By Tyler Cromer and Allison Rizer: For More Info, Go Here…
For the near future in today’s pandemic environment, Medicare beneficiaries will be using significantly fewer traditional Medicare benefits. This shift has major implications for Medicare Advantage (MA) plans that must now use premium dollars to meet member needs at home and through non-traditional services. Fortunately, the Centers for Medicare & Medicaid Services (CMS) has gone a long way toward enabling benefit and contracting flexibility for MA plans to help high-risk beneficiaries stay safely in their homes.
A New Year, a Radical Pivot in Care Delivery
2020 is not turning out to be the year that anyone expected as the COVID-19 situation evolves rapidly. When the outbreak began, we anticipated the overrun of our country’s hospital resources, including beds and ventilators. To date, most of those fears have not been realized due to actions across the country to flatten the curve.
In this evolving situation, one thing is clear — individuals at higher risk for severe illness from COVID-19 should stay at home as much as possible for a significant amount of time. Since most Medicare beneficiaries meet the “higher-risk” criteria — either by age or presence of chronic conditions, or both — it is imperative that Medicare does what it can to help these beneficiaries remain safely at home.
To support beneficiaries in staying at home, Medicare has to flex in how and what it pays for, particularly in the Medicare Advantage (MA) program where private insurers continue to receive pre-set monthly payment amounts to cover all Medicare benefits. CMS continues to release guidance that acknowledges the evolving situation by granting broad flexibilities for MA plans to pay for services provided via telehealth and to waive or modify prior authorization, and has loosened requirements around other areas like enrollment and disenrollment. And recently, CMS provided an important new flexibility allowing MA plans to change their benefits mid-year to respond to the needs of their members during the COVID-19 public health emergency.
CMS is using “enforcement discretion” to allow mid-year benefit enhancements and additional benefits provided in connection with COVID-19. CMS guidance highlights that plans can expand or add benefits that address issues or medical needs raised by COVID-19, such as meal delivery and medical transportation services. These benefits must be provided uniformly to similarly situated enrollees.