Watch Phil Capriotti on The Wealth Council

LEARN MORE
CLIENT PORTAL

CMS Finalizes Payment Rule, Including Update to the Custody Definition

Medicare payment rules prohibit coverage for a service if a beneficiary is not financially responsible for the care or if another government entity is obligated to provide or pay for the item or service. For years, the Medicare rules interpreting and implementing this general prohibition used an extremely broad definition of custody as it applied to people in the custody of penal authorities. In addition to people physically detained in jails and prisons—situations where federal and state law require the institution to provide and pay for necessary medical care—the rules created a bar to payment for care for people on bail, parole, probation, home detention and halfway houses. That meant that people living in the community who sought and received care from providers with no connection to the penal authority were denied Medicare coverage.

This disconnect was unique to Medicare. Though Medicaid and health insurance obtained through the ACA marketplaces are also barred from making payment where the insured is not responsible for the cost of care and/ or there is another responsible government entity, their payment policies recognize that, upon release, the individual becomes responsible for procuring and paying for their own health care so the payment prohibition ought not apply, even if there is some ongoing relationship between the penal authority and the enrollee.

CMS’s updated rule brings Medicare into line with these other government health insurances and with the practical realities of modern criminal justice practices by removing the bar on payment for those who are on bail, parole, probation and home detention or who are required to reside in halfway houses.

As part of this change, CMS is also updating the definition of custody for the purposes of the existing Special Enrollment Period for people who were recently incarcerated, and will allow people who have been released from physical detention and are on bail, parole, probation, or home detention and individuals required to reside in halfway houses to enroll or re-enroll in Medicare Part B without having to wait until after that status is terminated to reestablish Medicare coverage. This change will increase access to care during a complicated transition and will also increase administrative simplicity because it more closely aligns with the Social Security Administration’s criteria for determining incarceration status.

CMS Finalizes Payment Rule, Including Update to the Custody Definition

Share:

View the Latest Posts:

Your Medicare Plan May Be Changing—Even If Your Health Hasn’t

You’re happy with your doctors. Your prescriptions haven’t changed. Your Medicare coverage worked well this year. So, is reviewing your plan really necessary? It’s a worthwhile step. Your healthcare needs may stay the same while your plan’s costs and coverage change. Taking time to review the details this fall can help you make a more informed decision about the year ahead. Medicare Open Enrollment runs October 15 through December 7 each year. Changes made during this period take effect January 1, as long as the plan receives your enrollment request by December 7. That means this fall’s enrollment decisions affect your coverage for 2027. Start With the Notice You Might Be Tempted to Skip If you have a Medicare Advantage or prescription drug plan, your plan sends an Annual Notice of Change, often called an ANOC, each fall. It explains changes to costs, coverage, and other plan details that begin

Medicare Open Enrollment 2027: 7 Things to Review Before December 7

Medicare Open Enrollment is one of the most important times of the year for people who already have Medicare. From October 15 through December 7, 2026, Medicare beneficiaries have an opportunity to review their current coverage and make changes for 2027. Any coverage changes made during this period generally take effect on January 1, 2027. Even if you are satisfied with your current plan, taking time to review your coverage can be worthwhile. Medicare Advantage and prescription drug plans can change from year to year—including premiums, provider networks, prescription drug coverage, copays, deductibles, and additional benefits. Here are seven areas worth reviewing before making your Medicare decisions for 2027. 1. Review Your Current Plan’s Changes for 2027 One of the biggest Medicare mistakes is assuming that because a plan worked well this year, it will automatically work the same way next year. Plans may change their: Monthly premiums Deductibles Copayments

Before Your Next Appointment: 5 Medicare Questions That Can Help Prevent Costly Surprises

You schedule an appointment, hand over your insurance card, and assume your coverage will take care of the rest. Then a bill arrives—or the pharmacy tells you that your new prescription needs approval. Understanding your Medicare coverage before you use it can help you prepare for expenses, address paperwork, and ask better questions. Whether you are new to Medicare or have had coverage for years, these five questions are worth keeping handy. 1. Can I Use This Doctor With My Coverage? “Do you take Medicare?” is a starting point, but the next question depends on how you receive your benefits. With Original Medicare, you can generally use doctors and hospitals that accept Medicare throughout the United States. Ask whether the provider accepts assignment, meaning they agree to accept the Medicare-approved amount as full payment for covered services. With Medicare Advantage, you may need to use your plan’s network for non-emergency

7 Medicare Enrollment Mistakes to Avoid When Turning 65

Turning 65 is an exciting milestone—but it also brings important Medicare decisions. With multiple enrollment periods, coverage options, and deadlines to understand, even a small mistake could lead to delayed coverage, unexpected expenses, or lifelong penalties. Here are seven common Medicare enrollment mistakes and how you may be able to avoid them. 1. Assuming Medicare Enrollment Is Always Automatic Some people are automatically enrolled in Medicare Parts A and B, while others must enroll themselves. If you are already receiving Social Security or Railroad Retirement Board benefits before turning 65, enrollment may happen automatically. If you are not receiving these benefits, you will generally need to sign up for Medicare. Do not assume your coverage will begin automatically. Confirm your enrollment status before your 65th birthday. 2. Missing Your Initial Enrollment Period Your Medicare Initial Enrollment Period is a seven-month window that generally includes: The three months before your 65th