Watch Phil Capriotti on The Wealth Council

Sundays @ 1PM on Fox Business

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:

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

Original Medicare vs. Medicare Advantage: What Should You Choose at 65?

As your 65th birthday approaches, you will have several important Medicare decisions to make. One of the biggest is choosing how you want to receive your Medicare benefits. Should you select Original Medicare, or would a Medicare Advantage plan better fit your needs? Both options can provide valuable healthcare coverage, but they work very differently. The right choice depends on your doctors, prescriptions, budget, travel plans, and personal preferences—not simply on which option has the lowest advertised premium. Here is what you should understand before making your decision. First, What Is Original Medicare? Original Medicare is the traditional federal Medicare program. It includes: Medicare Part A, which generally helps cover inpatient hospital care, skilled nursing facility care, hospice care, and certain home healthcare services. Medicare Part B, which generally helps cover doctor visits, outpatient care, preventive services, medical equipment, and other medically necessary services. With Original Medicare, you can generally

Medicare Wellness Visits Explained: What Is Covered—and What Is Not

When you become eligible for Medicare, you may hear several similar-sounding terms: the “Welcome to Medicare” visit, the Annual Wellness Visit, and a routine physical exam. Although these appointments can all play a role in managing your health, they are not the same—and Medicare may cover them differently. Understanding the distinction before scheduling an appointment can help you ask the right questions, make better use of your benefits, and avoid unexpected costs. The “Welcome to Medicare” Preventive Visit The “Welcome to Medicare” preventive visit is a one-time appointment available during the first 12 months that you have Medicare Part B. This visit is designed to establish a baseline for your health and create a preventive-care plan. Your provider may review your medical and social history, discuss screenings and vaccines, check basic measurements, perform a simple vision test, assess certain health risks, and provide a written checklist of recommended preventive services.