CMS Releases Coronavirus Guidance for Medicare Advantage and Part D Plans

Julie CarterMedicare WatchLeave a Comment

Update 3/27/20: Congress passed and the President signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act (H.R. 748). Relevant changes have been made to the original post below.

Original post 3/26/20: On March 10, the Centers for Medicare & Medicaid Services (CMS) issued guidance around the requirements and flexibilities Medicare Advantage (MA) plans, Part D plans, and certain Medicare-Medicaid plans have to help provide health care coverage to people with Medicare for coronavirus testing, treatments, and prevention. The guidance identifies what plan sponsors must do during a disaster or emergency as declared by their states, and also what the plans are permitted to do. Since the issuance of the guidance, some of the optional flexibilities have become mandatory due to passage of federal legislation.

Medicare Advantage Provisions

Required MA Actions

In addition to various emergency declarations from the federal government, all U.S. states, territories, and the District of Columbia have issued emergency declarations in response to the coronavirus outbreak. Such declarations trigger special rules for MA plans under 42 CFR 422.100(m)(1).

This includes requiring them to cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities if those facilities have participation agreements with Medicare. In addition, the plans must provide the same cost-sharing for the enrollee as if they had gone to a contracted facility.

During the emergency, MA plans must also make access to care easier by waiving requirements for gatekeeper referrals. Any permissible changes that plans make that benefit enrollees (such as reductions in cost-sharing and waiving prior authorizations, as discussed below) must immediately take effect. Normally, such adjustments would be subject to a 30-day notification requirement. Further, these changes must be uniformly applied to similarly situated enrollees who are affected by the emergency.

CMS also flags that all MA plans must have business continuity plans in place to ensure restoration of business operations following disruptions, including emergencies.

Formerly Optional but Now Required MA Actions 

When the guidance was issued, MA plans could waive cost-sharing for coronavirus testing and the associated provider visit. Since then, the Families First Coronavirus Response Act was signed into law, which waives deductibles and copayments or coinsurance for testing and associated provider visits. It also bars MA plans from using any type of prior authorization or other utilization management tools for the testing products or services.

Optional MA Actions 

Other ways to ease beneficiary access are still optional. For example, plans may reduce or waive cost-sharing for additional services, including for telehealth benefits, without running afoul of the federal anti-kickback statute.

MA plans are already allowed to offer telehealth benefits not covered by Original Medicare, including visits for beneficiaries in any geographic area and from a variety of places, including the beneficiary’s home. Beyond waiving cost-sharing, CMS guidance clarifies that MA plans may also expand telehealth benefits during times of emergency. Any such changes must apply to all similarly situated enrollees on a uniform basis.

Relatedly, using new authorities provided by the coronavirus emergency supplemental bill, CMS is also lifting the geographic and originating site telehealth restrictions for people with Original Medicare. Typically, these telehealth benefits are subject to the standard Part B deductible ($198 in 2020) and 20% coinsurance. However, in complementary guidance, the U.S. Department of Health & Human Services noted that it is allowing providers to reduce or waive these cost-sharing amounts for telehealth visits during the coronavirus public health emergency.

Medicare Part D Provisions

CMS refers Part D plans to previously issued emergency response guidance and outlines several additional actions sponsors may take during the coronavirus outbreak.

Required Part D Actions

Part D plans must have business continuity plans in place to ensure restoration of business operations following disruptions, including emergencies.

Plans must also ensure beneficiaries have adequate access to covered drugs dispensed at out-of-network pharmacies when needed. Enrollees remain responsible for any cost-sharing under their plan as well as additional out-of-network charge.

Regarding any drug shortages that may result from the coronavirus emergency, CMS notes plans should consult Section 50.13 of Chapter 5 of the Part D manual to determine next steps. That guidance notes, in part, that “when a drug shortage occurs, Part D sponsors should begin by considering the type of drug involved, condition(s) being treated by the drug, expected length of the drug shortage, and which enrollees are impacted. Based on this information, Part D sponsors can work with their enrollees and providers to find appropriate therapeutic alternatives.”

In addition, CMS notes that if a coronavirus vaccine becomes available, Medicare will cover it. All Part D plans will be required to cover the vaccine if it is a Part D drug. In legislation passed after the guidance was issued—the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136)—Congress eliminated any cost sharing under Medicare Part B for an eventual vaccine. 

Formerly Optional but Now Required MA Actions

Prior CMS memos stated an expectation that Part D plans would relax “refill-too-soon” edits to provide enhanced access to Part D drugs at the point-of-sale and to permit beneficiaries to obtain the maximum extended day supply. The current guidance merely gives plans the option to do either or both. However, under the CARES Act, all Part D and MA-PD plans are required to allow 90-day fills during the emergency period, if requested by the enrollee. There is an exception for safety edits.

Importantly, both changes are permitted to extend beyond the expiration of disaster declarations and CMS urges plans to work closely with beneficiaries before reactivating such restrictions to ensure continuing access to needed medications.

Optional Part D Actions

In situations when a disaster or emergency makes it difficult for enrollees to get to a retail pharmacy, or enrollees are prohibited from going to a retail pharmacy (e.g., in a quarantine situation), plans may also relax their policies to permit mail and home delivery.

Plans may also waive prior authorization requirements that would otherwise apply to Part D drugs used to treat or prevent coronavirus, if or when such drugs are identified. Any such waivers must be uniformly provided to similarly situated enrollees.

Read the CMS guidance.

Read the CARES Act.

Medicare Rights will continue to monitor this evolving situation.

We will provide updates and information as available. If you have questions about your Medicare coverage and the coronavirus national emergency, please check our coronavirus resource page and call our National Helpline at 800-333-4114.

For the latest on Medicare coverage and services regarding COVID-19, read Medicare Rights’ article on What You Need to Know About Medicare Coverage and the Response to Coronavirus. We are updating this resource ongoingly, as new information becomes available.

Last week, we weighed in with two coalition letters to Congress that outlined shared priorities for any future legislation:

Read advocates’ letter to Congress.

Read the Leadership Council of Aging Organizations (LCAO) letter to Congress.

For more information on the coronavirus, please visit the Centers for Disease Control website.

For information and resources specific to CMS, visit the agency’s Current Emergencies website.

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