Incarcerated and Recently Released Consumers

Version 2.0. January 2024. This information is intended only for the use of entities and individuals certified to serve as Navigators, certified

application counselors, or non-Navigator assistance personnel in a Federally-facilitated Marketplace. The terms “Federally-facilitated

Marketplace” and “FFM,” as used in this document, include FFMs where the state performs plan management functions. Some information in

this manual may also be of interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the

Federal Platform. This material was produced and disseminated at U.S. taxpayer expense.

Incarcerated and Recently

Released Consumers

This fact sheet provides information and guidance that Navigators and certified application

counselors (collectively, assisters) need to know in order to help consumers who are

incarcerated or recently released understand their health coverage options.

Table of Contents

Marketplace Coverage ..................................................................................................................2

Medicaid/CHIP Coverage and Eligibility .......................................................................................5

Medicare Coverage ......................................................................................................................6

Scenario .......................................................................................................................................8

Additional Resources ....................................................................................................................8

The rules related to coverage of incarcerated consumers through a Marketplace are different

from the rules that apply to Medicaid, CHIP, or Medicare.

Marketplace Coverage

Incarcerated Consumers

The Affordable Care Act (ACA) states that consumers are not eligible to enroll or continue

enrollment in a qualified health plan (QHP) through the Health Insurance Marketplaces if they

are incarcerated unless they are incarcerated pending disposition of charges. The following

table lists consumers who the Marketplace does and doesn’t consider incarcerated for the

purposes of Marketplace eligibility.

Status Definitions

Incarcerated

Consumers

 Have been convicted of a crime and are sentenced to confinement in an institution such as a

correctional facility or inpatient mental health facility.

 These consumers have 30 days to report their incarceration status to the Marketplace and

terminate their existing Marketplace coverage.

Consumers NOT

Incarcerated

 Have not been convicted of a crime.

 Pending disposition of charges. This means the individual has been charged with a crime but

is waiting for the outcome of the charges to be determined. This includes situations in which

an individual is arrested but not convicted of a crime and convicted of a crime but awaiting

sentencing, whether confined to a correctional institution or released on bail, bond, or other

conditional release.

 Consumers pending disposition of charges can enroll or continue existing enrollment in a QHP

through a Marketplace, if otherwise eligible.

 However, if convicted, consumers are no longer eligible for Marketplace coverage if

they are incarcerated and should end their existing coverage through a Marketplace.

 Have been convicted of a crime and are sentenced to a partial, limited, or alternative form of

confinement. This includes consumers who are on probation or parole; living in the community

after a sentence has been served; allowed work release; under home confinement; or residing

in a halfway house or other type of residential community supervision as a result of a

conviction.

 These consumers may be eligible to enroll or continue existing enrollment in a QHP

through a Marketplace, if otherwise eligible.

 If consumers’ probation or parole is revoked, they are no longer eligible to enroll in a

QHP through a Marketplace, and, if already enrolled, they should end their existing

coverage through a Marketplace.

Marketplace coverage can be terminated by:

 The enrollee, by contacting the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-

889-4325) or by visiting HealthCare.gov.

 The application filer, by contacting the Marketplace Call Center or by visiting

HealthCare.gov.

 Any adult age 18 or over who is on the application and applied for Marketplace coverage,

by contacting the Marketplace Call Center.

 An adult age 18 or over listed as a tax filer on the incarcerated consumer’s application for

Marketplace coverage, even if the tax filer didn’t apply for coverage, by contacting the

Marketplace Call Center.

 An individual authorized on the incarcerated consumer’s behalf, if neither the

incarcerated consumer nor any adult on the application is able to contact a Marketplace

to report a change and end enrollment through the Marketplace, by contacting the

Marketplace Call Center

Additionally, individuals can seek help with the process of reporting a change in eligibility from a

Navigator, a certified application counselor (CAC), or an agent or broker registered with a

Marketplace. Visit Find Local Help to locate an agent, broker, or assister. Incarcerated

consumers may also seek the help of a correctional facility representative.

The Marketplace does not terminate coverage for incarcerated consumers automatically, so the

consumer is responsible for monthly premiums until their Marketplace coverage is terminated.

Incarcerated consumers may continue their enrollment in private health insurance coverage

outside the Marketplaces through the individual, or non-group, market.

Instructions on reporting a change and ending Marketplace coverage using HealthCare.gov are

available at HealthCare.gov/reporting-changes/cancel-plan.

Household Members of an Incarcerated Consumer

Consumers who have an incarcerated individual in their household must determine whether to

include the incarcerated individual on Marketplace applications as a non-applicant.

 Consumers must include an incarcerated consumer as a non-applicant if the

incarcerated consumer is expected to be included in a household’s tax return for the year

a member of the household is applying for coverage. The rest of the family can continue

to enroll in coverage through the Marketplace, if eligible.

 Consumers must not include an incarcerated consumer as a non-applicant if the

incarcerated consumer is not expected to be included in a household’s tax return for the

year a member of the household is applying for coverage through the Marketplace.

