Social Security

A. Purpose
This emergency message (EM) outlines the changes made to the SEP for Formerly Incarcerated Individuals, and the Medicare custody definition. This EM outlines the updates to the eligibility criteria for Medicare beneficiaries using the SEP for formerly incarcerated individuals.

CMS finalized a proposal to narrow the definition of “custody” in Medicare’s no legal obligation to pay payment exclusion, to facilitate access to Medicare by individuals who are on bail, parole, probation, or home detention, or who are required to reside in halfway houses. In addition, the final rule revised the special enrollment period (SEP) to tie eligibility criteria for formerly incarcerated individuals to data made available to SSA. Finally, the rule made for the special enrollment period (SEP) eligibility criteria for formerly incarcerated individuals to be inclusive of individuals who are transitioning to residency in halfway houses.

The changes to the special enrollment period eligibility criteria will clarify and simplify the eligibility requirements as applied to individuals released from incarceration and will facilitate access to Medicare. In addition, aligning Medicare and SSA policies more closely promotes equity among all individuals who are eligible for coverage under Medicare.

B. Eligibility:

To be eligible for this SEP, an individual would have to:
• Demonstrate that they are eligible for Medicare, and
• Due to being incarcerated (incarcerated refers to individuals who are determined to be incarcerated through data made available to SSA (See GN 02607.160 and GN 02607.700)), 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, on or after January 1, 2025, as defined above, either through the appropriate discharge documents or data available to SSA.
Starting January 1, 2025:
1. 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.
2. Individuals on parole, probation, home confinement or released from confinement to residency in halfway houses, 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 02607.200C.
Example 1: Bob comes into the Field Office, on February 3, 2025, to enroll in this SEP. Bob was released from incarceration, on January 1, 2025, and is residing in a Halfway House. Bob demonstrated they are officially released and provided evidence. Bob can choose an entitlement date retroactive to January 2025 or choose March 2025.

Note: If verification of release documentation cannot be obtained using directions in GN 02607.840, the individual cannot use the SEP. Use normal processing guidance to process a denial if the individual is not within any enrollment period (IEP, GEP, SEP) (SM 03040.065E.5).