Medicare Special Enrollment Period for Formerly Incarcerated Individuals: What Advocates Need to Know

As the overall population ages, the prison and jail population is aging too. Older adults reentering our communities are disproportionately older adults of color, especially Black men. The unique and significant disadvantages caused by structural racism in the criminal justice system and throughout their lives follow individuals well beyond the prison and jail walls. As a result, older adults leaving prison and jail are at risk of being unable to access health care, housing, and a range of health and economic security benefits that could help them transition smoothly and live securely in the community.

With support from AARP Public Policy Institute, Justice in Aging is releasing a series of issue briefs to ensure advocates and service providers are aware of the unique challenges older adults reentering the community after incarceration face and to provide the tools they need to connect their older adult clients to the safety net benefits they need. This first issue brief in the series discusses the Medicare Special Enrollment Period for formerly incarcerated individuals.

We gratefully acknowledge Georgia Burke, formerly Justice in Aging’s Director of Medicare Advocacy, for authoring the first edition of this issue brief. Georgia’s passion and thought leadership was foundational to Justice in Aging’s advocacy to improve access to health care for older adults leaving incarceration.

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Introduction

Older adults leaving incarceration face significant challenges in connecting with healthcare benefits when they return to their communities. Getting and using Medicare coverage is one of those challenges. The Special Enrollment Period for formerly incarcerated individuals (“Post-Incarceration SEP”) helps alleviate these challenges by allowing eligible individuals to enroll in Medicare during any part of the year and to avoid late enrollment penalties.

Although most older adults returning to the community are also Medicaid-eligible, some are not. How reentry challenges play out depends in part on whether an older adult returning to the community also qualifies for state Medicaid coverage.

The Medicare Post-Incarceration SEP came into effect on January 1, 2023 and was modified effective January 1, 2025.^[1] It is an important improvement in the process of obtaining or restoring Medicare coverage. The Post-Incarceration SEP provides significant relief from the prior rule which required those returning to the community to wait until the next available enrollment period, which often meant waiting until the Medicare General Enrollment Period (January through March annually) to enroll. The prior rule also imposed late enrollment penalties, even if the individual was incarcerated when they first became eligible for Medicare. Under the Post-Incarceration SEP, individuals leaving custody now have a 12-month period in which to enroll or re-enroll in Medicare and can do so without being subject to a late enrollment penalty.

This issue brief explains the details of the Post-Incarceration SEP and looks at how it interacts with other existing Medicare rules. It provides scenarios of how Medicare enrollment plays out for Medicare-eligible individuals and spotlights issues that might arise for individuals in different circumstances including:

• Those with or without premium-free Medicare Part A
• Those who were enrolled in Medicare prior to incarceration and those who never enrolled
• Those also eligible for Medicaid coverage

What Happens to Medicare While a Person Is Incarcerated?

Medicare enrollment can begin or continue during incarceration if premiums are paid, but the Medicare program stops paying for health care services while an individual is in the custody of a penal authority.^[2] Individuals who turn 65 while incarcerated have the right to enroll in Medicare during the Initial Enrollment Period surrounding their 65th birthday, but enrolling would entail paying premiums and would not result in any access to Medicare services. As a result, many people who are eligible for Medicare are not enrolled while incarcerated and need an SEP to gain access upon release.

What Is the Post-Incarceration SEP?

The Post-Incarceration SEP applies both to Medicare Part A (42 C.F.R. § 406.27(d)) (for those who do not qualify for premium-free Part A)^[3] and Part B (42 C.F.R. § 407.23(d)).^[4] It allows individuals to avoid Medicare’s late enrollment penalties for both Parts A and B (whether they never enrolled in Medicare, chose to disenroll, or were disenrolled because they stopped paying their monthly premium).

