Table of Contents
Introduction
When older adults leave prison or jail, they often face particular challenges to successful reentry into their communities. They may be leaving with chronic health conditions as well as physical and mental disabilities that inhibit activities of daily living. As a result of structural racism in the criminal legal system and the criminalization of poverty, older adults leaving carceral settings are more likely to be low-income people of color. They are at risk of not meeting their basic needs due to discrimination and gaps in public benefits and social services systems. However, opportunities exist for advocates, states, and federal policymakers to connect older adults leaving prison and jail to programs that help them thrive. This policy paper identifies promising practices and models in housing, health care and economic security to better support older adults transitioning from carceral settings to the community.
Connecting to Housing
Stable housing is vital for older adults re-entering the community. Yet formerly incarcerated older adults face high risks of homelessness due to various factors, including lack of income and housing discrimination against people with criminal records. The 2023 California Statewide Study of People Experiencing Homelessness, for instance, found that a significant number (33%) of older adults in the study identified their criminal records as a barrier to securing permanent housing.[1] Worse yet, homelessness also increases the risk of reincarceration due to the rising criminalization of acts related to homelessness, such as loitering or sleeping outside.[2] An additional challenge is that these unhoused older adults, who often have complex medical conditions or physical and cognitive disabilities, need a range of supports to find and maintain housing.
Some states and local communities are, however, developing ways of delivering these supports and increasing access to housing for formerly incarcerated people. Two promising models for supporting this population include: (1) Permanent supportive housing with a “Housing First” approach; and (2) Medicaid 1115 waivers that provide housing-related services.
Provide Permanent Supportive Housing with a “Housing First” Approach
An important intervention that can meet the housing needs of formerly incarcerated older adults is permanent supportive housing (PSH). PSH provides rental assistance and voluntary supportive services without time limits, and PSH usually targets households with disabilities at risk of or experiencing chronic homelessness. PSH supports, which aim to promote housing retention and independent living, may include wraparound services such as case management and behavioral health treatment.[3] PSH programs can also be tailored for specific subpopulations, such as older adults and people with prior involvement in the criminal legal system.
Importantly, PSH programs tend to adopt a “Housing First” approach. Housing First is a proven model of addressing homelessness that expedites access – with minimal preconditions – to permanent housing with voluntary supports. Housing First programs have low-barrier admissions policies and, unlike other types of housing, generally do not screen people out because of criminal records (with limited exceptions).[4] When these programs do screen for criminal history, they still seek to minimize the impact of criminal records. For example, before denying anyone based on a criminal conviction, Housing First programs may encourage applicants to provide mitigating information, such as medical records or letters of support from third parties, in order to conduct holistic and individualized assessments of applicants’ criminal histories and present circumstances.[5] Such practices reduce overbroad, discriminatory housing denials based on criminal records.
Research has demonstrated that PSH with a Housing First approach is effective in keeping people housed and can break the cycle between incarceration and homelessness. One recent example is the Denver Supportive Housing Social Impact Bond Initiative, a study which provided supportive housing to people experiencing chronic homelessness who also had a history of involvement with the criminal legal system. Results showed that 77% of participants remained stably housed after three years, and participants had an average of 40% fewer re-arrests than people who received services in the community but did not receive supportive housing.[6] In a similar study of a program called Returning Home Ohio (RHO), researchers evaluated a program offering PSH to people re-entering the community with certain medical needs and at risk of homelessness. Compared to the control group, participants were 40% less likely to be re-arrested and 61% less likely to return to prison within a year. In addition, over a period of nearly four years, approximately 79% of participants maintained their housing.[7]
Given PSH’s effectiveness and the high rates of homelessness among formerly incarcerated older adults, communities should consider prioritizing this group for placement in PSH. Most PSH placements occur through a community’s HUD-funded coordinated entry system run by groups called Continuums of Care (CoCs). CoCs exist in every state, and each CoC operates a coordinated entry system that prioritizes eligible households for referral to homeless interventions like supportive housing, with higher-need households given higher priority for referrals. (One barrier for the reentry population, however, is that people must meet HUD’s definition of “homeless” to qualify for CoC assistance; people leaving institutions, such as prisons, are only eligible if they meet narrow criteria.)[8]
Coordinated entry assessments focus on a household’s vulnerability to continued homelessness, and CoCs can incorporate an individual’s history of incarceration into these evaluations. For example, various CoCs use assessment tools that ask about people’s contacts with the criminal legal system and the frequency or length of time an individual has been incarcerated.[9] Such assessments recognize that people’s criminal legal involvement creates barriers to housing and indicates a greater need for assistance. Some CoCs also consider older age in their prioritization criteria for similar reasons.[10] By prioritizing formerly incarcerated older adults for referrals to PSH, communities can target limited PSH resources to people with some of the greatest housing challenges and meet this population’s needs.
