DPSS ePolicy

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Federal Medicaid regulations prohibit Federal Financial Participation (FFP) for certain individuals due to institutional status.

Individuals who are inmates of public institutions are not eligible for Medi-Cal (MC).  An individual is considered an “inmate of a public institution” from the date of incarceration in a prison, county, city, or tribal jail, until permanent release, bail, probation, or parole.

Effective January 1, 2014, Assembly Bill (AB) 720 amended Senate Bill (SB) 1147, requiring the suspension of MC benefits rather than discontinuance, for all inmates (regardless of age) who are MC beneficiaries at the time of incarceration.  Benefits are suspended for up to 12 months or until the inmate is released, whichever occurs first.  Additionally, AB 720 requires the restoration of MC benefits on the day the inmate is released from the public institution, if they are released within 12 months of their incarceration date.

Title 42, United States Code (U.S.C.), Section 1396d and Title 42, Code of Federal Regulation (CFR), Section 435.1008(a)(l) state that FFP is not available in expenditures for services provided to certain individuals who are residing in public institutions.  Title 42 CFR Section 435.1009 states that an inmate of a public institution is a person who is residing in a public institution.

On October 11, 2016, the California Department of Corrections and Rehabilitation (CDCR) amended the California Code of Regulations (CCR) Title 15, Crime Prevention and Corrections, Division 3 – Adult Institutions, Programs and Parole, which authorized CDCR to develop the Alternative Custody Program and Enhanced Alternative Custody Program (EACP). 

Effective January 1, 2010, SB 1147 (Chapter 546, Statutes of 2008) required the suspension rather than the termination of MC benefits for individuals under 21 years of age, who were MC beneficiaries at the time they became inmates of a public institution.  SB 1147 also required restoration of MC benefits on the day the beneficiary was released from a public institution.

Not Eligible to MC

The following individuals are considered inmates of a public institution and are not eligible to MC:

1. Incarcerated in a public institution.
   • This includes individuals being held prior to arraignment, conviction, or sentencing.  It does not include individuals who are out on bail or their own recognizance.
2. Incarcerated but can leave prison or jail on work release or work furlough and must return at specific intervals.
3. Released from prison or jail due to a medical emergency, who would otherwise be incarcerated but for the medical emergency.
4. A minor is in a juvenile detention center prior to disposition (judgment) due to criminal activity of the minor.
5. A minor after disposition is placed in a detention or correctional facility, including a youth ranch, forestry camp, or home which is part of the criminal justice system.
6. A minor is placed on probation by a juvenile court, or on juvenile intensive probation with specific conditions of release, including residence in a juvenile detention center.
7. A minor is placed on probation by a juvenile court, or on juvenile intensive probation to a secure treatment facility contracted with the juvenile detention center if the secure treatment facility is part of the criminal justice system.
8. The federal inmate is participating in a RRC.
   • The DOJ, FBOP retains responsibility for payment of health care services rendered to individuals residing in RRCs.

Eligible to MC

The following individuals are not considered inmates of a public institution and may be eligible to MC, provided that all other MC requirements are met:

1. An individual who after being arrested but before booking is escorted by police to a hospital for medical treatment and held under guard.
2. An individual is in prison or jail and transferred temporarily (one or two months) to a halfway house or residential treatment facility, prior to a formal probation release order.
3. An individual is released from prison or jail, probation, parole, or release order, with a condition of:
   • Home arrest;
   • Work release;
   • Community service;
   • Outpatient treatment; or
   • Inpatient treatment.
4. An individual is released from prison or jail under a court probation order due to a medical emergency.
5. A minor is in a juvenile detention center prior to disposition (judgment) due to care, protection or in the best interest of the child (e.g., Child Protective Services), if there is a specific plan for that person that makes staying at the detention center temporary (one to two months).  This could include those juveniles awaiting placement but still physically present in juvenile hall.
6. A minor placed on probation by a juvenile court, or on juvenile intensive probation with home arrest restrictions.
7. A minor placed on probation by a juvenile court, or on juvenile intensive probation to a secure treatment facility contracted with the juvenile detention center, if the secure treatment facility is not part of the criminal justice system.  This would include juveniles who become wards of the court and placed in a 24-hour non-medical residential facility which provides counseling and other rehabilitative services.
8. A minor is placed on probation by a juvenile court, or on juvenile intensive probation with treatment as a condition of probation:
   • In a psychiatric hospital;
   • In a residential treatment center; or
   • As an outpatient.
9. An individual with tuberculosis is under an order of detention to protect public health:
   • In a residential treatment center;
   • In a skilled nursing facility; or
   • In a county, city, or tribal jail awaiting placement for treatment.

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