CMS Adds New Coverage Requirements to MA Plans Under COVID-19

Regulation | April 28, 2020 | by Nicole Fallon

An April 21 CMS memorandum to Medicare Advantage Organizations(MAOs) amends prior guidance and establishes new requirements and temporary flexibilities during the COVID-19 national emergency, which include coverage for COVID-19 testing and test-related services and for Medicare services received from out of network providers.

Specifically, for tests or services on or after March 18 through the national emergency period, MAOs are required to cover the following without cost sharing to the plan enrollee:

  • Clinical laboratory tests for the detection and diagnosis of the virus strain that causes COVID-19 and the associated administration of the test
  • Specified COVID-19 testing-related services under Medicare Part B provided by: physicians, hospital outpatient departments, critical access hospitals, rural health clinics and federally qualified health centers for the following HCPCS evaluation and management codes :
    • Office and other outpatient services
    • Hospital Observation services
    • Emergency department services
    • Nursing facility services
    • Domiciliary, rest home or custodial care services
    • Home services
    • Online digital evaluation and management services.
  • COVID-19 vaccines and their administration, once available. This will be covered under Medicare Part B drugs not Part D

In addition, MAOs are prohibited from imposing prior authorizations or other utilization management requirements during this time period for the above-listed items.

This memo supersedes the March 10 memorandum previously provided to MAOs related to COVID-19 flexibilities and requirements.

In addition, the April 21 memorandum now also requires MAOs to:

  • Cover Medicare Part A & B services and supplemental MA benefits provided at non-contracted Medicare facilities (a.k.a. out-of-network providers);
  • Waive, in full, requirements for gatekeeper referrals, where applicable;
  • Charge the same contracted-facility cost sharing to enrollees for services regardless whether the service was received at a non-contracted facility;
  • Make changes that benefit the enrollee effective immediately without the 30-day notification requirement;
  • Suspend all quantity and days’ supply limits under 90 days for all covered Part D drugs with the exception of safety edits.

Finally, CMS also provided MAOs a number of new temporary flexibilities that they have the option of adopting including:

  • Reducing/waiving additional cost sharing in COVID-19 impacted areas: is encouraging plans but not requiring them to waive or reduce enrollee cost sharing (e.g. co-pays or co-insurance) for COVID-19 treatments and other services for enrollees in areas impacted by the outbreak.This flexibility must be tied to the COVID-19 outbreak.
  • Allow more than 14-day supply of Part D drugs to long term care facilities: CMS will use its enforcement discretion to allow Part D drug plans to approve pharmacies dispensing greater than a 14-day supply for all applicable Part D drugs to provide more flexibility to LTC facilities and pharmacies to coordinate with each other. 
  • Delay involuntary disenrollment of enrollees absent from their plan service area for more than 6 months when the absence is the result of COVID-19 national emergency.
  • Continue enrollees SNP eligibility and not disenroll enrollees if unable to recertify their status (e.g. duals – Medicaid eligibility) as a result of the COVID-19 emergency.
  • Waiving or relaxing prior authorization policies at any time to facilitate access to services and/or Part D or other formulary drugs to reduce burden on enrollees, plans and providers.

For MA and Part D beneficiaries unable to pay their plan premiums during this time, CMS is encouraging plans to use flexibilities afford to them to not disenroll an enrollee for failure to pay their plan premiums and/or to extend their existing non-payment grace period in order to ensure continued access to needed care for these individuals during the COVID-19 emergency.