation needed for enrollment, as they may
lack or not have on hand at the time of their arrest any form of
government-issued identification.16  Furthermore, for a variety of
reasons some justice-involved individuals might be reluctant to
enroll in health coverage.17

15  “The Implications of Expanded Medicaid Eligibility for the Criminal
Justice Population: Frequently Asked Questions.” Community Oriented Correctional Health Services.  May 2011.
16  “The Implications of Expanded Medicaid Eligibility for the Criminal
Justice Population: Frequently Asked Questions.” Community Oriented Correctional Health Services.  May 2011.
17  Some incarcerated individuals may be unwilling to enroll in federal
assistance programs due to issues such as delinquent child-support payments
or their involvement with gangs. (Executive Report of the Working Group on
Health Reform and Criminal Justice: Implications for the Delivery of Behavioral Health Services to the Criminal Justice Population Cycling through Jails.  
Community Oriented Correctional Health Services. September 2011.).  Also,
some jails that have tried to enroll incarcerated individuals at the time of their
release from jail found that after their release individuals were reluctant to
stay and complete any necessary enrollment paperwork.

• Information technology challenges
Assuming that jail staff do become involved in enrolling eligible
individuals into new health coverage options, one of the issues
that will need to be considered is the information technology capacity of jails.  For some jails there may need to be new hardware
installed to connect with the state exchange.  
There also may be some complications associated with county
information technology staff permitting electronic linkages to the
exchanges and issues related to establishing appropriate protections to ensure private health data are not compromised.  Counties that opt to enroll eligible incarcerated individuals will need
to work with state exchange planning commissions and state
Medicaid agencies to develop streamlined electronic enrollment
processes and procedures.

• Challenges associated with eligibility
changes
Individuals in jail pending disposition of charges who are in the exchange eligibility category should be able to enroll in an exchange
plan or if already enrolled in one be able to maintain this coverage,
although how exactly plan benefits and billing would operate for
this population is unclear. However if an individual is adjudicated
guilty the ACA requires that the enrollee must report this to the
state exchange as s/he would no longer be eligible for coverage. In
practice this would most likely require correctional facility staff or
other eligibility determination workers associated with the jail to
report this eligibility change to the exchange.  Yet federal rules also
allow a member of the enrollee’s household to report the eligibility
change and the state exchange itself is permitted to verify incarceration status via certain data sources. 
Regardless, questions remain about how exactly this reporting
process and coverage termination would occur within the jail setting. The rules further state that inmates are permitted to apply for
exchange coverage to help coordinate potential coverage upon
release from incarceration and that newly released qualified individuals are eligible for a special enrollment period.    
The ACA also requires that individuals self report when their income
changes to account for potential changes in the amount of premium subsidy support available to help them purchase exchange plan
coverage. This reporting is necessary because they may experience
an income increase or drop that affects whether they are eligible for
either Medicaid or exchange plan coverage. For individuals in jails,
similar to reporting changes in eligibility status, it is unclear how this
income change reporting might occur. Additionally with income
shifts there are other complications associated with maintaining
coverage of health services for incarcerated individuals. 
For example, if an individual is held in custody pre-adjudicated
for a substantial period of time and enrolled in an exchange plan,
without any income this person would likely eventually fall into

5

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

Medicaid’s eligibility category while they are in jail.18 Yet because
of existing Medicaid coverage limitations for all incarcerated individuals, any health services they might receive would be unable to
be reimbursed by Medicaid. 
Final rules related to the exchanges attempt to minimize coverage
gaps for individuals that move from exchange plan coverage to
Medicaid by allowing for the last day of exchange plan coverage to
be the day prior to the start of Medicaid coverage, if the individual is
eligible for the program. States could also potentially help reduce the
administrative burden associated with eligibility shifts by ensuring
that there are some plans offered that participate in both Medicaid
and the exchange market.  Both of these options could potentially
help individuals held pre-adjudicated for long periods of time in that
they would at least be able to remain enrolled in coverage. 

