The Pressure Test by 46 North

IDOC / Centurion Health of Indiana · Contract #64083 · Sep 22, 2026 · @Someone

Bottom line

Indiana is paying more every year for a prison health contract it can no longer enforce. Contract #64083 with Centurion Health of Indiana, a Centene subsidiary, now authorizes $1,015,608,223 across six amendments.

Over five years the per diem at a comparable census rose about 31%. In the same period the State's staffing paybacks were cut twice, loosened, and then deleted. Performance penalties are now capped at $70,500 a month, about 0.4% of the current term, and the excess goes to Centurion's own payroll.

The State audits 258 performance measures and can charge for 145 of them. Inmate deaths, overdose data, infection control, access to care, staffing competency, pharmacy and prescriptions carry no penalty. The ICE detainee add-on runs about $341,000 per clinical FTE a year and carries no penalty of any kind.

The contract ends March 31, 2027. If a new vendor isn't awarded and staffed by then, the State negotiates a third short extension against a deadline, on the vendor's terms.

The contract by the numbers

Authorized spending has grown from $643.2 million for four years to $1,015.6 million through March 31, 2027. Centurion won in 2021 as the most expensive of four bidders, and the outgoing vendor, Wexford, bid about $30 million a year less (WFYI / AP, May 2021).

Term. Four years, July 1, 2021 through June 30, 2025, with an option to reach eight years under RFP §1.14. Amendment 4 extended nine months to March 31, 2026, and Amendment 6 extended one year to March 31, 2027. Each extension is terminable by the State on 90 days' notice.

Contract #64083 base Section 2, Amendments 4 and 6 · 6 pricing periods

At the 26,700-inmate band, the only census in both extension tables, the rate rose from $19.00 to $20.80 in one year, a 9.5% increase. The step from Year 4 into Amendment 4 was 9.6%. Since Year 1 the rate is up 31%.

Amendment 6's $213,575,956.91 reconciles within $2 to the 27,001-inmate band plus the ICE fee. Amendment 4's does not. Its $152.2 million is $15.2 million more than nine months at its own planning band (25,800 inmates, $182.75 million a year).

Annualized, Amendment 4 authorized $203.0 million, almost exactly what Amendment 6 later priced at 26,700 to 27,001 inmates ($202.7 to $203.6 million). The next year's increase appears to have been budgeted before it was negotiated.

Where Indiana is losing

Seven findings, ranked by what each costs the State. The first three are laid out in detail in the sections that follow.

1. The State pays for a full staff whether or not the staff shows up. The per diem is priced on a staffing matrix of 791.84 FTEs, down from 825.38 in 2021 (Indiana Lawyer, June 2026). The payback for unfilled hours was cut twice, measured more loosely, and then deleted in June 2025. Two of those changes were retroactive and forgave money already owed.
2. Penalties above $70,500 a month go back to Centurion. Exhibit G sets the State's cost of each failed facility audit at no less than $5,000, so the cap absorbs about 14 failures a month. Every failure after that is free, and the uncollected amount funds Centurion's payroll, which the per diem already covers.
3. Nearly half the scorecard carries no penalty. 113 of 258 measures can be failed at no cost, including inmate-death review, overdose data, infection control and access to care. The scorecard also runs on the vendor's records, and IndyStar found ICE-detainee backlogs far higher than what Centurion reported to the State (Indiana Capital Chronicle, July 2026).
4. The ICE add-on costs more than twice the prison rate and carries no penalty of any kind. $9.96 million a year for about 600 detainees is roughly $45.50 per detainee per day, against $20.66 per inmate in the main contract. Its staffing matrix has no physician, dentist or psychiatric prescriber. Two detainees have died, and ICE counted 804 doses not given in 22 days of April, 44 of them because the medication was not on hand (Indiana Capital Chronicle).
5. The renewal option has no price attached. The State can extend to eight years, but Amendments 4 and 5 say the price of any extension must be mutually agreed. Centurion names its number, and the State has accepted two increases of about 9.5% in a row. Amendment 4 appears to have budgeted the second one a year early.
6. The State negotiates against the clock. Amendment 4 was signed 14 days before the contract expired and Amendment 6 was signed 20 days before. IDOC issued a solicitation in September 2025 and canceled it on May 20, 2026, after Amendment 6 was signed (Indiana Lawyer); the contract ends March 31, 2027.
7. Performance security is $5 million on a $214 million year. Amendment 2 set evidence of financial responsibility at $5 million, 2.3% of the current term. What Exhibit A §1.25 originally required is not in the amendment file.

The recovery rights, removed one amendment at a time

In 2021 Centurion owed the State for every staffing hour below 90% of the matrix. Since July 1, 2025, it owes nothing for unfilled hours.

