Men and women leaving jails or prison face some of the highest overdose risk of any population in the country. Typically, by the 3rd month of release, an estimated 75 percent of previously incarcerated people with an opioid use disorder (OUD) experience a return to opioid use, and formerly incarcerated individuals are between 10 to 40 times more likely to die of an opioid overdose than the general population, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) [1]. That gap is not the availability of treatment anymore but more of an accreditation and continuity-of-care problem: Are the systems that touch this population before, during, and after their incarceration, actually built to hand that person off to one another — without losing them in the transition? This is a defining element which can spell success or failure.
The Accreditation Landscape
There are three accrediting bodies that shape how behavioral health providers serve the general population, including previously incarcerated persons with substance use disorders (SUD), and each plays a distinct role in how behavioral healthcare programs are structured and standardized.
CARF International’s Behavioral Health Standards Manual allows an accredited organization to add a Criminal Justice specific population designation on top of the core ASPIRE to Excellence and General Program Standards that every accredited organization must meet [2]. CARF also separately accredits Court Treatment and Diversion/Intervention programs, giving drug courts, diversion programs, and jail-based treatment programs a defined accreditation pathway that is distinct from the standard outpatient or residential SUD programs. It’s more specialized and population specific, giving special attention to the needs of formerly incarcerated people.
The Joint Commission, which also accredits behavioral health organizations, including opioid treatment programs (OTPs), under its Comprehensive Accreditation Manual for Behavioral Health Care and Human Services, and many community providers that provide care to that population also hold Joint Commission accreditation for their broader SUD treatment operations.
The National Commission on Correctional Health Care (NCCHC) also occupies a narrower but important role: it’s the only accrediting body authorized by SAMHSA to accredit opioid treatment programs (OTPs) operating inside correctional facilities [3]. This is important because federal law requires a methadone-dispensing OTP to be both certified by SAMHSA and accredited by a SAMHSA-approved body; a jail or prison seeking to operate methadone treatment on-site must generally go through NCCHC rather than the standard community accreditation route. It’s a very difficult route. As of 2021, only 30 correctional facilities nationally had achieved NCCHC’s OTP accreditation, illustrating how early-stage this specific segment of the field still is [4]. To put that into a broader context, of the thousands of correctional facilities in the United States (adult prisons, local jails, and juvenile confinement facilities), that’s less than half of 1 percent of correctional facilities nationwide.
The 2024 Federal Rule Change
The regulatory landscape changed significantly in 2024. SAMHSA and the U.S. Department of Health and Human Services published the first substantial revision to 42 CFR Part 8, the federal regulation governing opioid treatment programs, in more than 20 years [5]. The final rule took effect April 2, 2024, with an October 2, 2024 compliance date, and directly addressed correctional institutions and facilities and the need for change: under the newly revised rule, jails and prisons could now register as a hospital or clinic, allowing them to directly dispense methadone to treat OUD and to manage acute opioid withdrawal, rather than relying solely on an outside OTP for every dose [6]. This new rule also replaced the old requirement that inmates must have had at least one year of active addiction for admission into the program with a formalized clinical determination, and it codified telehealth as an additional method of care and allowed for more take-home dose flexibility — which was first introduced during the COVID-19 public health emergency [7]. This was the biggest change in 20 years to the rules on correctional medications for OUD. The rules are starting to catch up with the science. Standards, policies, and surveyor expectations at CARF, NCCHC, and state licensing bodies are still catching up to what the new rules allow.
What Continuity of Care Actually Requires
Accreditation standards translate this new regulatory shift into very specific and real operational requirements. NCCHC now recommends universal OUD screening for everyone entering a facility, initiation or continuation of medications for opioid use disorder (MOUD) during incarceration (sometimes known as medication-assisted treatment, or MAT), and continuity of MOUD treatment at both entry and release, with coordination happening directly with community-based treatment providers [8]. This “warm handoff” model requires correctional health staff and community SUD providers to share clinical information, confirms the inmate receives an appointment before release rather than simply issuing a referral (hoping the individual actually uses it and makes an appointment), and, in the best-performing facilities, provides a bridge supply of medication so the person is not left without treatment during the first days back in the community, when overdose risk is highest. This population may self-medicate when proper medications are not available to them [9].