The SEP starts on the date of release from confinement and extends for 12 months after the month of release. Enrollment is effective the first day of the month following enrollment, but individuals can, with payment of premiums, obtain 6 months retroactive coverage starting no earlier than the first of the month they were released from confinement.^[5]

Individuals can enroll in Part D once they have enrolled in Part A or Part B. Note, however, that retroactive coverage under the Post-Incarceration SEP only applies to Part A and Part B services. Enrollment in the Part D prescription drug benefit is prospective, so Medicare does not cover prescription drugs during the retroactive period.^[6]

Individuals apply for the Post-Incarceration SEP through the Social Security Administration (SSA) using application form CMS-10797.^[7]

Who Is Eligible for the SEP?

A person is eligible for the SEP if:

• They have been released from confinement in a jail, prison, or other penal institution or correctional facility since January 1, 2023;^[8]
• That release from confinement happened within the last 12 months;
• They demonstrate that they are eligible for Medicare; and
• They demonstrate that they failed to enroll or reenroll in Medicare Part B (or, if applicable, premium Part A) due to being confined. ^[9]

Examples

Ms. Jones was released from incarceration in March 2025. She is eligible for the Post-Incarceration SEP from March 2025 through March 2026 if she meets the requirements of Medicare eligibility and failed to enroll or reenroll due to being confined.

Mr. Griffith was released from prison in January 2025 and started five years of parole. He is eligible for the SEP starting in January 2025 through January 2026 if he meets the requirements of Medicare eligibility and failed to enroll or reenroll due to being confined.

How Can a Person Demonstrate That They Have Been Released From Confinement?

Individuals should provide their official release documents to SSA if they have them. SSA also uses data it collects from jails, prisons, and other penal institutions or correctional facilities and certain mental health institutions to determine release for purposes of determining eligibility for the Post-Incarceration SEP.^[14] For people who have been released from incarceration and are currently on parole, probation, or home confinement, SSA data should indicate they have been released. Individuals residing in halfway houses are also eligible for the SEP, but may need to provide documentation of their release from confinement.^[15]

If a person is released from incarceration and should be eligible for the Post-Incarceration SEP, but SSA does not have a record of release, the new SEP rule allows for SSA to accept other documentation of release. This can include discharge documents or other documents as evidence of release.^[16] For example, a letter from a parole or probation officer may work as documentation. SSA also has a process for helping an individual obtain their documents of release.^[17]

How Does Medicare Enrollment Play Out in Practice?

There are many permutations for older adults reentering the community, depending on their particular circumstances. Below are scenarios that illustrate situations that advocates may encounter when assisting their Medicare-eligible clients.

Opportunity for Retroactive Enrollment

Mr. Carver, age 68, has been in a state prison for five years and has never enrolled in Medicare. He completed his sentence and was released from custody without supervision on February 5, 2025. Because of his work history, he qualifies for premium-free Part A. Although his income upon release is low, he received an inheritance from his brother that makes his assets too high for him to qualify for Medicaid.

Mr. Carver used most of his time in the first couple of months in the community working to secure stable housing and did not apply for Medicare until June 10, when he used the Post-Incarceration SEP to apply for Part B. His coverage could begin on July 1 but, because he incurred thousands of dollars in medical bills in May and June, Mr. Carver opted to pay premiums for retroactive coverage back to February.^[18] Because Mr. Carver is eligible for premium-free Part A, he does not need an enrollment period to sign up for Part A. His part A can start retroactively six months before he applied.^[19]

Note: Mr. Carver does not have the option of only paying for retroactive coverage for May and June, the months in which he incurred expenses. If he chooses retroactive coverage, he must pay Part B premiums for all uncovered months up to and including the month of release (not to exceed 6 months total) – in this example February 2025.

Mr. Smith, 70, was released without condition on July 5, 2024. He applied for Medicare coverage on March 12, 2025, using the Post-Incarceration SEP and chose retroactive coverage. His retroactive coverage extends back to September 1, 2024 (the 6^th month before the month of enrollment). He cannot get retroactive coverage beyond six months from the date he applied.