After Release from Incarceration

After incarcerated consumers are released, they or their household should report a change in

incarceration status as well as any income or other changes, as soon as possible, within 30

days.

 When consumers apply for health coverage after being released from incarceration, they

may qualify for lower costs on monthly premiums and out-of-pocket costs, if otherwise

eligible. This will depend in part on their household size and income during the year

they’re seeking coverage.

 After they’re released, consumers have a 60-day Special Enrollment Period (SEP) to sign

up for Marketplace coverage, if otherwise eligible. During this time, they can enroll in

private health insurance through the Marketplace even if it’s outside the Open Enrollment

Period (OEP). After this 60-day SEP, they generally won’t be able to buy private health

insurance until the next OEP, unless they qualify for another SEP.

Consumers can find more information about their qualification for an SEP following release from

incarceration by visiting HealthCare.gov/coverage-outside-open-enrollment/special-enrollment-

period or by calling the Marketplace Call Center.

Recently released consumers can visit HealthCare.gov to start a new Marketplace application or

update an existing application by reporting a life change if they had a Marketplace plan earlier in

the year or want to be added to a Marketplace application for other family members already

enrolled in Marketplace coverage. If they are joining their family’s plan, they may need

authorization from the family member who opened the Marketplace account to make changes.

Consumers can also call the Marketplace Call Center or find free in-person help in their

community by visiting Localhelp.HealthCare.gov.

Tips for Assisters

Consumers who receive health coverage after being released from incarceration may need help

understanding their health coverage options. Assisters can aid in the transition of recently

released consumers by:

 Explaining the basics of health insurance, including the costs associated with health care

services under different plans (i.e., premiums, out-of-pocket costs, deductibles, and

coinsurance).

 Helping consumers learn about community health centers or other health care providers

that might have experience caring for consumers recently released from incarceration.

 Advising consumers to obtain coverage and schedule an appointment with a physician as

soon as possible following their release from incarceration.

Medicaid/CHIP Coverage and Eligibility

Individuals who are incarcerated may be enrolled in Medicaid, if otherwise eligible, but may only

receive Medicaid-covered services under limited circumstances. For purposes of Medicaid and

CHIP, an “inmate” is an individual of any age who is in custody and held involuntarily through

operation of law enforcement authorities in a public institution, other than a child care institution,

publicly operated community residence that serves no more than 16 residents, or a public

educational or vocational training institution for purposes of securing educational or vocational

training.

A public institution can include a correctional institution operated by, or under contract with, the

United States, a state, a territory, political subdivision of a state or territory, or an Indian tribe for

the confinement or rehabilitation of persons charged with or convicted of a criminal offense.

The “inmate payment exclusion” is a coverage and reimbursement exclusion, meaning that

federal financial participation (FFP) is not available for Medicaid services provided to the

individual who is incarcerated, unless the individual is admitted to a medical institution as an

inpatient. This is called the “exception” to the inmate payment exclusion. A qualified “medical

institution” includes only a hospital, nursing facility, intermediate care facility for individuals with

intellectual disabilities, or a psychiatric residential treatment facility (for individuals under age 21)

that meets applicable federal regulations and conditions of participation. (For guidance on the

Medicaid inmate payment exclusion policy, see Medicaid.gov/federal-

policyguidance/downloads/sho16007.pdf).

In addition to the inmate exclusion, Medicaid also includes a coverage exclusion related to

services for patients in institutions for mental diseases (IMDs), which include residential

treatment facilities of over 16 beds that are primarily engaged in the diagnosis, treatment, or

care of persons with mental diseases.

Individuals are no longer considered “inmates of a public institution” when they are on parole,

probation, have been released to the community pending trial, are on home confinement, are

voluntarily residing in a correctional institution for a temporary period of time after their case is

adjudicated while arrangements are being made for transfer to a community residence, or are

residing in a supervised “halfway house” if they have freedom of movement and association,

including the ability to work outside the facility, use community resources, and seek health care

in the community to the same or similar extent as other Medicaid beneficiaries.

Inmates of a public institution are not eligible for the Children’s Health Insurance Program

(CHIP).

Using Medicaid While Incarcerated

As noted above, FFP is not available for Medicaid services provided to inmates of a public

institution unless the exception to the payment exclusion for beneficiaries receiving inpatient

care applies. Retroactive Medicaid coverage generally is available for services received in a

medical institution in the three-month period prior to application, if the individual would have

been Medicaid-eligible.

Applying for Medicaid or CHIP While Incarcerated or When Recently

Released

Individuals can apply for Medicaid at any time before, during, or after incarceration. (NOTE: A

positive eligibility determination for CHIP can only be made after release, since inmates of a

public institution are ineligible for CHIP). Those who apply and are found eligible for Medicaid

during incarceration may be able to get needed medical care more quickly after they’re

released. Medicaid and CHIP eligibility rules vary by state and by the circumstances of the

individual and the individual’s household. There are no special rules or exceptions to the

modified adjusted gross income (MAGI) calculations for incarcerated individuals or for their

household members. However, the incarceration of one household member may affect the

Medicaid or CHIP eligibility of other household members. Individuals may apply for Medicaid or

CHIP through:

 The Health Insurance Marketplace.

