Medicare Heads Up: April 24, 2020

Welcome to Medicare Heads Up, a regular feature intended to deliver state and national Medicare-related headlines that will keep consumers abreast of developments that affect their coverage and costs. This week:

Medicare trust fund may be at risk due to the coronavirus

Medicare’s Trustees expect the Part A hospital insurance program to be able to pay the full costs of Part A claims until 2026, at which point Part A will only be able to cover 90 percent of claims costs. The Trustees report on Medicare’s finances annually and had projected the same “exhaustion” date in their report last year.

These figures don’t take into account reduced payroll taxes and medical spending due to the coronavirus, however, and this could lead Medicare into financial trouble sooner. Under a “high cost” scenario, the Trustees estimate the Part A trust fund could be unable to pay full costs as soon as 2023.

Trustees expect continued Medicare Advantage enrollment growth

The Medicare Trustees predict the total number of people enrolled in Medicare Advantage plans to increase from an estimated 40 percent this year to 43 percent in 2029, and to remain stable thereafter. Medicare Advantage enrollment has doubled over the past decade. