Incarcerated Medicare Beneficiaries

If a Medicare beneficiary becomes incarcerated, it’s important for them to understand how incarceration affects their Medicare enrollment and benefits.

• Who does Medicare consider incarcerated?
• How do Social Security benefits work when someone is incarcerated?
• Original Medicare
  • Free Part A
  • Premium Part A
  • Part B
    • Part A & B Special Enrollment Period (SEP) for formerly incarcerated people
  • Medicare Advantage (Part C) & Medicare Prescription Drug Plans (PDP) (Part D)
  • Medicare Cost Plans

How does Medicare determine if someone is incarcerated?

CMS relies on data from SSA for Medicare enrollment and eligibility. Upon release, the Medicare eligible individual should contact SSA at 1-800-772-1213 (TTY users can call 1-800-325-0778) to inquire about enrolling.

How do Social Security benefits work when someone is incarcerated?

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) payments generally don’t get paid during the months that a beneficiary is incarcerated. Upon conviction and sentencing to jail or prison for more than 30 days, the Social Security Administration (SSA) will suspend a beneficiary’s Social Security benefits. SSA can reinstate their benefits the month after the month they’re released. However, if a beneficiary’s confinement lasts for 12 consecutive months or longer, SSA will terminate their eligibility for payments and they must file a new application after their release. If SSA suspends disability benefits or SSI payments because the beneficiary was incarcerated, they can request that SSA reinstate them. They will need to contact SSA and provide a copy of the release documents before SSA can act on the request

Example: George received monthly Social Security disability benefits before he was convicted of a crime and incarcerated on May 15, 2020. His benefits were suspended effective May 2020. On October 10, 2020, George was released from incarceration. His benefits were reinstated effective November 2020. Since Social Security benefits are paid in the month following the month for which they are due, George will receive his November benefit in December 2020.

For more information about Social Security Benefits while incarcerated, visit www.ssa.gov or contact SSA at 1-800-772-1213. TTY users can call 1-800-325-0778.

Original Medicare

1. Free Part A

A beneficiary’s entitlement to Medicare Part A (Hospital Insurance) continues while they’re incarcerated. However, Medicare will generally not pay for medical items and services given to a beneficiary while they’re incarcerated. 

2. Premium Part A

Making premium payments
A beneficiary usually doesn’t pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if they or their spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A." However, if the beneficiary doesn’t qualify for premium-free Part A, they may be able to purchase Part A. This is called “Premium Part A.” To keep their Premium Part A coverage while incarcerated, they must pay their Part A premiums or their coverage will end. 

Medicare Part A and B premium payments are due every month. If they aren’t paid by the due date, the beneficiary will get a second notice from Medicare asking for their payment. If the bill remains unpaid within 30 days of the second notice, the beneficiary will get a delinquency notice from Medicare. If the beneficiary doesn’t pay the overdue amount within 30 days they will lose coverage.

Failure to make Premium Part A payments while incarcerated
Incarcerated Medicare beneficiaries must continue making Part A premium payments or their coverage will end. If Premium Part A coverage ends due to an incarcerated beneficiary's failure to make premium payments, the beneficiary will be able to enroll using the Special Enrollment Period for Incarcerated Individuals. This SEP begins the day the person is released from incarceration (if the release date is on or after January 1, 2023). The SEP ends the last day of the 12th month after the person is released from incarceration.

If the beneficiary does not enroll during their IEP or other applicable SEP, they may enroll during the annual General Enrollment Period (GEP), which runs from January 1 through March 31 of each year. If the beneficiary has to buy Part A, but doesn’t buy it when they’re first eligible for Medicare, or their Premium Part A expires while incarcerated and they don’t enroll during the SEP for Incarcerated Individuals, they may have to pay a 10% penalty in addition to the monthly premium amount.   Their monthly premium may go up 10% for each 12-month period they could have had Part A, but weren’t enrolled. They will be subject to the higher premium for twice the number of years that they failed to sign up timely.  If the beneficiary enrolls during the GEP, their Premium Part A coverage will begin the first day of the month after the month they enroll.

Example: If you were eligible for Part A for 2 years but didn't sign up, you'll have to pay the higher premium for 4 years. Usually, you don't have to pay a penalty if you meet certain conditions that allow you to sign up for Part A during a Special Enrollment Period.

3. Part B

Premium payments while incarcerated 
To keep their Part B (Medical Insurance) coverage while incarcerated, a beneficiary must pay their monthly premiums or their coverage will end. Social Security benefits generally aren’t payable while someone is incarcerated, so the beneficiary must set up a direct-bill plan if they want to continue paying their monthly Part B premiums. 