Leverage Medicaid Section 1115 Waivers to Provide Housing Supports
New flexibilities in the Medicaid program offer opportunities for states to address enrollees’ health-related social needs, including housing through Section 1115 Demonstration waivers.[11] Through these waivers, states have started to use Medicaid funding to cover housing supports such as housing search assistance and eviction prevention services. Section 1115 waivers also allow states to provide certain Medicaid recipients with temporary rental assistance for up to six months, which can serve as a critical bridge while people connect to long-term supports.[12] States with approved waivers have targeted these housing services to subpopulations that often include formerly incarcerated older adults, such as people with criminal legal system involvement or people at risk of or experiencing homelessness.
Oregon, for example, is leveraging a Medicaid 1115 waiver to offer comprehensive housing supports for formerly incarcerated older adults. Under Oregon’s 1115 waiver, some Medicaid enrollees – including people 65 and older – who are transitioning from carceral settings or at risk of or experiencing homelessness can qualify for various Medicaid-funded housing benefits. These benefits include rental and utility assistance for up to six months. Other available housing supports include home modifications necessary for health and safety, as well as tenancy sustaining services that help individuals with issues like communicating with landlords, understanding leases, and referring people to legal aid.[13] Oregon’s Medicaid-funded housing supports therefore aim to provide a broad range of assistance in finding and retaining housing.
As states continue to implement these waivers, cross-sector collaboration will be key for successful outcomes. To support such collaborations, the U.S. Department of Health and Human Services (HHS) and Housing and Urban Development (HUD) recently launched the Housing and Services Partnership Accelerator program. The Accelerator program provides technical assistance for participating states with approved 1115 waivers covering housing-related services. A central focus of the program is to foster partnerships between the housing, health, and aging and disability sectors to better align systems and advance strategies for reducing homelessness for older adults and people with disabilities.[14] HHS and HUD should encourage states to include entities providing reentry services, such as state departments of corrections (DOCs), in these interdisciplinary efforts as well. Doing so could result in more coordination across agencies to prevent homelessness for older adults leaving incarceration.
Connecting to Health Care
Leverage Medicaid 1115 Demonstrations to Connect to Home and Community-Based Services
States can also use 1115 waivers to provide health care and supports to individuals reentering the community after incarceration. People leaving incarceration, including older adults, exhibit disproportionately high rates of chronic health conditions, as well as disproportionately high rates of disability, mental health disorders, and substance use.[15] They also tend to have little to no income and few resources, and therefore rely on programs like Medicaid to meet their health care needs. Unfortunately, due to Medicaid law’s prohibition on federal reimbursement for medical services in jails and prisons, people leaving incarceration often experience gaps in their care that lead to poor health outcomes, including exacerbated health conditions, repeated hospitalizations, frequent use of emergency rooms, and high overdose and suicide rates.
Recognizing that medical services are essential to improve health outcomes for individuals leaving incarceration, nearly half of states have received or are currently seeking Section 1115[16] demonstration authority to waive Medicaid’s federal “inmate exclusion” and allow access to Medicaid services starting thirty to ninety days prior to release from incarceration.[17]
The Centers for Medicare and Medicaid Services (CMS) encouraged states to apply for 1115 demonstrations to deliver pre-release Medicaid eligibility and reentry services in guidance to states from April 2023.[18] CMS is requiring all states to include a minimum set of benefits in their demonstrations: case management to assess needs and assist with access to pre- and post-release services, Medication-Assisted Treatments for substance use disorders, and a 30-day supply of prescription medication. However, because 1115 demonstrations give states flexibility in whom to serve and what services to include, there is significant variation among current reentry demonstrations in the target populations eligible to access pre-release services and in the types of services provided.
Although people leaving incarceration have high rates of disability, states’ demonstration applications largely leave out the home and community-based services (HCBS) that are key for people who need support with activities of daily living. Excluding HCBS in the pre-release phase can easily translate into their exclusion from reentry planning altogether. For example, the implementation guide for California’s Justice Involved CalAIM initiative did not include any HCBS in pre-release screening, assessments, reentry planning and post-release service coordination, until disability and aging advocates raised this with the state.[19]
Despite heavy investment in pre-release supports, older adults and people with disabilities are at risk of unmet care needs that can lead to housing instability, poor health outcomes, and institutionalization if access to necessary HCBS is not integrated into these demonstrations. In light of disproportionately high disability rates among individuals leaving incarceration, states should include pre-release activities that anticipate a need for HCBS, and screen and connect individuals with Medicaid HCBS at reentry by:
- Requiring screening for HCBS in pre-release needs assessments.