Mr. Smith’s application involves one additional wrinkle. Because Mr. Smith applied in March, which is during the General Enrollment Period (GEP) (January 1-March 31 annually), his advocate should tell him to be sure to inform SSA that he wants to use the Post-Incarceration SEP and not apply under the GEP provisions. It is worth cautioning him since, if he applies using the GEP, he will incur late enrollment penalties.^[20]

Alternative for Individual Without Premium-Free Part A Eligibility

Mr. Ng, 66, left state prison on March 12, 2025, after being exonerated of a crime for which he served 20 years. He does not meet the financial qualifications for Medicaid coverage and does not have a sufficient work history to qualify for premium-free Part A. Mr. Ng can use the Post-Incarceration SEP to apply both for Part A and Part B coverage. However, he cannot afford the steep premiums for Part A (over $500/month) and is hesitant to enroll. Because he is not entitled to free Part A, he is eligible for Marketplace coverage as an alternative to Medicare. He decides that enrolling in a Marketplace plan with subsidies is more cost-effective than paying both Part A and Part B premiums. He uses a Marketplace SEP for individuals leaving incarceration, which begins the day of his release and extends for 60 days.^[21] He also qualifies for Marketplace subsidies to lower his premiums. If he decides at some later date that he wants to enroll in Medicare instead, Mr. Ng may face late enrollment penalties.^[22]

Individual Released to a Halfway House

Ms. Nunez, 68, who qualifies for premium-free Part A, left a carceral institution in late February 2025. She is required to live in a halfway house for one year. Ms. Nunez cannot receive Social Security benefits while residing in the halfway house, but she is eligible for Medicare. She called SSA on March 1, enrolled in premium-free Part A, and provided documentation of her release to confirm that she is eligible for the Post-Incarceration SEP for Part B. She applied in March and her Medicare Part B coverage began in April. She must pay her Medicare Part B premium directly since she is not receiving Social Security benefits and does not qualify for Medicaid.

Individual Previously Enrolled in Medicare

Ms. Johnson, 75, has been in a state prison for one year and, in August 2025, will begin serving the last two years of her sentence in the community under home detention. She was enrolled in Medicare prior to being incarcerated. Although her Social Security benefits were suspended while she was in prison, she was able to use savings to continue paying her Part B premiums and remain enrolled. When she returns to the community in August under home detention, she will be able to start using her Medicare benefits because she will no longer be in custody.

Mr. Lee, age 68, was already enrolled in Medicare Parts A and B when he entered a carceral institution at age 66. His Part B premium had been automatically deducted from his Social Security benefit payment. After incarceration began, his Social Security benefits stopped and so did the automatic payment of his Part B premium. After automatic premium payments stopped, SSA gave Mr. Lee a three-month grace period and then disenrolled him from Part B. He paid no attention since Medicare was not paying for any of his health care. When he returned to the community and his Social Security benefits were reinstated, he was shocked to find that SSA had deducted the three months of Part B premiums during the grace period from his first benefit check.⁹ This deduction is in addition to the regular prospective Part B premium deduction from the Social Security benefit.

What Happens to People Eligible for Medicaid?

Leaving incarceration works differently for Medicare-eligible individuals who, upon return to the community, also qualify for Medicaid. Individuals who are enrolled in premium-free Part A and Medicaid when they leave a carceral setting should be directly enrolled in Medicare Part B by their state Medicaid program, which will typically pay their Part B premium.^[24] Those who are not already enrolled in Medicare Part A will need to enroll themselves and may need to use the Post-Incarceration SEP to avoid late enrollment penalties prior to getting Medicaid started. Below are some examples of the interaction of Medicare and Medicaid coverage and issues that advocates may encounter.

Individual Already Enrolled in Medicare Part A and Medicaid

Mr. Broz, 66, finished serving a three-year sentence. Prior to incarceration, he had Medicaid coverage through expansion. His state’s policy is to suspend Medicaid during the entire period of incarceration, rather than disenroll individuals. Mr. Broz signed up for Medicare Part A when he turned 65, but not Part B because he was incarcerated and could not afford the premium. Before release, his state reviewed his eligibility and moved his suspended enrollment to the Medicaid aged and disabled (A&D) group. Since Mr. Broz was already enrolled in Medicare Part A and was low-income, the state also enrolled him in Part B and began paying his Medicare Part B premium. When he returned to the community, with only a very small SSA benefit, he continued to be eligible for Medicare and Medicaid and the state continued to pay his Part B premium. It was easy for him to “turn on” both his Medicare and Medicaid benefits. He does not need the Medicare Post-Incarceration SEP. He does, however, need counseling on how Medicare and Medicaid work together and could benefit from assistance from a SHIP counselor in determining how he will access his Medicare benefits (i.e., choosing among Original Medicare, Part D coverage, and Medicare Advantage options).