Failure to make Part B premium payments while incarcerated
If the incarcerated beneficiary doesn’t pay their Medicare premiums, they’ll lose their Part B coverage. They’ll be able to re-enroll in Part B during the GEP. If they enroll during the GEP, their coverage will start the first day of the month after the month they enroll.

If a beneficiary doesn’t remain enrolled in Part B while they’re incarcerated, they may face a late enrollment penalty when they re-enroll. In that case, their monthly premium may go up 10% for each 12-month period they could have had Part B, but weren’t enrolled. In most cases, they will have to pay this penalty for as long as they have Part B.

Becoming Medicare eligible while incarcerated
People who turn 65 and get Social Security benefits are auto-enrolled into Medicare Part A and B. If they aren’t getting Social Security benefits, they are reminded by mail to sign up for Medicare during their Initial Enrollment Period (IEP). The IEP is a 7-month period that begins 3 months before the month a person turns 65 and ends 3 months after the person turns 65. 

Individuals who are incarcerated when they turn 65 won’t be automatically enrolled in Medicare because they don’t get Social Security benefits while they’re incarcerated. They also won’t get anything in the mail reminding them to sign up for Medicare. If someone is incarcerated when they turn 65, they need to contact SSA to enroll in Medicare. If someone doesn’t enroll in Medicare when they turn 65, they could have gaps in their coverage or face a late enrollment penalty (LEP).

Example: If you waited 2 full years (24 months) to sign up for Part B and didn’t qualify for a Special Enrollment Period, you’ll have to pay a 20% late enrollment penalty (10% for each full 12-month period that you could have signed up), plus the standard Part B monthly premium ($164.90 in 2023) + $32.98 (20% [of $164.90] late enrollment penalty).

Medicare Part A & B Special Enrollment Period (SEP) for formerly incarcerated people

 An SEP is available for formerly incarcerated people who didn’t enroll (or re-enroll) in Premium Part A or Part B because they were incarcerated.

Eligibility: 
To be eligible for this SEP, a person must:

• Demonstrate they’re eligible for Medicare.
• Show they didn’t enroll or re-enroll in Medicare Part A or B during another enrollment period they were eligible for because they were incarcerated (as defined in 42 CFR §411.4(b)).
• Have proof they were officially released from custody on or after January 1, 2023 (either through the appropriate discharge documents or through data available to SSA).

Duration: 
This SEP begins on the day the person is released from incarceration (if the release date is on or after January 1, 2023). The SEP ends the last day of the 12th month after the person is released from incarceration.

Example: Mrs. Q was released from jail on March 1, 2023. Mrs. Q has until March 31, 2024, to enroll in Medicare using this SEP. 

Late Enrollment Penalty (LEP):
The Premium Part A LEP and Part B LEP don’t apply when beneficiaries enroll under this SEP.

Coverage start date:
Coverage starts the first day of the month, following the month of enrollment. People can also choose to have retroactive coverage back to their release date. People can only request retroactive coverage up to 6 months in the past.  So if a person’s release date was February 1, 2023, and they waited to enroll in Medicare until December 1, 2023, their retroactive coverage would begin on June 1, 2023 (6 months before December). People who choose to get retroactive coverage must pay the premiums for that coverage, back to the retroactive start date.

Example 1: Mr. Miller was incarcerated in July 2016 at the age of 59. He turned 65 in March 2022 but failed to enroll in his IEP while incarcerated. Mr. Miller is released from incarceration on June 12, 2023.  His SEP starts the day he is released, and runs until June 30, 2024. Mr. Miller provides the appropriate documentation of his release, and enrolls on June 22, 2023. His coverage start date options are:

• Option 1 – Prospective: Coverage to begin the first of the month, after the month of enrollment. If Mr. Miller chooses this option, and enrolls on June 22, 2023, his coverage would be effective July 1, 2023.
• Option 2 – Retroactive: Coverage starts retroactively on June 1, 2023. If Mr. Miller chooses this option, he will be responsible for paying Medicare premiums back to the June 1, 2023.

