Effective Dates: 1/08/2025 - Present

Identification Number:
HI 00805 TN 117
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Supplementary Medical Insurance Entitlement
Type:POMS Full Transmittals
Program:Medicare
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part HI – Health Insurance

Chapter 008 – Requirement for Entitlement and Termination

Subchapter 05 – Supplementary Medical Insurance Entitlement

Transmittal No. 117, 01/08/2025

Audience

PSC: BET, BTE, CR, CST, CTE, DEC, EHI, LCC, PAS, PCS, PETL, RECONR;
OCO-OEIO: BET, BIES, CCRE, CR, CTE, EIE, ERE, FCR, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DEC, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

Updating this section due to the changes that are being published in CMS-1809-P.

Summary of Changes

HI 00805.386 Exceptional Conditions Special Enrollment Period (SEP) for Formerly Incarcerated

Removing the current eligibility criteria in Section B to include individuals who have been released from incarceration or who are on parole, probation, home detention, or who are required to live in halfway houses, to further support these individuals. Also, adding the following language in the note under subsection C:

"For individuals who were released from incarceration to a halfway house prior to 1/1/25 and would have otherwise been eligible for this SEP prior to that date, technicians should consider other enrollment options, including, but not limited to the SEP for other exceptional conditions found at HI 00805.387.”

HI 00805.386 Exceptional Conditions Special Enrollment Period (SEP) for Formerly Incarcerated

 

A. Background

Section 1862(a)(2) and (3) of the Social Security Act generally prohibits Medicare payment for covered services while the recipient is incarcerated, as the incarcerated individual is provided healthcare through their penal institution (see HI 00620.070C). Further, section 202(x)(1)(A) of the Act prohibits the payment of Old-Age, Survivors, and Disability Insurance (OASDI) benefits to individuals who are incarcerated (see GN 02607.160).

For example, if an individual turns 65 and qualifies for Medicare while incarcerated and is not yet receiving OASDI benefits, that individual is not automatically enrolled in Medicare Part A. If these formerly incarcerated individuals do not enroll or reenroll into Medicare, they may go months without health insurance coverage upon their release.

Prior to the implementation of this SEP on 1/1/23, such formerly incarcerated individuals would only be able to enroll in Medicare during the General Enrollment Period (GEP) which could result in a significant delay in coverage. Further, delaying enrollment means that they may incur a premium surcharge for premium Part A and/or a premium surcharge for Part B for the rest of their lives.

These instructions provide an SEP for formerly incarcerated individuals released on or after January 1, 2023. Individuals released prior to January 1, 2023 are not covered under the SEP regulations at 42 CFR § 407.23(d).

B. Eligibility

Definition: For the purposes of these instructions, incarcerated refers to individuals who are determined to be incarcerated through data made available to SSA (See GN 02607.160 and GN 02607.700).

NOTE: As of January 1, 2025, individuals on parole, probation, home confinement or released from confinement to residency in halfway houses, will be able to demonstrate that they have been released from confinement and will also be eligible for this SEP. See GN 02607.200.C.

For evidentiary requirements, see Section C.

To be eligible for this SEP, an individual would have to:

  • •

    Demonstrate that they are eligible for Medicare; and

  • •

    Due to being incarcerated (as defined in this section), failed to enroll or reenroll in Medicare premium Part A or Part B during another enrollment period in which they were eligible to enroll while they were incarcerated; and

  • •

    There must be a record that the individual has been officially released from incarceration on or after January 1, 2023, or released from confinement to residency in a halfway house, as defined above, on or after January 1, 2025, either through the appropriate discharge documents or data available to SSA.

C. Evidence

  1. 1. 

    Use normal processing instructions for handling of verification of inmate’s official release documents in GN 02607.840.

  2. 2. 

    Halfway House Residency Verification: Individuals residing in halfway houses are generally not eligible for OASDI benefits (See GN 02607.001 and GN 02607.200). However, individuals who have been released from incarceration on or after January 1, 2025, and are residing in a halfway house, are eligible for this SEP. An individual need not prove residency in a halfway house in order to qualify for this SEP. If verification of the formerly incarcerated individual’s release can be determined using the instructions in GN 02607.840, the halfway house resident is eligible for this SEP.

    a. If verification of release documentation cannot be obtained using directions in GN 02607.840, the individual cannot use the SEP.

