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 (meaning the individual is in custody of penal authorities as described in this POMS) 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.

For example, upon their release such 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 these individuals. These only provide provisions for incarcerated individuals released on or after January 1, 2023 a special enrollment opportunity. Individuals released prior to January 1, 2023 are not covered under the regulations.

Definition: For the purposes of these instructions, incarcerated refers to individuals who are in custody including, but not limited to:

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  individuals who are under arrest;

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  incarcerated, imprisoned;

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  escaped from confinement;

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  under supervised release;

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  on medical furlough;

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  required to reside in mental health facilities;

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  required to reside in halfway houses;

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  required to live under home detention;, or

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  confined completely or partially in any way under a penal statute or rule.

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

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  Demonstrate that they are eligible for Medicare, and

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  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

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

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

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.

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

Individuals have the option to choose an entitlement date:

- Option1: 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.

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  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.

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  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.

- 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.

See HI 00805.277 Processing SEP Enrollments for processing instructions.

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

HI 00805.277 Processing SEP Enrollments