Example 2: Ms. Bennings was incarcerated in February 2020 at the age of 67. When she was incarcerated she was enrolled in Part A and B. During incarceration, she was terminated from Part B for failure to pay premiums. She didn’t re-enroll in Part B while in prison. She is released from prison on April 15, 2023, and files for an SEP on November 4, 2023.  Her coverage start date options are:

• Option 1 – Prospective: Coverage starts the first of the month, after the month of enrollment. If Ms. Bennings chooses this option and enrolls on November 4, 2023, her coverage would be effective December 1, 2023.
• Option 2 – Retroactive: Her earliest possible coverage start date is May 1, 2023, (coverage can’t be retroactive for more than 6 months). If Ms. Bennings chooses this option, she’ll be responsible for paying Medicare premiums back to May 1, 2023 (or whatever coverage start date she chooses).

 People who may qualify for this Special Enrollment Period can contact Social Security  at 1-800-772-1213 or use form CMS-10797 to enroll.

* A formerly incarcerated individual may first need to use the Part A or Part B SEP to meet the qualifications to enroll in any of the three plan types.

4. Medicare Advantage (Part C) & Medicare Prescription Drug Plans (PDP) (Part D)

General eligibility for Medicare Advantage Plans 
Before anyone can join a Medicare Advantage plan, they must:

• Be entitled to Medicare Part A and enrolled in Medicare Part B.
• Live in the plan's service area.

General eligibility for Prescription Drug Plans
Before anyone can join a Medicare Prescription Drug Plan they must:

• Be entitled to Medicare Part A or enrolled in Medicare Part B.
• Live in the plan’s service area.

Automatic disenrollment for incarcerated beneficiaries
When an individual is incarcerated, the incarceration is considered outside the service area of the plan. Individuals who become incarcerated while enrolled aren’t able to maintain enrollment because they don’t meet the eligibility requirement of living in the plan’s service area. 

These beneficiaries will be disenrolled based on incarceration data from the Social Security Administration (SSA). Disenrollment’s are effective the 1^st day of the month after the beneficiary’s incarceration starts. Plans will notify beneficiaries about their disenrollment. Plans aren’t allowed to supersede the incarceration data within SSA’s systems. Beneficiaries who wish to dispute their incarceration status must contact SSA. 

Special Enrollment Period (SEP) for formerly incarcerated people
The SEP for Changes in Residence may be used by people who weren’t eligible for enrollment in a plan because they were incarcerated (i.e. out of the plan service area) and have now been released. There’s also an SEP for formerly incarcerated beneficiaries who have Part A and Part B.

The SEP starts on the date the person is released, and lasts for 2 months. To join a Medicare Advantage or Medicare drug plan, the person must be enrolled in Part A and/or Part B, depending on the type of plan they want to join.

Formerly incarcerated beneficiaries must ensure they meet all general eligibility requirements before they can join a plan.

To join in a Medicare plan, beneficiaries can call 1-800-MEDICARE (1-800-633-4227), join a plan online via Medicare.gov, or contact the plan or an agent of the plan directly. Beneficiaries must indicate they have been released from incarceration and provide the date of release.

Part D LEP
Generally, if a beneficiary is eligible to enroll in Part D and they don’t have creditable coverage, they may have to pay a Part D Late Enrollment Penalty (LEP) if they sign up for Medicare drug coverage later.

While incarcerated, beneficiaries are considered to be outside the service area. They aren’t eligible for Part D and can’t have creditable coverage, as a result, the time they’re incarcerated doesn’t count towards the Part D LEP.

Get more information on the Part D LEP and creditable coverage.

5. Medicare Cost Plans

General eligibility
Before anyone can join a Medicare Cost Plan, they must:

• Be entitled to Medicare Part A and enrolled in Medicare Part B, or enrolled in Medicare Part B only.
• Live in the plan’s service area.
• Find a plan that is accepting new members.

Automatic disenrollment for incarcerated beneficiaries
When an individual is incarcerated, the incarceration is considered outside the service area of the plan. Individuals who become incarcerated while enrolled aren’t able to maintain enrollment because they don’t meet the eligibility requirement of living in the plan’s service area. 

These beneficiaries will be disenrolled based on incarceration data from the Social Security Administration (SSA). Disenrollment’s are effective the 1^st day of the month after the beneficiary’s incarceration starts. Plans will notify beneficiaries about their disenrollment. Plans aren’t allowed to supersede the incarceration data within SSA’s systems. Beneficiaries who wish to dispute their incarceration status must contact SSA. 

Enrolling after incarceration
Formerly incarcerated beneficiaries must first meet all general eligibility requirements, including entitlement for Part A and enrollment in Part B.

If they’re eligible, beneficiaries can join a Cost Plan any time the plan is accepting new members.  Formerly incarcerated beneficiaries have an SEP to join a Cost Plan that includes prescription drug coverage. Get more information about how Cost Plans work or call 1-800-MEDICARE for more information.