Two drafting errors sit inside that history. Amendment 2 replaces "95%" in a section that said 85% in Amendment 1 and 90% originally. Amendment 4 deletes Section 1.C, while Exhibit G still says the vendor must reimburse IDOC for staffing vacancies; the contract outranks its exhibits, so the safer reading is that staffing paybacks are gone.

Amendment 2's quarterly action plans are the last visible check. The Indiana Lawyer requested them from IDOC in June 2026 and had received none at publication (Indiana Lawyer).

The scorecard with no teeth

The State audits 258 measures in 38 categories and can charge for 145 of them. The other 113, in 20 categories, are audited for the record only.

Amendment 2, Exhibit G performance categories (version June 9, 2023) · 20 categories

A failed audit is a score under 90% in one category at one facility. It costs Centurion $5,000, credited on the next invoice, after a 14-day window in which Centurion may submit documentation to cure it. A systemwide quarterly average under 90% is a breach of contract.

The categories that can be charged include chronic care, sick call, specialty care, mental health, medication administration and emergency services. The ones that cannot include death review and overdose data, where the State most needs a lever.

Amendment 6's cap sets the ceiling on all of it. $70,500 a month equals 14 failed audits across every facility and every chargeable category combined.

The ICE add-on

Amendment 5 pays Centurion $830,343 a month, flat, for detainee care at Miami Correctional Facility. The fee does not move with the detainee count, and the amendment waives every staffing payback and performance penalty.

Amendment 5, Exhibit B-1 · 8 expense lines, $9,964,117.60 total

Operational and administrative costs, $3.11 million, exceed the entire clinical payroll. "Other personnel costs" add $1.55 million, unexplained, on top of $1.05 million in benefits and taxes. The exhibit's "percent allocated to ICE contract" column reads 0.00% on every line.

The fee buys 29.2 FTEs, about $341,000 per FTE a year. The main contract runs about $257,000 per FTE at its planning census, and that figure includes pharmacy and off-site hospital care. At the 600-plus detainees reported in June, the fee is about $45.50 per detainee per day, against $20.66 per inmate in the main contract (Indiana Capital Chronicle).

The amendment covers medical, dental and mental health, and the State bought a $22,485 panoramic dental x-ray for it. The matrix has no physician, dentist or psychiatric prescriber. Either main-contract staff treat detainees, which raises whether detainees also sit in the main per-diem census, or detainees go without that care.

ICE's own accounting shows what a no-penalty clause protects. Over 22 days in April, 804 doses were not given, 44 of them because the medication was not on hand. Two detainees have died, the Governor has ordered a review, and the ACLU of Indiana has sued (Indiana Capital Chronicle).

The amendment also names the federal counterparty as the "U.S. Immigration and Naturalization Services," an agency abolished in 2003.

Pharmacy and 340B: what the State cannot see

Pharmacy runs about $19.5 million a year inside the per diem, and the contract has never required a single report on what it costs. The subcontractor is Clinical Solutions, LLC, a certified women's business enterprise, at 9.12% of the current term; its share was 10.54% through Amendment 3 and 8.99% in Amendment 4.

The vendor changed before day one. Centurion's bid named BosWell Prescription Center, the incumbent's pharmacy and IDOC's registered 340B contract pharmacy, at $16.3 million a year. Clinical Solutions appears instead, effective September 1, 2021, a swap that required State consent under Section 5.B. The file records neither the reason, what the State received for consenting, nor who owns Clinical Solutions.

The State is a drug buyer with no price protection. Hepatitis C antivirals sit outside the per diem; IDOC buys them through a 340B arrangement with the state health department as covered entity. The only 340B term in six amendments makes Centurion cover the cost difference if the State fails a federal audit because of Centurion's actions (Amendment 1, §5). Nothing governs ceiling-price reconciliation, contract-pharmacy fees or an inventory audit.

Pharmacy failures cost nothing. Exhibit G's Pharmacy Services and Prescriptions categories, 16 measures, carry no penalty. That includes the standard that every prescribed medication arrive within 48 hours.

What the State already holds:

• A records right under Section 4 that reaches subcontractor pharmacy cost
• The formulary, run through a P&T committee chaired by IDOC's chief medical officer
• Off-site hospital care capped by statute at Medicare plus 4% (IC 11-10-3-6)

What it has never had:

• A duty to report pharmacy cost by drug, pharmacy and price paid
• A clause returning manufacturer rebates and discounts
• A NADAC benchmark for generics
• A pharmacy audit protocol with a delivery deadline

IDOC issued a pharmacy-services request for information with responses due July 1, 2026 (Indiana Lawyer). Carving pharmacy out of the per diem is now a live option for the rebid.