Medicare program does not pay for service

Items or services furnished to Medicare beneficiaries in state or local custody

Effective Date: July 9, 2010
Implementation Date: July 9, 2010


The Medicare program does not pay for services if:
The beneficiary has no legal obligation to pay for the services
No other person or organization has a legal obligation to provide or pay for that service.
In addition, under the Social Security Act Section 1862(a)(2) and (3), Medicare does not pay for the services if the services are paid for directly or indirectly by a governmental entity.

The regulations at 42 CFR 411.4(b) describe the special conditions that must be met in order for Medicare to make payment for individuals who are in custody and states:
“Payment may be made for services furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met:
1. State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody, and

2. The state or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts."
To avoid improper denial of claims, providers and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions described above should submit claims for such services using modifier QJ.

For inpatient claims where the incarceration period spans only a portion of the stay, hospitals should identify the incarceration period by billing as noncovered all days, services, and charges that overlap the incarceration period.

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