Potential Model Eligibility
and Enrollment Systems and
Processes
While there may be commonalities across jurisdictions, there can
be no standard set of specific enrollment procedures and protocols, and planning initiatives will be distinctive to each county. In
addition to having different considerations based on jail size, every
county has different types of relationships established within
their criminal justice and health care systems and operates under
unique state constraints. 
The following is a sampling of local and state practices that may
be able to serve as models for counties and states as they plan for
ensuring that vulnerable and underserved populations eligible
for health coverage in 2014, such as incarcerated individuals, are
enrolled as efficiently as possible.

Interagency Partnerships and Medicaid in
the New York City Jail System
In most jails, the department of corrections or the sheriff’s office is responsible for the provision of health care services to all
inmates.  In New York City (NYC) however, the Department of
Health and Mental Hygiene (DOHMH) is responsible for medical,
mental health, substance abuse, dental, discharge planning, and
transitional health care services for all inmates in the city’s jails. 
This helps facilitate a comprehensive public health approach to
health services for the incarcerated population.  Along those lines,
the DOHMH with assistance from the local department of social

18  In final federal regulations pertaining to the exchanges issued 3/12/12,
the U.S. Department of Health and Human Services indicated that it would
consider comments regarding maintaining coverage for incarcerated individuals leaving custody in future guidance.

6

Box 2: Key Local Criminal Justice
Stakeholders to Involve in Planning
for 2014 Health System Changes
For counties that choose to do so, developing plans to enroll
eligible individuals in county jails in the appropriate health
plan option in 2014 will involve a number of different stakeholders within the local criminal justice system, listed below:
County Officials: As elected officials, county officials can
lead and coordinate efforts among county jails, other county
agencies and community partners to plan for enrolling eligible individuals
County Sheriff: As a county official, the county sheriff can
serve an important leadership role in supporting enrollment
efforts and can promote public awareness about how providing justice-involved individuals with appropriate physical and
behavioral health services can lead to greater public safety
Jail Warden: Responsible for the secure confinement of
individuals in jail who are being held prior to their trials or
are serving short sentences after being convicted; could help
facilitate initial enrollment processes at booking and/or as
part of pre-release planning services
Pretrial Services Officer: Responsible for assessing individuals immediately after booking; although there could be some
time and resource constraints with attempting to conduct
enrollment at this stage, they could help facilitate the initial
stages of enrollment processes at booking and/or provide
information about health resources
Social Worker and/or Pre-Release Planning/Reentry Jail
Staff: Would likely serve a key role in enrolling eligible individuals in jails into appropriate health coverage options and/
or provide information about health resources
Other key individuals within the local criminal justice
system: Other individuals serving important roles in the local
criminal justice system, such as the district attorney’s office,
public defenders, judges and others should be aware of the
ACA’s health coverage opportunities for certain incarcerated
individuals; some, such as probation officers, may also be
directly involved with providing information to recently released inmates about health coverage options (see Alameda
County example)
Criminal Justice Coordinating Council (CJCC): Some counties have formed CJCCs, which are comprehensive committees made up of a wide range of individuals and entities connected to the criminal justice system, including local elected
officials; CJCCs could help bring together a diverse group of
key stakeholders to discuss potential enrollment processes
for incarcerated individuals   

County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

services invests substantial resources into Medicaid eligibility
screening and pre-enrollment services for mentally ill inmates
who account for about one-third of the NYC jail population, totaling approximately 30,000 admissions per year.  The DOHMH has
state-funded discharge planning staff who facilitate the screening
and pre-enrollment of eligible incarcerated individuals into various public entitlement programs including Medicaid.  Discharge
planning services, including benefits screening, generally begin
after the inmate has been in custody more than a week, and
negotiated arrangements with the state help address initial enrollment barriers related to lack of identification. Upon release, many
pre-screened inmates receive temporary pharmacy cards to help
them obtain needed psychotropic drugs prior to their Medicaid
determination and the city’s Service Planning and Assistance
Network can assist mentally ill inmates with discharge planning
services that they were unable to get while in jail, including the

