# Presentation: 043024

## Enrolling Jail Diversion Program Participants in Medicaid, SSI, and SSDI

- GAINS TAPA Center for Jail Diversion Easy Access Net/Teleconference
- August 25, 2005

## Agenda 

- 2:00-2:30   Medicaid SSI/SSDI:
- 	Overview including issues of “fleeing felons”; disability criteria; pre-release agreements and suspension of Medicaid during incarceration
- 2:30-2:40   Debbie MacKie, St. Louis County, MO Jail Diversion Program
- 2:40-2:50   Promising Practices:  Deborah Dennis, Policy Research Associates
- 2:50-3:30   Questions and Discussion

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Overview of the SSI/SSDI and Medicaid Enrollment Process for Criminal Justice-Involved Individuals

- Yvonne M. Perret, MA, MSW, LCSW-C
- Advocacy and Training Center
- Baltimore, MD

## Overview of SSI/SSDI

**SSA has two disability programs**:
_***Supplemental Security Income***_** (SSI):  Disability program for people who are low income and aged, blind or disabled.  Income based on need.  Includes limits on income and resources for eligibility.  Limited federal benefit rate.**
_***Social Security Disability Income***_** (SSDI):  Based on earnings put into FICA.  Income amount dependent on earnings history.  No limit on resources.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## SSI and SSDI: Similarities

- Both require countable income from earnings to be less than $830/month (2005), which is Substantial Gainful Activity (SGA) for 2005. (For people who are blind, earnings are $1,380/month).
- Both have same medical criteria.
- Both have health insurance tied to the program.
- Both have work incentives.
- Both have similar application process

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

**Notes:**
FOR YP:  Ohio is 209B state...more restrictive limit on resources for ABD:  $1500.  Has`spenddown.  Eligibility income is 64% of Federal Poverty Level or $5958.  SSI is total of $6948/year.  Issue is resource limit.

## SSI and SSDI: Differences

**SSI:**
**Limit on resources:  $2,000 for individual applicant**
**Maximum federal  benefit: $579/mo. (2005)****	**
**Living arrangement affects benefit amount**

**SSDI:**
**No limit on resources**
**Benefit based on earnings.  Average benefit:  $895/mo. (2005)**
**No effect on benefit from living arrangement.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Health Insurance		

**SSI:**
**Medicaid eligibility automatic in most states**
**Other states require additional eligibility criteria**
**SSDI:**
**Provides Medicare after two years of eligibility**
**Part D Prescription program begins January, 2006**
**Restricted formulary for adults with serious mental illness**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Medicaid

_***Eligibility in General:***_
**States have different eligibility rules**
**Some states have Federal only Medicaid with a state match**
**Some states have a state option Medicaid**
**States applying for additional waivers that generally reduce Medicaid coverage though it may expand populations**
**People cannot be found eligible for Medicaid while in a jail or prison**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Special Criminal Justice Issues

_***ELIGIBILITY FOR SSI/SSDI***_**:**
**Institutions may have pre-release agreements with SSA, either formally written or informal.**
**Individuals institutionalized can apply for SSI benefits within 30 days of their release.**
**SSDI applications can be done by phone or on-line.  SSI applications require a phone or in-person contact.**
**SSA should assign a contact person to the institution to assist with this procedure.**
**The individual should inform SSA of any delays in release and should notify SSA when released.**
**This may help with decisions on applications sooner.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## “Fleeing Felons”

**At time of application for SSI, applicants required to complete “Statement of Claimant”, SSA 795.**
**This form asks two main questions:**
**Does the individual have any outstanding felony warrants?**
**If the individual is on parole/probation, is he/she in violation?**
**If the answer to one or both of these is yes, these problems must be addressed for the application to move forward.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## SSA’s Criteria for Disability

**To be eligible for either SSI or SSDI, an individual must meet three criteria:  **
**(1)  The person must have a medically determinable physical or mental impairment *****that either meets or is equivalent to the listing of impairments that DDS considers.***
**(2)  The duration of the impairment must have lasted or be expected to last 12 months or more or result in death.**
**(3)  The person must show significant functional problems caused by the medical impairment.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Functional Areas Considered