  3. 3. 

    Individuals on parole, probation, or home confinement on or after January 1, 2025, will be able to demonstrate that they have been released from confinement and will also be eligible for this SEP. See GN 02607.200.C.

NOTE: For individuals who were released from incarceration to a halfway house prior to 1/1/25 and would have otherwise been eligible for this SEP prior to that date, technicians should consider other enrollment options, including, but not limited to the SEP for other exceptional conditions found at HI 00805.387.

D. Duration

  1. 1. 

    This SEP duration would begin the day of the individual’s release from incarceration, as defined above, as long as it is on or after January 1, 2023.

  2. 2. 

    The duration end date will be the last day of the 12th month after the individual is released from incarceration.

    Example: The individual was incarcerated when they turned 65 and therefore missed their IEP. The individual was released from jail on March 13, 2023. They have until March 31, 2024, to enroll under the SEP for Formerly Incarcerated Individuals.

    NOTE: Count the 12 months starting with the month after the month of release. In the example in this section, count starting from April 1, 2023, until the last day of the 12th month, which will be March 31, 2024.

E. Calculation of Premium Surcharge

There will be no premium surcharge if enrolled pursuant to this SEP.

F. Effective Date

Individuals have the option to choose an entitlement date:

- Option 1: Individuals enrolling in this SEP can choose a prospective entitlement to begin the first day of the month following the month of enrollment.

- Option 2: Individuals enrolling in this SEP can opt for a retroactive entitlement date retroactive to the first day of the month of their release from incarceration, so long as their enrollment is on or after January 1, 2023.

  • •

    If the application is filed within the first full 6 months of the SEP, the effective date is retroactive to the date of their release from incarceration.

  • •

    If the application is filed in the last 6 months of the SEP, the coverage effective date is retroactive to the 6th month before the month of enrollment.

Example 1: Bob Miller is incarcerated in July 2016 at the age of 59 and turns 65 in March 2022 but fails to enroll in the IEP while incarcerated. Bob is released from incarceration on June 12, 2023. SEP begins the day Bob is released and will run until June 30, 2024. Bob provides the appropriate documentation and enrolls on July 22, 2023. Bob's effective date options are:

- Option 1: Effective date to begin the first of the month after the month of enrollment. If Bob Miller chooses this option, and enrolls upon the day of being released from incarceration, Bob's coverage would be effective August 1, 2023.

- Option 2: Retroactive: Effective date retroactive to June 1, 2023 (or the earliest date of eligibility, if later than the month of release). If Bob Miller chooses this option, Bob will be responsible for paying Medicare premiums back to the date of coverage.

Example 2: Carla Bennings is incarcerated in February 2020 at the age of 67. At the time of incarceration Carla was enrolled in Part A and B. During incarceration, Carla was terminated from Part B for failure to pay premiums. Carla did not attempt to reenroll in Part B while in prison. Carla was released from prison on April 15, 2023 and files for SEP on November 4, 2023. The effective date options are:

- Option 1: Effective date to begin the first of the month after the month of enrollment. If Carla Bennings chooses this option, the coverage would be effective December 1, 2023.

- Option 2: Retroactive: Effective date retroactive to May 1, 2023, since it can only be 6 months retroactive. If Carla Bennings chooses this option, Carla will be responsible for paying Medicare premiums back to the date of coverage.

G. Processing

See HI 00805.277 Processing SEP Enrollments for processing instructions.

H. References

GN 02607.160 Title II Prisoner Suspension Provisions

GN 02607.200 Special Legal Considerations For Prisoner Suspensions

GN 02607.700 Suspending Title II Benefits To Prisoners, NGRIs, Incompetent to Stand Trial or Sexually Dangerous Persons By Using PUPS

GN 02607.840 Retirement, Survivors, and Disability Insurance (Title II) Reinstatement Policies for Prisoners

HI 00805.277 Processing SEP Enrollments


HI 00805 TN 117 - Supplementary Medical Insurance Entitlement - 1/08/2025