Maine Jails Can Now Bill Medicaid for Addiction Treatment. The Bill Arrives in 2028.

For sixty years, federal Medicaid law has treated incarceration as a wall. A person in a county jail is not eligible for Medicaid coverage, so the jail pays for every doctor visit, every dose of medication, and every psychiatric evaluation out of the same budget that buys mattresses and meals. County officials have complained about that arrangement for as long as anyone can remember, and for most of that time the complaint went nowhere.

On Sept. 25, the Centers for Medicare & Medicaid Services approved Maine's Whole Person Care waiver, opening a door in that wall. Under the approval, correctional facilities can bill MaineCare — Maine's Medicaid program — for certain health services delivered up to 60 days before someone is released. Youth correctional facilities get 90 days, according to The Maine Monitor, which reported the approval on Oct. 1.

"This is one of the largest changes in the criminal-legal system in 30 years," Dr. Courtney Pladsen, MaineCare's medical director, told the Monitor.

The change matters most for people leaving custody with an opioid use disorder, a group that accounts for a disproportionate share of the state's overdose deaths. Maine's jails and prisons have been legally required to provide opioid addiction treatment since a 2019 ruling in Smith v. Aroostook County, the ACLU of Maine case that forced counties to continue medication-assisted treatment for people already receiving it. What the ruling did not do was pay for it. The waiver does — at least for the pre-release window.

Sixty Years of a Wall, and the Door Congress Left Open

The exclusion dates to Medicaid's creation. Federal law bars the program from paying for health care for incarcerated people, which is why correctional health care has always been a county line item rather than a shared federal one — and why the quality of care inside a jail depends heavily on the size of the local tax base.

The workaround came from Congress in 2018, when a bipartisan law passed during the first Trump administration let states seek Section 1115 waivers specifically for reentry services in carceral facilities. States apply, HHS negotiates, and the resulting demonstration allows Medicaid to cover a defined set of services during a window before release. Maine now joins 21 other states and the District of Columbia operating one.

Maine's path was slow by design. Gov. Janet Mills signed the authorizing law in July 2023, directing the Department of Health and Human Services to apply. Assembling the application took roughly a year and a half and required input from all 15 of the state's county-run jails, the Maine Sheriffs' Association, and the Department of Corrections. Pladsen said the lesson from that process was that the counties are not interchangeable.

"I heard very clearly from the sheriffs that what happens and works in Aroostook County is not going to work and what happens in Cumberland County," she said. "And so rather than having one uniformed initiative and one uniformed implementation plan, we are going to work with each county individually."

What the Waiver Actually Covers

The list of newly billable services is longer than the headlines about buprenorphine suggest. MaineCare will now cover case management and reentry planning, medication treatment for substance use disorder, HIV and hepatitis C treatment, family planning services, and a 30-day supply of prescriptions handed to a person at the moment of release.

Approximately 30,600 people leave Maine's prisons and county jails each year, and the state estimates that roughly 70 percent of them are eligible for MaineCare. Beginning coverage before release means a prescription can be active and a prescriber identified while the person is still inside, rather than after they have spent their first night back in the community.

"We'll be able to provide really much more comprehensive services within all the jails in the state of Maine in the pre-release period," said Dr. Alane O'Connor, who works with the Maine Sheriffs' Association and oversees extended-release buprenorphine programs at the Franklin and Somerset county jails.

Why a 30-Day Supply Is Not a Logistics Detail

For a person on daily buprenorphine or methadone, an interruption in medication produces withdrawal within a day or two, and withdrawal is the moment of highest relapse risk. The waiver's prescription provision is an attempt to remove that gap at the one point where the state controls both the medication supply and the person's location. It is also narrow: it covers the supply, not the appointment that follows it.

The approval also renewed Maine's authority to bill Medicaid for residential substance use treatment in facilities with more than 16 beds — a longstanding federal restriction many states have waived — and added short-term inpatient coverage for adults with serious mental illness in certain settings meeting the federal definition of an institution for mental disease.