- Including HCBS navigation services in the 1115 demonstration for individuals who need assistance with activities of daily living or other supports.
- Including application support and service certification assistance as a reimbursable service provided by in-reach case management.
- Including coordination of HCBS at reentry as a covered reimbursable service.
- Including HCBS coordination as part of housing navigation and support through the reentry planning process.
Advocates should provide input to their state Medicaid agencies during all stages of the reentry demonstration waiver process on these recommendations, from application through implementation. It is critical for HCBS advocates to be at the table so that older adults and people with disabilities are not left behind as states undertake this transformative opportunity.
Foster Connections to Medicare Enrollment Counseling
As discussed above, due to the low incomes and savings of people leaving incarceration, Medicaid is a common health care option. However, it is not the only option. Adults age 65 and older and people with disabilities may be eligible for Medicare.
Medicare coverage is helpful for a number of different reasons. For some older adults re-entering with higher incomes or savings, Medicare may be their only health coverage option. For other individuals who are also eligible for Medicaid, enrolling in both Medicaid and Medicare can result in more expansive provider networks and broader service coverage.
Enrolling in Medicare at re-entry can be confusing. Unfortunately, many older adults leaving incarceration nor people in the reentry sector do not know Medicare is an option, and, if they do, they probably have questions like:
- How do I know if I am eligible?
- How do I avoid late enrollment penalties?
- Is there help available for Medicare premiums and other costs?
- My Social Security check is being reduced by past-due Medicare premiums. Is there anything I can do?
There is a network of free, unbiased Medicare counselors who are part of the State Health Insurance Assistance Program (SHIP network) available in every state. For example, a SHIP counselor can:
As the incarcerated population grows older, there is an opportunity to connect the re-entry sector with SHIP counselors. For instance, many states are currently in the process of hiring a large cohort of re-entry navigators as part of Medicaid re-entry demonstrations. These navigators could identify individuals likely eligible for Medicare, advise them of their coverage options, and refer them to their local SHIP. Navigators can also take advantage of outreach resources developed by CMS and translated into eight languages (Arabic, Chinese, Haitian Creole, Korean, Russian, Spanish, Ukrainian, and Vietnamese) to help individuals connect to Medicare, Medicaid, and other health coverage upon re-entry.
Connecting to Economic Security
Supplemental Security Income (SSI) and Social Security are foundational benefits that help older adults and individuals with disabilities to secure housing and pay for other basic needs. To ensure that the SSI program better supports formerly incarcerated older adults, the SSI 12-month suspension limit should be removed, and the Social Security Administration (SSA) should share best practices for the pre-release process.[20]
Allow SSI To Resume Upon Release for Individuals Who Previously Qualified
For individuals who were receiving public benefits prior to incarceration, being able to re-connect to these benefits is important for a successful transition to the community. For older adults who are not yet eligible for age-based benefits and only qualify for disability-based benefits, the re-connection rules differ between SSI disability and SSDI, with the SSI rule making it difficult for individuals to quickly resume their prior benefit.
An individual who received SSDI or another Social Security benefit prior to incarceration can reinstate their benefit upon release with no significant limitations. In contrast, an individual who received SSI prior to incarceration can only reinstate their SSI benefit after their release if it is within 12 months of when their SSI benefit was suspended. In practice, the differing rules mean that individuals who previously received SSDI are able to easily re-connect to benefits, while individuals who previously received SSI on the basis of disability are negatively impacted by the 12-month suspension limit and may need to file a new disability application.
A more effective and equitable process would allow SSA to reinstate the SSI benefit regardless of how long the person has been incarcerated, as is the case with SSDI. This change would make the SSI rule consistent with the SSDI rule and also be more consistent with our understanding of disability. There is no indication that being incarcerated for more than one year improves disability and, if anything, is more likely to worsen a disabling condition.
Share Best Practices for SSA’s Pre-Release Process
Individuals who were not receiving SSI or Social Security before incarceration can use SSA’s pre-release process to submit an application up to several months before their anticipated release, with SSA determining the individual’s potential eligibility and payment amount based on their anticipated circumstances.
Individuals with little to no income and resources can qualify for SSI if they are age 65 or older or if they meet SSA’s definition of disability. The disability determination process is notoriously difficult and can take several years for individuals whose applications are denied and who must appeal the denial. Formerly incarcerated individuals with disabilities who are homeless or housing-insecure experience barriers with even basic elements of the application process, such as having a stable address or phone number, making it difficult to successfully complete an application. Improving the effectiveness of SSA’s pre-release process would help individuals with disabilities to submit complete and comprehensive disability applications to SSA, and increase the likelihood of individuals who qualify actually receiving the disability benefit upon release.