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 In-person, online, by mailing a paper application, or over the phone with the State

Medicaid or CHIP agency. Individuals can find their state Medicaid agencies at

HealthCare.gov/medicaid-chip/getting-medicaid-chip.

Some states facilitate the Medicaid application process for incarcerated individuals prior to

release. Other states facilitate enrollment at entry as an inmate of a public institution and then

suspend an individual’s Medicaid coverage while they are incarcerated. States must suspend—

they may not terminate—the Medicaid coverage of certain youth who become incarcerated.

Consumers should check the rules in their state.

Medicaid Eligibility and Incarceration in Another State

If an individual is incarcerated by their home state but sent to an out-of-state facility, the

individual’s home state remains their state of residence for purposes of Medicaid eligibility. If an

incarcerated individual intends to reside in a different state after their release, the individual can

use an address from that state when applying for Medicaid. Medicaid does not require

incarcerated individuals to have a fixed or home address; however, they must list an address

through which they can be contacted after release. Individuals applying for Medicaid before,

during, or after incarceration may use the address of a probation or parole office or community

residential facility for this purpose.

Medicare Coverage

CMS relies on data from Social Security Administration (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.

Maintaining Medicare While Incarcerated

Although Medicare will generally not pay for their health care costs while in jail, incarcerated

consumers who have Original Medicare should consider maintaining their Part A and Part B

coverage to ensure that the coverage will be effective upon their release. For most consumers,

Part A (hospital) coverage is free, and they do not have to pay a monthly premium to maintain

coverage. To maintain Part B (outpatient) coverage, consumers will have to pay the monthly

Part B premium. If they do not pay the monthly premium, they will be unenrolled and lose Part B

coverage.

 If consumers lose their Part B coverage, they have to wait until the General Enrollment

Period (GEP) from January 1-March 31 to re-enroll and wait until July 1 for Part B

coverage to start again.

 Consumers released from incarceration may face a coverage gap if they are released

after the GEP.

 Consumers can also face premium penalties for late or delayed enrollment in Part B

while they are eligible, which can make their Medicare coverage more expensive in future

years.

For more information on Medicare coverage of items and services furnished to beneficiaries in

custody under a penal authority, visit CMS.gov/files/document/mln908084-patients-custody-

under-penal-authority.pdf.

Applying for Medicare While Incarcerated or When Recently Released

Consumers who become eligible for Medicare while incarcerated should actively enroll in

Original Medicare Part A and Part B coverage to ensure that Medicare will pay for health care

services upon their release. All consumers have a seven-month initial enrollment period (IEP)

that includes the three months prior to turning 65, the month of their birthday, and the three

months after turning 65.

Incarcerated consumers who anticipate being released from incarceration should actively enroll

in Part A and Part B coverage while in prison to ensure that Medicare will pay for health care

services upon their release from prison. They will not be automatically enrolled in coverage. If

consumers do not enroll in Medicare during their IEP, they may have to pay a late enrollment

penalty when they sign up.

Recently released consumers may qualify for a Medicare SEP to enroll in a Medicare

Advantage Plan or Medicare Prescription Drug Plan within two full months after the month

they’re released from jail.

Scenario

Samantha is 26 years old and is seeking advice on obtaining Medicaid coverage for her mother,

Jean, who is currently incarcerated but scheduled to be released in four months. Samantha

wants to know whether her mother may submit an application and start receiving coverage while

still incarcerated.

To help Samantha, you should inform her that:

 Jean can apply for Medicaid while she is incarcerated. The Marketplace or her state of

residence will determine whether Jean is eligible for Medicaid based on her household

size, income, and other eligibility criteria.

 If Jean submits an application while incarcerated and is found eligible, she may have

timely access to the full array of Medicaid-covered services upon release, since

enrollment has been activated before her release.

 If Jean is found not to be eligible for Medicaid, she will have a 60-day SEP, active upon

her release, to enroll in Marketplace coverage, if otherwise eligible.

 Federal Medicaid payment will be limited to certain inpatient services in a medical

institution while Jean is incarcerated, if Jean applies while still incarcerated and is found

eligible.

Additional Resources

 Assisting Incarcerated and Recently Released Consumers

 Understanding the Health Insurance Marketplace

If You're Incarcerated:

 English: CMS.gov/marketplace/outreach-and-education/understanding-the-

marketplace-if-incarcerated.pdf

 Spanish: CMS.gov/marketplace/outreach-and-education/understanding-the-

marketplace-if-incarcerated-spanish.pdf

 Health coverage for incarcerated people: HealthCare.gov/incarcerated-people

 Medicaid Eligibility and Enrollment for Justice-involved Populations:

Medicaid.gov/stateresource-center/mac-learning-collaboratives/downloads/justice-

involved-populations.pdf

Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.