|
November 7, 2022
CMS issues a final rule impacting Entitlement and Special Election Periods
On October 28, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to implement sections of the Consolidated Appropriations Act, 2021 (CAA). These changes are intended to simplify original Medicare enrollment rules and extend coverage of immunosuppressive drugs for certain beneficiaries. The rule was published in the Federal Register on November 3, 2022 and can be found here.
Medicare Entitlement
The rule modifies entitlement rules defining when a beneficiary’s Medicare Part A and Part B coverage becomes effective. Beginning January 1, 2023, Medicare coverage will become effective in the month after enrollment for individuals enrolling in the last three months of the initial enrollment period (IEP) or in the general enrollment period (GEP).
Special Election Periods (SEPs)
Within this rule, CMS also finalizes a number of special enrollment periods (SEPs) to provide individuals who meet certain exceptional conditions and who missed a Medicare enrollment period a chance to enroll outside of the GEP and without a late enrollment penalty (LEP). The new SEPs include:
- SEP for Individuals Impacted by an Emergency or Disaster with an extended SEP duration of six months after the end of the emergency declaration. The SEP also will apply if the disaster or emergency situation occurs in the area where the individual’s authorized representative resides.
- SEP for Health Plan or Employer Error for use in situations where the individual demonstrates that their employer or health plan (including its brokers and sales agents) materially misrepresented information related to enrolling in Medicare timely. This SEP would extend for six months after the individual notifies the Social Security Administration (SSA) and allows for an attestation process if documentation is not available.
- SEP for Formerly Incarcerated Individuals will allow individuals to enroll following their release from correctional facilities. This SEP is extended to 12 months post-release and allow individuals to choose between retroactive coverage (with premium payment) back to their release date (up to 6 months) or coverage beginning the month after the month of enrollment.
- SEP to Coordinate with Termination of Medicaid Coverage after January 1, 2023 allows individuals who have missed a Medicare enrollment period to enroll in Medicare after termination of their Medicaid eligibility. This SEP allows the enrollee to choose retroactive coverage (with premium payment) back to the date of termination from Medicaid (but no earlier than January 1, 2023) or coverage beginning the month after the month of enrollment.
- SEP for Other Exceptional Conditions, with a six month duration, which is determined case-by-case, to allow an enrollment period when circumstances beyond the individual’s control prevented them from enrolling during the IEP, GEP or other SEPs.
Immunosuppressive Drug Benefit (Part B-ID)
For those with end stage renal disease (ESRD) and no other coverage, the rule adds eligibility to enroll in a new benefit period beyond the 36-month post-transplant period that is specifically and only for coverage of immunosuppressive drugs. This “Part B-ID” benefit allows for enrollment beginning in October 2022 and coverage starts as early as January 1, 2023. This benefit includes:
- Ability to enroll or disenroll at any time if eligible,
- Coverage only for immunosuppressive drugs and no other Part B benefits or services,
- An attestation that the enrollee is not enrolled in and does not expect to enroll in other coverage like a group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs,
- A requirement that the enrollee notify the SSA within 60 days if they sign up for other coverage, which would end their Part B-ID benefit,
- A lower monthly premium that is less than the standard Part B premium, with an annual deductible, 80% coverage of the Medicare approved amount for the immunosuppressive drug after the deductible is met, and
- Allowance for those enrollees eligible for certain Medicare Savings Programs (MSPs) to have states cover the Part B-ID premium, and for Qualified Medicare Beneficiaries (QMBs), cover their cost-sharing as well.
Medicare Advantage (MA) Sponsors should ensure that their Sales, Marketing and Enrollment teams are aware of these changes. Entitlement period modifications and new SEPs that provide beneficiaries with broader flexibility in their eligibility and enrollment decisions may require updates to MA Sponsor enrollment policies, procedures and training.
| 
