Medicare Claims for Incarcerated and Unlawfully Present Beneficiaries

Generally, Medicare does not pay claims for items or services furnished to a beneficiary in state or local custody under a penal authority or for services rendered to an alien beneficiary who was not lawfully present in the United States (unlawfully present) on the date of service.

The Medicare Claims Processing Manual, IOM 100-04, Chapter 1, Section 10.4 states:

·         Under Section 1862(a)(2) of the Social Security Act “the Act”, the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service.

·         Under Section 1862(a) (3) of the Act, if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services.

These provisions are implemented by regulations 42 C.F.R.§411.4, 411.6, and 411.8, respectively.

·         Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit payable under Title II. Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residing permanently in the U.S.

Additional information will be posted on the Novitas Website at: https://www.novitas-solutions.com/claims/bulletins/index.html