The Money Question That Started This

County jails pushed for the waiver because the alternative was their own budgets, and those budgets were losing. A January report from the Maine County Corrections Professional Standards Council documented what jail administrators had been saying anecdotally: county jails spent more than $12.6 million on addiction and mental health treatment in a single year, a figure that has been climbing and that counties have patched with temporary money, including opioid settlement funds.

"This is good news," said Somerset County administrator Tim Curtis, a member of the council that assembled the cost estimates by working with each county individually. "This is beneficial to the county taxpayer but most of all it's beneficial to the inmate that needs certain services and coverage."

That sentence describes the coalition that made the waiver possible. Counties want budget relief. Providers want continuity of care. Sheriffs want fewer people returning to their facilities within months of release. The sheriff running a jail and the physician running an extended-release buprenorphine clinic are, in this instance, arguing for the same policy.

Two Years, Fifteen Jails, and No Electronic Records

The approval is not the implementation. Maine has 120 days to submit a plan to the federal government describing how it will stand up the program, and Pladsen has been explicit that this is where the difficulty lives: fifteen separate workflows instead of one uniform rollout.

The first obstacle is infrastructure. Most Maine jails have no electronic health record system, which means they currently have no clean way to document a service, let alone bill for one. Installing that technology and training staff to use it is a prerequisite for drawing down federal money, and it will pace the rollout. Pladsen said the state expects facilities to begin billing MaineCare on July 1, 2028, with the timeline varying considerably from county to county. O'Connor's assessment was blunter: "I think it's still going to be a lengthy process in terms of getting everything up and running."

National groups are trying to shorten that gap. The Health and Reentry Project, which works at the intersection of health policy and incarceration, launched a technical assistance center on Oct. 1 aimed at states in exactly this implementation phase.

"This will make it easier when someone leaves to have access to medications and easier for them to see a doctor because those connections to services will start prior to release," said Vikki Wachino, the project's executive director. She framed the payoff in both directions: "We know that when people have access to health care and access to mental health care, they are less likely to experience the criminal justice system or to be reincarcerated."

A Second Change Hiding in the Same Approval

Buried in the same approval is a first for Maine: a pathway for MaineCare to reimburse traditional healing services provided through eligible Tribal health programs serving the Wabanaki Nations. Federal Medicaid rules have historically had no billing category for Indigenous healing practices, which meant Tribal health programs could offer them but not bill for them. Maine's waiver creates one.

The provision arrived through years of negotiation with the Wabanaki Nations rather than through the corrections work, and it will take effect on an even longer horizon than the jail changes — the state's posted timeline puts traditional healing services in October 2027. It is the kind of item that gets lost in coverage of a jail-billing story, and it may prove the more durable policy change.

What the Waiver Does Not Do

The honest caveats start with the calendar. Between now and mid-2028, thousands of Mainers will be released with the same medication cliff they have always faced, in a state where opioid settlement dollars have been covering in-custody treatment costs year to year. A waiver approval changes who is allowed to pay for care. It does not build a bed, hire a prescriber, or create a single post-release appointment.

It also stops at the gate. Coverage extends to services during incarceration and the 60 days before release. Housing, employment support, and the community treatment capacity a person needs in the first week out are governed by other programs with other budgets, and the waiver expands none of them. Medicaid is a payment mechanism, and payment mechanisms are necessary but rarely sufficient.

And the eligibility rules outside the waiver still apply. MaineCare enrollment depends on income and category, and federal policy around work requirements and redeterminations keeps shifting, which is why state officials describe pre-release enrollment as the strategic value of the waiver rather than just the billing change. Signing someone up while they are in custody, in a room with a case manager, is far easier than expecting them to complete an application in the weeks after release.

What Maine has bought, for now, is a policy mechanism and a two-year construction project. The county jails that have been rationing care for a decade and the people who walk out their doors are watching the same timeline.