Individuals age 65 or older have a much simpler SSI application experience, as they do not need to go through the disability determination process. Ensuring an effective SSA pre-release process should allow virtually all of these formerly incarcerated older adults to receive SSI benefits upon release.
The details of SSA pre-release agreements can vary, both from state to state and even within the same state as a local jail may have their own pre-release agreement. SSA should review how the process works now, gather best practices from existing SSA pre-release agreements and other relevant reentry efforts, and share this information with federal, state, local, and community partners interested in and engaged in this work. The work of gathering and sharing best practices can help identify areas where applicants or application partners lack adequate information, or where gaps exist in operations or policy. This information can help SSA to improve its outreach, as well as its pre-release processes and coordination. Better coordination can also help maximize the impact of pre-release work in other benefit programs like Medicare and SNAP, helping formerly incarcerated individuals to access all of the benefits they qualify for more quickly, at a time when they need them the most.
Conclusion
Whether in the context of health care, housing, or economic security, reentry and aging advocates and state and federal policymakers have opportunities to support older adults leaving prison and jail by connecting them to and improving the important services and programs that allow them to age with dignity in their communities.
Endnotes
Benioff Homelessness and Housing Initiative, “Toward Dignity: Understanding Older Adult Homelessness” (May 2024). ↑
See, e.g., The Appeal, “Cities Rush to Criminalize Homelessness After Supreme Court Ruling” (August 2024). ↑
HUD Exchange, Permanent Supportive Housing (PSH); HUD, Notice CPD-16-11, Notice on Prioritizing Persons Experiencing Chronic Homelessness and other Vulnerable Homeless Persons in Permanent Supportive Housing (July 2016). ↑
HUD does not require homeless assistance projects funded by the Continuum of Care program to disqualify households based on criminal history, and the agency strongly discourages projects from excluding people on the basis of criminal records. However, projects may be subject to other federal, state, or local laws that require them to screen out people with certain records, such as people on sex offender registries who may be prohibited from living in certain areas. HUD Exchange, Fair Housing and Equal Access – Criminal History. ↑
HUD, “Implementing Housing First Practices for People Involved with the Criminal Justice System.” ↑
Urban Institute, “Housing First Breaks the Homelessness-Jail Cycle” (July 2021). ↑
HUD, “Reducing Offender Recidivism and Reconnecting Opportunity Youth” (2016). ↑
People who are leaving institutions where they have stayed for more 90 days do not meet HUD’s definition of “homeless” and are not eligible for CoC-funded homeless assistance, including many PSH programs. Only people who were homeless before entering an institution where they stayed for 90 days or less qualify as “homeless.” 24 CFR § 91.5; 24 CFR § 578.3. Other types of homeless assistance, such as Medicaid-funded housing supports, may have broader eligibility criteria. ↑
HUD, “Strategies for Prioritizing People with Criminal Records in Coordinated Entry Systems.” ↑
See, e.g., Cobb Homeless Alliance, “What is Coordinated Entry?”; Lee County Continuum of Care Written Standards & Coordinated Entry Policies and Procedures (July 2023). ↑
States can also use other Medicaid authorities, such as state plan authorities, to cover health-related social needs. See CMS, Coverage of Health-Related Social needs (HRSN) Services in Medicaid and the Children’s Health Insurance Program (CHIP) (November 2023). ↑
Center on Budget and Policy Priorities, “States Can Use Medicaid to Help Address Health-Related Social Needs” (February 2024). ↑
Oregon Health Authority, Frequently Asked Questions (FAQ): OHP 1115 Medicaid Waiver for 2022-2027. ↑
Housing and Services Resource Center, Housing and Services Partnership Accelerator Program Overview. ↑
Health Affairs, Vol 41, No. 10, “The Links Between Disability, Incarceration, and Social Exclusion,” (Oct, 2022). ↑
§1905(a)(30)(A) of the Social Security Act. ↑
As of August 2024, CMS approved eleven such demonstrations, with thirteen applications pending approval. Hinton, Elizabeth, Pillai, Akash, and Diana, Amaya, KFF, “Section 1115 Waiver Watch: Medicaid Pre-release Services for People Who are Incarcerated,” (Aug. 19, 2024). ↑
CMS, SMD #23-003 “Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who are Incarcerated,” (April 17, 2023). ↑
California Department of Health Care Services, Policy and Operational Guide for Planning and Implementing the CalAIM Justice-Involved Reentry Initiative (October 20, 2023) (final version that includes reference to home and community-based services has not been made public by the time of this publication.). ↑
The Social Security Advisory Board has also made a number of recommendations to improve reentry for SSI claimants in its report on Supplemental Security Income and Incarceration (2024). ↑