Medicare-Eligible Individual With Medicaid Eligibility

Ms. Low, 70, qualifies for free Medicare Part A, and though she was enrolled in Medicaid previously, her state disenrolled her after one year of incarceration.^[26] She has been in a state prison for ten years and, in November 2024, began serving the last two years of her sentence in the community on parole. She enrolled in Part A and Part B (using the Post-Incarceration SEP) upon her release from prison. With her small Social Security retirement benefit and no assets, she qualified for her state Medicaid program. The state started paying Ms. Low’s Part B premium in November. She uses Medicare as her primary insurance and Medicaid provides wrap-around benefits such as dental, vision, and transportation to her doctors’ appointments.

Medicaid-Eligible Individual Who Is Not Eligible for Free Medicare Part A

Mr. Wilson, age 80, was incarcerated in a federal prison for 60 years. He was granted parole this month. Because he was incarcerated at age 20, Mr. Wilson does not have enough work history to qualify for premium free Part A. Prior to his release, Mr. Wilson meets with a social worker who helps him apply for Medicaid and he is determined eligible. Once released, Mr. Wilson contacts a SHIP counselor to help him enroll in Part A and Part B. To avoid the steep Part A premium, he will need to use the Conditional Part A enrollment process so that Medicaid coverage of the premium can start at the same time that Medicare does.^[27]

Medicaid Pre-Release Services

Mr. Gonzales, 75, is currently in a California state prison and expects to return to the community in two years. He has complex medical conditions, including developing dementia, and also will need home and community-based services to stabilize his health in a community setting. California has begun to offer certain pre-release Medicaid services to high need individuals like Mr. Gonzales.^[28] Other states have applied for waivers similar to California’s to provide pre-release services, all with the goal of improving care continuity and ensuring better access to needed care immediately upon reentry.^[29] These innovative waivers offer promise for significant positive change and, if states incorporate planning specifically directed to the unique needs of dually eligible individuals, this could be a major step in smoothing access for Mr. Gonzales and others like him to the many services necessary to live safely and have their needs met in a community setting.

Conclusion

The Medicare Post-Incarceration SEP is an important step in improving access to Medicare services for individuals returning to the community. Justice in Aging is available to provide technical assistance to advocates working with clients to navigate the reentry process and establish stable health care coverage in the community. We also are interested to learn from advocates about any challenges and opportunities they are seeing in implementation. Questions can be sent to info@justiceinaging.org.

Endnotes

1. CMS, Fact Sheet: CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC), (Nov. 1, 2024). ↑

2. Effective January 1, 2025, the Centers for Medicare and Medicaid Services (CMS) narrowed its description of custody in the Medicare payment exclusion rule to apply only to people who are physically detained. Read more about this change in our fact sheet. ↑

3. If a person is eligible for premium-free Part A, they can enroll at any time and they do not face Part A late enrollment penalties. ↑

4. The Social Security Program Operations Manual System (POMS) provision discussing the Post-Incarceration SEP is found in the SSA, POMS HI 00805.386. ↑

5. 42 C.F.R. §§ 406.27; 407.23 ↑

6. See 42 C.F.R. § 423.38(a)(3)(iii); CMS Prescription Drug Benefits Manual, Ch. 3, p. 41 at 19. ↑

7. Note that as of July 15, 2025, the application form has not yet been updated to reflect new regulations, effective January 1, 2025. The POMS HI 00805.386 has been updated. ↑

8. The SEP only applies to release dates on or after January 1, 2023, and does not offer retroactive relief of late enrollment penalties prior to that date. ↑