_***Activities of daily living***_**:  Dressing, bathing, eating, cooking, shopping, transporting oneself, maintaining a place to live, budgeting, washing, using a phone, etc.**
_***Social Functioning***_**:  Ability to communicate with and get along with other people.**
_***Maintaining Concentration, Persistence and Pace in the Completion of Tasks***_**:  Memory, concentration, following instructions, completing tasks in comparable time period to others, distractiblility, focus.  Cognitive tasks. **
_***Repeated Episodes of Decompensation***_**:  Three or more attempts to work within the last year resulted in symptom increase and inability to maintain employment.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Sequential Evaluation:  The Process of Determining Disability

- “**Sequential Evaluation”—Process used by SSA and DDS to determine disability.**
**Consists of 5 major steps.**
**Person can be found eligible at step 3 or 5.**
**Medical records are basis for making determination.  Information from others (family, friends, other service providers) also considered.****    **

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Sequential Evaluation: The Steps

**Step 1.  Is the person making SGA?**
***If yes, denied.                           ******	****** If no, on to step 2.*****            **
**Step 2.  Does the person have a severe impairment?**
***If yes, on to step 3.                 ******	****** If no, denied.***
**Step 3.  Does the impairment meet or equal the listing?**
***If yes, APPROVED!******	******	****** If no, on to step 4.***
**Step 4.  Does the impairment allow for past relevant work to be done?  (*****In other words, can the person do work he/she did in the past?)***
***If yes, denied.      ******	******	******If no, on to step 5.***
**Step 5.  Considering the person’s age, work history and education, can he/she do any work that exists in national economy?**
***If yes, denied.        ******	******	******If no, APPROVED!***

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Special Criminal Justice Issues

**Incentive payments:  Certain state and local correctional facilities and mental health institutions can receive payment for every SSI recipient disenrolled following incarcerated/hospitalized.**
**To receive payment, the institution must have a signed agreement with SSA.**
**For every SSI or SSDI recipient suspended from benefits because of information provided, the institution receives:  $400 for information received within 30 days and $200 for information received 30-90 days after confinement.**** **

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Special Criminal Justice Issues

**SUSPENSION/TERMINATION OF SSI/SSDI:**
**SSI is suspended when a person is in a jail or state hospital for a full calendar month. **
**After 12 months of suspension, SSI benefits are terminated.  Upon release, the individual has to re-apply.**
**SSDI:  Continues while in jail prior to conviction of a felony.  After such conviction, benefits are suspended.  No new re-application is needed to reinstate, simply what’s called a “re-determination.”**
**Legal proof of release is required to re-determine benefits. **

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Special Criminal Justice Issues 

**SUSPENSION RATHER THAN TERMINATION OF MEDICAID**
**Possible under Federal law**
**Requires state legislative approval**
**Usual barrier is re-tooling of computer systems that put people in termination rather than suspense if institutionalized.**
**Bazelon Center has model law for states to use as guide.**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Entitlement Enrollment in St. Louis, MO’s Jail Diversion Initiatives

**Debbie MacKie, MS, LPC**
**BJC Behavioral Health**
**St. Louis, MO **

## Jail Diversion Initiatives in St. Louis County, MO

**Mental Health Court **
**Post-booking Jail Diversion **
**Pre-booking through CIT **

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Recognizing the need...

- 5 year federal ACCESS demonstration project (completed in ‘00) to help homeless individuals with SMI get into service.
- Most of the target pop. lacked ability to go through the normal application process and a large % were involved w/ justice system.
- Establishing internal specialists at the CMHC dramatically increased the likelihood of securing benefits
- Institutionalized for all clients entering services (not just homeless) under Community Services Team.

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## How it works...

_**All**_ new admissions to service without current coverage are referred to Entitlement Specialist to assist with application.
- Jail Diversion Team Intensive Case Managers are given priority access for scheduling their clients for application.

