COVID-19 Creates New MA Plan Obligations and Flexibilities

Center for Managed Care | March 13, 2020 | by Nicole Fallon

CMS issued a recent memorandum outlining both the obligations and flexibilities afforded to Medicare Advantage(MA), Special Needs Plans (SNPs) and Part D plans (PDP) have under law related to “disasters and emergencies resulting from COVID-19.” 

These plan obligations and flexibilities occur under any of the following triggering events: a presidential declaration of disaster or emergency, a secretarial declaration of a public health emergency, or a declaration by the Governor of a State or Protectorate. They end when the source of the declaration says the disaster or emergency has ended or 30 days has elapsed and no end date was included in the original declaration.

 Note: Since the original publication of this article, the President declared a national emergency under the Stafford Act on March 13,  which is one of the triggers for MA plans to comply with the following requirements.

In these circumstances, according to CMS, plans must:

  • Cover Part Medicare A & B services and MA/SNP supplemental benefits even when provided by non-contracted, Medicare-certified facilities;
  • Waive, in full, requirements for gatekeeper referrals, where applicable;
  • Charge enrollees the same cost sharing for in-network and out of network facilities’ services;
  • Make changes that benefit the enrollee effective immediately without the typically required 30-day notice. (e.g., waive prior authorizations, reduce/eliminate cost sharing)

While plans are required to do the above in an emergency/disaster situation, CMS also gave plans permission do more, including:

  • Waive or reduce enrollee cost sharing for plan enrollees impacted by the outbreak as long as this is done uniformly for all its impacted enrollees;
  • Provide access to telehealth services regardless of geography and in a variety of settings including the enrollee’s home;
  • Waive prior authorization requirements that would otherwise apply to tests or services related to COVID-19 at any time even in situations where a geographic area has not had a triggering emergency or disaster declaration.

Part D plans must abide by the “adequate emergency access for enrollees” requirements under the rule, which include:

  • Allowing plans to waive refill limits --  “refill-to-soon” policies and maximum extended day supply -- in cases where access to Part D drugs can be reasonably expected to be disrupted .This change in policy can pre-date an emergency declaration and extend past its expiration.
  • Allowing enrollees to access to their drugs from out-of-network pharmacies if unable to obtain from an in-network pharmacy. However, the usual out-of-network charges to the enrollee will apply in these circumstances.
  • Allowing plans to relax their restrictions on home or mail delivery of prescription drugs in cases where an enrollee cannot access a retail pharmacy or may be quarantined.
  • Allow plans to waive prior authorization for Part D drugs used to treat or prevent COVID-19, if or when such drugs are identified.

CMS also notes that should a COVID-19 vaccine become available, it will be covered under Medicare and as such under MA, SNP, and PDP.

In related news earlier this week, member health plans of the American Health Insurance Plan (AHIP) association have announced indicated that they will be embracing much of the flexibility offered to them under the emergency and disaster provisions of the law and regulation and outlined by the CMS memorandum. “We will take action to ease network, referral, and prior authorization requirements and/or waive patient cost-sharing. We will also take action so that patients will have continuous access to their regular prescription medications while at the same time avoiding potential problems such as drug shortages.”

Politico reported as of March 10 that New York, Nevada and Washington state have already ordered health plans to waive co-pays and deductibles for coronavirus testing.