Article Detail - JD DME
Individuals in Custody of Penal Authority
Incarceration Claim Denials
Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute or rule at the time items and services were furnished.
Definition of Patients in Custody
Under Medicare Program regulations, a patient is considered to be in custody if the patient is:
- Incarcerated in a jail, prison, penitentiary, or similar institution
- On medical furlough or similar arrangement
- Escaped from confinement
- Required by criminal law to live in a mental health facility
Starting January 1, 2025, patients in custody no longer include patients who are:
- Released to the community pending trial (including those released on bail)
- On parole
- On probation
- On home detention
- Required to live in a halfway house or other community-based transitional facility
Special Conditions When Medicare Will Pay
Payment may be made for services furnished to individuals in the custody of the police, other penal authorities, or a government agency only if the following conditions are met (42 CFR §411.4(b)):
- State or local law requires individuals to repay the cost of medical services they receive while in custody.
- State or local government entity enforces the requirement to pay by billing those individuals, whether or not covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe.
Refunds/Adjustments
Suppliers may receive correspondence identifying claims that were paid during periods when the beneficiary was incarcerated.
Appeals
Suppliers who disagree with the claim repayment amount or refund amount may file a redetermination request.
For information on how to file an appeal, refer to the CMS First Level of Appeal: Redetermination by a Medicare Contractor webpage.
