Federal and state officials have grown increasingly concerned about the large number of individuals with serious mental illness who leave state prisons without health insurance and therefore without access to treatments and services to help them live successfully in the community and avoid recidivism and use of emergency care. Their disability and low income would qualify many for Medicaid, but complex eligibility rules and application procedures have created barriers.

A demonstration project in three Oklahoma correctional facilities significantly improved access to Medicaid for discharged inmates with mental illness, according to a report from the Substance Abuse and Mental Health Services Administration (SAMHSA), which funded the project. On the day of release, about 25% of eligible inmates were enrolled in Medicaid, compared with 8% of eligible inmates at the same facilities in the three years before the program and 3% of eligible inmates discharged from similar facilities during the program period.

Although the program was implemented in June 2007 and evaluated over the next year, Mathematica Policy Research (MPR), which provided technical assistance and conducted the evaluation, began work in January 2005 with an interagency steering committee of staff from a wide range of state agencies to design the model program. Three facilities were chosen that represent 23% of all inmates in Oklahoma's correctional facilities and about 36% of inmates with serious mental illness in the state: a 1,400-bed, medium-security facility for men with designated units for inmates with mental illness; a 200-bed, maximum-security facility for women with units for inmates with mental illness; and a 2,000-bed, maximum-security prison with a mental health unit.

The model program aimed to achieve Medicaid enrollment on the day of release for all inmates with mental illness in a three-step process: about six to nine months before their release, identify inmates with severe mental illness who are likely eligible for Medicaid; four months before release help them apply for federal disability benefits; and two months before release assist them with subsequent Medicaid applications. Critical to the success of the program, according to MPR's evaluation, were new appropriations from the state legislature that enabled the Oklahoma Department of Mental Health and Substance Abuse Services to hire three discharge managers to improve discharge planning for the target group. The evaluation also indicated that staff training, interagency agreements that simplified application procedures, and sustained interagency collaborations were critical to successful implementation.

The 78-page report, Establishing and Maintaining Medicaid Eligibility Upon Release From Public Institutions, provides a description of program implementation, analyses of outcomes (both quantitative and qualitative), and a summary of key lessons learned. An important chapter details the complex federal Medicaid rules governing establishment and maintenance of eligibility—as well as lapses and suspension for inmates in state facilities—and Social Security Administration rules and procedures for establishing disability and becoming eligible for cash assistance. Barriers created by federal and state policies are identified and solutions proposed.

"The study underscores the importance of interagency collaboration to help people with serious mental illness and substance abuse disorders obtain access to needed services to sustain their life in the community," said SAMHSA Administrator Pamela S. Hyde, J.D., when the report was released. "As a result, barriers to health and behavioral health care are reduced and recovery is supported so that people do not find their way back into higher cost systems."

The report is available on the SAMHSA Web site at www.samhsa.gov/shin.