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Entitlement Specialist

- Employed by the CMH agency to assist Seriously Mentally Ill consumers in making application for Social Security, Medicaid, and other benefits
- Cross trained by the local Social Security Administration staff, Division of Family Services (Medicaid) staff
- Maintains direct relationships with SSA and DFS staff to facilitate application process

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Entitlement enrollment

- All clients are given opportunity to meet with the *Entitlement Specialist* to access needed resources and services.
- Access to benefits is fundamental to reducing homelessness among the mental ill (Sullivan, 2000, p. 1139). Benefits (Burt, 1989; Robertson, 1986; Bybee, 1994; and Landoff, 1997).
- Offenders meet with the Entitlement Specialist who will assist the client in determining their eligibility and applying for the following:

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Entitlements and assistance

- Social Security
- SSI
- SSDI
- Medicaid
- Food Stamps
- Social Security Card
- Birth Certificates (for housing/employment)
- State ID cards

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Div. of Family Services worker

- A DFS worker is also on site to assist clients in completing the
- Food Stamp application
- TANF application
- Food Stamps –
- ($142 a month for 1 person),
- Emergency Food Stamps are available and usually takes about 30 days,

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Statistics

**95% of defendants participate**
**74% successfully completed the program and had their charges dismissed**
**Social Security Benefits: 26% to 54% **
**Medicaid: 7% to 68%**
**Food Stamps: 37% to 47%**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Promising Practices for Enhancing Access to SSA Disability Programs

**Deborah Dennis, MA**
**Policy Research Associates, Inc.**
**Delmar, NY**

## Current Reality...

- Nationally, 37% of SSA disability applications are approved upon initial submission
- Increases to 53% after appeals

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

**Notes:**
  This figure is for ALL applicants for SSA disability programs – for homeless and/or mentally ill persons, we suspect the rate is significantly lower.

## What We Know Is Possible...

- Approval rates on initial
- application of 60-95%can be achieved

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## What Does It Take?

- Adequate staffing or collaboration with a provider that assists with SSI applications
- Training
- A focus on the initial application
- Become an applicant’s representative (SSA Form 1696)
- Use consultative exams effectively
- Work closely with medical providers
- Relationships with hospital and clinic medical records departments
- Reach out to DDS and SSA
- Develop medical summary reports signed by a physician
- Collecting and reporting on outcomes

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## PRA Activities Related to Enhancing Access to SSI

*Stepping Stones to Recovery* reference manual published by SAMHSA
*Stepping Stones to Recovery *training curriculum and Train-the-Trainer program
*Promising Practices for SSI Outreach* – an issue brief based on interviews with more than 25 programs
- SOAR – SSI/SSDI Outreach, Access, and Recovery – Technical Assistance Initiative

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## Why SOAR?

- Realized that training wasn’t enough
- Line staff were excited about learning new skills, but frustrated by:
- Lack of agency support
- Limited access to medical records for documentation
- No access to physicians, psychologists, and psychiatrists for medical evaluations
- Poor relationships with DDS and SSA

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## SOAR Technical Assistance Initiative

- Offered to States participating in the Federal Interagency Policy Academies on Homelessness
- Requires collaboration and planning among key stakeholders – Corrections identified as key team member
- Provides technical assistance designed to increase access to SSI in 14 states
- Strategic planning with pilot in 1-2 communities in each State
- Train-the-Trainer program to give each State the capacity to provide on-going training
- Emphasis on measuring outcomes to ensure long-term support and broad dissemination

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## SOAR States

- Arizona
- Florida
- Georgia
- Hawaii
- Kentucky
- Louisiana
- Montana

- Ohio
- Oklahoma
- Oregon
- Utah
- Virginia
- Washington
- Los Angeles County

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI

## For more information, please feel free to contact...

**Yvonne M. Perret, MA, MSW, LCSW-C**
**Executive Director**
**Advocacy and Training Center**
- _[yperret@hereintown.net](mailto:yperret@hereintown.net)_** **
**Debbie MacKie, MS, LPC **
**BJC Behavioral Health**
- _[djm3062@bjc.org](mailto:djm3062@bjc.org)_** **
**(314) 206-3764**
**Deborah Dennis, MA**
**Policy Research Associates, Inc.**
- _[ddennis@prainc.com](mailto:ddennis@prainc.com)_** **
**(518) 439-7415, ext. 238**

- GAINS TAPA Center Net/Teleconference: Enrolling Jail Diversion Program Participants in Medicaid, SSI & SSDI