A significant barrier for individuals reentering communities after incarceration is accessing health care.

For many, health appointments are conditions to release and parole, and often medical care is lifesaving for those with mental health issues and substance use disorders.

This article discusses the health care options under the federal Medicare program. New changes expanding access to recently incarcerated individuals took effect Jan. 1, 2025.

Health Insurance: The 3 M’s

In an ideal world, a formerly incarcerated individual would be able to obtain work or return to a job and receive health insurance from employment.

The more likely scenario, however, is that the individual would need to obtain health insurance from one of the three M’s: Marketplace, Medicaid, or Medicare.

Marketplace: The Health Insurance Marketplace®, also known as the Patient Protection and Affordable Care Act (ACA), “Obamacare,” or the “Exchange” is available to individuals who do not have other types of health insurance and are not incarcerated.

“Incarcerated” under Marketplace means in jail or prison. You can still purchase a Marketplace plan if you are on probation, parole, on house arrest, living at home, in a residential facility, or halfway house. Once released from incarceration, individuals have a 60-day Special Enrollment Period (SEP) to apply for and select a plan.

If you are in jail or prison waiting for the outcome of charges or “pending disposition,” you can create an account or log in to HealthCare.gov to apply for and enroll in a Marketplace plan.

Medicaid: Medicaid, sometimes called Medical Assistance, is the state’s needs-based health insurance program, which means an individual must meet qualifying income and asset limits.

Medicaid is suspended for individuals who are residing in a jail, prison, or other correctional facility, but is available to individuals who are legally confined to the home by a monitoring device, on parole, probation, or have been released to the community pending trial (including those under pre-trial supervision).

Medicare: The federal Medicare program is the health insurance program for individuals aged 65 and older or for certain individuals who are under 65 and disabled. Medicare has several parts:

• Part A provides hospital insurance and is free if an individual has worked enough to earn 40 quarters of employment credits. Otherwise, individuals must pay a premium up to $518 per month in 2025.

• Part B is medical insurance and comes with a premium for everyone; the standard premium in 2025 is $185 per month.

• Part C is an alternative option, where private health insurance plans bundle Parts A, B (and sometimes D). Premiums vary widely for these plans and they are subject to network restrictions.

• Part D is prescription drug insurance. Premiums for Part D vary widely, but the national base monthly premium is $36.78.

• Individuals who do not choose Part C may, in some cases, add a supplement plan for additional coverage. However, costs are often prohibitive for this additional coverage.

There are financial assistance programs available to help individuals with premium costs called Medicare Savings Programs (MSPs) and the Low-Income Subsidy (LIS).

Medicare During Incarceration

Individuals cannot receive Medicare coverage if incarcerated, which is defined as “in the custody of penal authorities” under 42 C.F.R. section 411.4.

In the recently published 2025 Hospital Outpatient Prospective Payment System (OPPS) rule, the Centers for Medicare and Medicaid Services (CMS) narrowed the description of “custody.” 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,” and as a result, Medicare can now pay for covered services for those individuals.

An individual’s entitlement to premium-free Part A continues while they are incarcerated. However, Medicare will generally not pay for medical items and services given to a beneficiary while they are incarcerated. Incarcerated Medicare beneficiaries with Premium Part A must continue making Part A premium payments or their coverage will end. All beneficiaries must also pay their monthly Part B premiums while incarcerated. If their premiums were being deducted from their Social Security check each month, they will need to set up a direct-bill plan because Social Security checks are not paid while a person is incarcerated.

Medicare After Incarceration

A Special Enrollment Period (SEP) is available for formerly incarcerated individuals who did not enroll (or re-enroll) in Premium Part A or Part B because they were incarcerated. Effective Jan. 1, 2025, an individual who is released from incarceration or confinement to residency in a halfway house is eligible for the SEP.

The SEP begins on the day the person is released from incarceration and ends the last day of the 12^th month after the person is released from incarceration. Under the new rule, this SEP is now based on the Social Security Administration (SSA) incarceration release determinations.

This revision is intended to streamline the Medicare enrollment and re-enrollment process for incarcerated individuals reentering their communities by using data already verified by SSA rather than requiring individuals to provide their own release documentation.

Conclusion

Access to health care is necessary for an individual’s successful reentry into the community. The new Medicare rule narrows the definition of “custody,” expands the former incarceration SEP, and now uses SSA data to streamline the enrollment and re-enrollment process.

These are all positive steps to assist formerly incarcerated seniors and individuals with disabilities obtain health insurance coverage to access the health care they need.

This article was originally published on the State Bar of Wisconsin’s Public Interest Law Section Blog. Visit the State Bar sections or the Public Interest Law Section web pages to learn more about the benefits of section membership.