The Medicaid Shift
Financing has historically been the weak link, largely because of the Medicaid Inmate Exclusion Policy, which has long prohibited Medicaid from paying for most services delivered during a person’s incarceration. That started changing in April 2023, when the Centers for Medicare & Medicaid Services (CMS) issued new guidance inviting states to apply for Section 1115 “reentry” demonstration waivers, partially lifting that exclusion for a defined pre-release window, typically 30 to 90 days, so states could bill Medicaid for services including case management and MOUD before someone was even released [10]. As of April 2025, CMS had approved 19 state reentry waivers, with nine more pending, and California became the first state to implement its waiver in October 2024 [11]. Separately, the Consolidated Appropriations Act, 2023 requires state Medicaid and Children’s Health Insurance Program (CHIP) programs to cover specific services for justice-involved youth starting January 1, 2025 [12]. For accredited providers, the good news is that this means the financing and clinical-coordination pieces for continuity of care are moving in the same direction at the same time and in a growing number of states.
What This Means for Providers
For behavioral health organizations deciding whether to build out justice-involved or correctional-facing SUD services, the key takeaway is that accreditation and continuity-of-care design are no longer separate decisions. A program trying to achieve CARF’s Criminal Justice population designation, or a Court Treatment or Diversion/Intervention accreditation, will need to show documented, tested handoff protocols with its correctional and community partners well before any survey, not just policies written to satisfy a CARF standard. A correctional facility considering in-house MOUD dispensing under the revised 42 CFR Part 8 needs to understand upfront that doing so on any meaningful scale using methadone still likely requires NCCHC accreditation specifically, and on a timeline measured in months, not weeks. And any organization operating in a state with an approved or pending Section 1115 reentry waiver has a genuine, near-term financing opportunity to fund pre-release engagement that did not exist five years ago; whether that organization’s clinical and billing infrastructure is actually in place to benefit from it is a separate, and sometimes overlooked, question.
The overdose statistics in this article are not new, nor is the underlying diagnosis: people leaving incarceration die because the systems meant to catch them do not talk to each other in time. What has changed is that federal regulations, accreditation standards, and Medicaid financing are simultaneously being rebuilt to close that gap and catch these people before they fall. For organizations serving justice-involved individuals with substance use disorders, this is both the opportunity the field has been waiting for and the compliance challenge that will separate the providers who can close the gap from those who simply document that they tried.
A. Ant, CADC-II, is CEO of Continued Compliance, Inc., and can be reached at continuedcompliance.com, [email protected], or (213) 864-8554.
References
[1] Substance Abuse and Mental Health Services Administration. “Breaking the Cycle: Medication-Assisted Treatment (MAT) in the Criminal Justice System.” SAMHSA Blog, 2019. samhsa.gov/blog/breaking-cycle-medication-assisted-treatment-mat-criminal-justice-system [2] CARF International. Behavioral Health Standards Manual, Section 4, Specific Population Designation Standards (Criminal Justice); South Carolina Department of Health and Human Services, “Accreditation Crosswalk for Rehabilitative Behavioral Health Services,” scdhhs.gov. [3] National Commission on Correctional Health Care. “Opioid Treatment,” NCCHC Standards Q&A. ncchc.org. [4] Washoe County, Nevada. “Washoe County Sheriff’s Office Detention Facility Awarded Accreditation from Commission on Correctional Health Care.” Press release, September 1, 2021. [5] Substance Abuse and Mental Health Services Administration. “42 CFR Part 8 Final Rule.” SAMHSA.gov, updated January 31, 2024. samhsa.gov/substance-use/treatment/opioid-treatment-program/42-cfr-part-8 [6] Rutgers Center of Excellence on Addiction / Justice Community Opioid Innovation Network (JCOIN). “Expanding Access to Methadone Treatment for Opioid Use Disorder in Carceral Settings.” Webinar summary, July 16, 2024. [7] Epstein Becker & Green, Health Law Advisor. “SAMHSA Final Rule Regarding OTPs Expands Access, Increases Flexibility for Patients.” 2024. [8] National Commission on Correctional Health Care. “Opioid Use Disorder Treatment in Correctional Settings.” Position Statement, 2021, updated April 2022. [9] Khantzian, E.J. “The Self-Medication Hypothesis of Addictive Disorders: Focus on Heroin and Cocaine Dependence.” American Journal of Psychiatry 142, no. 11 (1985): 1259–1264. [10] KFF. “Section 1115 Waiver Watch: Medicaid Pre-Release Services for People Who Are Incarcerated.” kff.org. [11] Justice Community Opioid Innovation Network (JCOIN). “State Pathways for Improving Pre-Release Services and Supports: Medicaid Initiatives & 1115 Reentry Waivers.” April 2025. jcoinctc.org. [12] National Conference of State Legislatures. “New Medicaid Options Can Help Inmates Transition Out of the Justice System.” ncsl.org.
