In the recently published 2025 Hospital Outpatient Prospective Payment (OPPS) rule, the Centers for Medicare and Medicaid Services (CMS) narrowed the description of “custody” and revised the special enrollment period (SEP) criteria for formerly incarcerated individuals. Under the final rule, individuals on bail, parole, probation, home detention, or residing in halfway houses are no longer considered to be “in custody of penal authorities.” As a result, Medicare can now pay for covered services. Additionally, the new rule revises the special enrollment period (SEP) for formerly incarcerated individuals for Medicare Premium Part A and Part B. The SEP is now based on the Social Security Administration (SSA) incarceration release determinations rather than referencing the Medicare payment exclusion rule. This revision is intended to streamline the Medicare enrollment and re-enrollment process for incarcerated individuals reentering their communities.
- The final rule was published on November 27, 2024, and goes into effect January 1, 2025.
- CMA provided comments to the proposed rule on September 9, 2024.
December 5, 2024 – C. Huberty