9. 42 C.F.R. §§ 406.27; 407.23 ↑

10. For details on SSA data exchange with carceral institutions and how SSA collects data from other sources, see SSA POMS GN 02607.410 et seq. ↑

11. CMS, Patients in Custody Under a Penal Authority (June 2025). ↑

12. See CMS, Fact Sheet: CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC), (“To facilitate access to Medicare coverage, CMS is finalizing our proposal to revise the eligibility criteria for the special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or on bail, parole, probation, or home detention and align more closely with the Social Security Administration’s criteria for determining incarceration status. In addition, the eligibility criteria will be expanded to include individuals released from incarceration to residency in halfway houses.”). ↑

13. 42 C.F.R. § 406.27(d)(1); 407.23(d)(1). ↑

14. See CMS.gov, How does Medicare determine if someone is in custody under a penal statute or rule. ↑

15. 89 FR 94512 (“[A]s SSA systems may not identify individuals in halfway houses as no longer in confinement, these individuals will likely need to provide documentation of discharge to SSA proving that they have been released from incarceration to affirm eligibility for this SEP.”), https://www.federalregister.gov/d/2024-25521/p-5225. ↑

16. 89 FR 94513 (“[W]e are revising our language at proposed §§406.27(d)(2)(i) and 407.23(d)(2)(i) to replace the term ‘‘discharge documents’’ with ‘‘documentation of discharge.’’ This will allow individuals who may not have specific discharge documents, but have other proof of their discharge, the ability to use the SEP.”) ↑

17. SSA POMS GN 02607.840 Retirement, Survivors, and Disability Insurance (Title II) Reinstatement Policies for Prisoners. ↑

18. Mr. Carver can sign up for premium-free Part A anytime; he does not need an enrollment to sign up. His Part A can be retroactive six months. ↑

19. CMS, Original Medicare (Part A and B) Eligibility and Enrollment. ↑

20. SSA, POMS HI 00805.382.C. ↑

21. CMS, Understanding the Health Insurance Marketplace if You’re Incarcerated (Jan 2025). ↑

22. CMS, Frequently Asked Questions Regarding Medicare and the Marketplace, at A.6. and A.9 (Apr. 28, 2016). ↑

23. CMS, Patients in Custody Under a Penal Authority (June 2025). ↑

24. Medicaid pays Part B premiums for most people dually eligible for Medicaid and Medicare. Medicaid will pay the Part B premium if: (1) The person is in a Medicare Savings Program like Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB), or Qualifying Individual (QI); (2) The person is in a Medicaid eligibility category that is in the state's buy in category; or (3) The state is requiring Medicare enrollment as a requirement of Medicaid eligibility. Chapter 1 of the Medicare Manual State Payment of Medicare Premiums ↑

25. 42 USC 1396a(a)(84)(B) (requiring states to redetermine eligibility prior to release for certain ”eligible juveniles”) and Section 206 of the Consolidated Appropriations Act of 2024 (directing the HHS Secretary to award state planning grants to improve continuity of care, including setting up standard procedures for renewing coverage while incarcerated); see also CMS, State Planning Grants to Promote Continuity of Care for Medicaid & CHIP Beneficiaries Following Incarceration. ↑

26. Note that, starting in January 2026, all states will be required to suspend, rather than terminate Medicaid coverage during incarceration. Section 205 of the Consolidated Appropriations Act of 2024; see also HARP, Medicaid’s New Role in Advancing Reentry: Key Policy Change, (Spring 2025) ↑

27. Justice in Aging, Fact Sheet: Medicare Part A Conditional Applications (Jan. 28, 2025). ↑

28. California has established a state webpage on its activities in planning and implementation of its waiver: https://www.dhcs.ca.gov/CalAIM/Justice-Involved-Initiative/Pages/home.aspx ↑

29. CMS released guidance through a State Medicaid Director Letter, SMD 23-0003, (Apr. 17, 2023) to states on designing demonstration projects under Section 1115 waiver authority. For an overview of pending state waivers see, KFF, Section 1115 Waiver Watch: Medicaid Pre-Release Services for People Who Are Incarcerated, (Aug. 19, 2024). ↑