Box 3: Steps Your County Can Pursue
to Prepare for Enrolling Justice-Involved
Individuals
The following are some steps that county officials, jail staff and
other county agencies working with incarcerated individuals may
want to consider as they begin to plan for health system changes
in 2014:
Improve data gathering and sharing: Gain a more comprehensive understanding of your county jail’s population characteristics
by collecting and analyzing relevant data; also determine how
data sharing and communication among stakeholders within
your county’s criminal justice system can be improved.
Consider current inmate screening and transition planning
processes: Evaluate current jail intake and discharge planning
services to determine if there may be a relatively straightforward
way to incorporate eligibility determination and enrollment
procedures or ways to modify existing enrollment practices to
accommodate the expected increase in newly eligible individuals. 
For example, counties with existing enrollment processes as part
of their reentry services could focus on adapting these efforts to
address anticipated needs in 2014. 
Also, jurisdictions that conduct pretrial screenings often include
health-related questions which potentially could be refined to
also identify possible eligibility for health coverage. Additionally, some jails that utilize existing transitional planning models
such as the APIC model (assess, plan, identify, coordinate) for
individuals with mental illness and co-occurring substance abuse
disorders might consider embedding eligibility screening and
enrollment at some point within this established process.1
Consider current roles of county staff interacting with justiceinvolved individuals: Assess whether it would be feasible for

completion of Medicaid applications.  Additionally, as New York is
one of the few states that suspend rather than terminate Medicaid
benefits upon incarceration, Medicaid beneficiaries incarcerated
less than 30 days are able to retain their status. Individuals who are
in custody more than 30 days can have their benefits suspended,
enabling them to generally reinstate coverage and gain access to
care more quickly upon release from jail.

• Comprehensive Reentry Services:
Allegheny County, PA
Well-designed county jail reentry programs may be able to serve
as models for enrolling eligible inmates in 2014.  For example, Allegheny County, PA established the Allegheny County Jail Collaborative (ACJC) in 2000 to better coordinate reentry services for county
jail inmates.  The Collaborative is comprised of representatives from
current staff responsibilities within the jail to be modified to
assist with eligibility determination and enrollment processes for
eligible inmates, or if state eligibility determination workers could
be utilized (see Salt Lake County, UT example). Alternatively there
may be other county staff, such as human services staff, who
could work more closely with county jails to facilitate enrollment
of eligible individuals.
Create or strengthen partnerships: Develop or enhance existing partnerships among local health care and community social
service providers serving justice-involved individuals to facilitate
better coordination and connection of justice-involved individuals to appropriate physical and behavioral health services. 
Connect with state-level officials: Communicate with statelevel policymakers, in particular state Medicaid directors, state
corrections officials and state exchange governing boards to
highlight the issue of how many newly eligible individuals for
both Medicaid and plans on the exchanges will come into contact with the criminal justice system. State officials may be able
to inform local planning efforts by providing estimates of the
number of newly eligible individuals in the state and potentially
by county.
Also, engage with state insurance regulators and health plan
providers about the needs of the justice-involved population and
how developing health plans that participate in both Medicaid
and the exchange market could help address challenges associated with eligibility changes.
Develop or improve jail diversion programs: Create or
strengthen county jail diversion programs to reduce inappropriate incarcerations of individuals with mental health and/or substance use disorders and instead connect them with communitybased support services.

1  Based on comments during NACo Sponsored Working Group on Medicaid Expansion.  February 23, 2012.

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County Jails and the Affordable Care Act: Enrolling Eligible Individuals in Health Coverage

the Allegheny County Jail, the county Department of Human
Services (DHS), the Court of Common Pleas (criminal division), and
the county Health Department.  The Jail Collaborative has initiated
comprehensive planning that includes reentry programming
which begins when individuals enter county jail. The wide range of
service coordination provided to incarcerated individuals includes
helping them apply for medical assistance and connecting them
to substance abuse treatment and/or mental health services.  Social workers at the jail assist in completing Medicaid enrollment
applications and supporting documentation prior to a planned
release and send the information to the local County Assistance
Office.  
Allegheny County DHS Justice Related Services and communitybased service coordinators may then also assist or accompany
individuals to the in-community office appointment with the
local the County Assistance Office to complete the application
process for Medicaid and to coordinate appropriate treatment
and support services post-release. In addition, the Allegheny
County Jail has developed a Discharge Center where staff help
individuals with their release by assisting with such items such as
medications, transportation, and appropriate clothing for their
release. These types of practices in Allegheny County and other
counties which have robust reentry support services can serve as
models for how enrollment could occur in jails in 2014. Additional
information regarding the Allegheny County programs is available
at www.alleghenycounty.us/dhs/jail.aspx.

• Post-Release Enrollment:
Alameda County, CA
California’s Bridge to Reform program is a Medicaid Demonstration Waiver that is designed to help the state plan for implementation of the ACA’s health care coverage expansion provisions.  One
of the primary initiatives of the program is the Low-Income Health
Program (LIHP) coverage expansion effort that uses federal Medicaid matching funds available through the waiver to help expand
health care coverage for low-income individuals in the state prior
to ACA Medicaid eligibility changes in 2014.  Alameda County is
one of the many counties in the state that have LIHPs, and their
program, HealthPAC, is an expansion of the existing County
Medical Service Program and aims to cover all county residents
with income under 200% FPL. The program has a component
that focuses on enrolling individuals just after their release from
jail during their probationary period, specifically focusing on the
AB109 population.19 While the effort is a pilot program, county
leaders view the initiative as a positive step toward connecting
justice-involved individuals to appropriate health care services
that could potentially be expanded in the future.

19  AB109 is a bill passed in 2011 by the California State Legislature to
address the U.S. Supreme Court order that mandated that California reduce
its prison population by May 2013 to address overcrowding issues. The law
moves inmates considered to be low-risk from state prisons to county jails,
and this is sometimes referred to as “prison realignment.”

8

• Preparing for 2014: Salt Lake County, UT
In Salt Lake County, UT, the Division of Behavioral Health Services
within the county’s Department of Human Services has helped
lead efforts to plan for how the justice-involved population within
the county will be affected by the ACA’s expansion of Medicaid
and creation of health insurance exchanges. By actively communicating with their state Medicaid office, they were able to gather
information demonstrating that most inmates in the county’s
jail system will fall into the new Medicaid expansion population
category.  To develop strategies for enrolling these newly eligible
individuals, they have created a health care services integration
coordinator position to help anticipate and plan for some of the
issues that the jail will need to consider in 2014.  Additionally, the
county is currently actively enrolling eligible inmates in Medicaid
so that they will be able to receive benefits upon their release. 
This process has been facilitated by the county directly employing
state Medicaid eligibility determination workers by paying the
Medicaid administrative match rate, as well as by working with
other community partners.  

Conclusion
There are a number of challenges to be addressed in terms of developing enrollment processes for incarcerated individuals who will
become newly eligible for health coverage through the ACA and
there are still unanswered questions related to the law’s implementation.  Consequently many counties will not be ready to enroll all
eligible individuals in jails by 2014 or may choose to wait to develop
enrollment strategies for this population group until after the ACA’s
coverage expansion provisions have taken effect.  
However, there are a number of reasons that some counties may
choose to consider beginning enrollment planning efforts for
justice-involved individuals.  The ACA’s expansion of health coverage can better connect individuals involved in the criminal justice
system to appropriate medical and behavioral health care services,
which in turn has the potential to reduce recidivism rates as well as
county jail health care costs. Considering the many possible public
health and criminal justice system benefits, counties may want
to begin taking incremental planning steps now and continue to
move forward on developing enrollment processes and procedures for eligible individuals in county jails even after 2014.  

Additional Resources
For further information on this topic and related issues, please see:
• NACo’s health reform implementation page: www.naco.org/
healthreformimplement
• NACo’s criminal justice programs: www.naco.org/programs/
csd/Pages/Justice.aspx
• Community Oriented Correctional Health Services (COCHS):
www.cochs.org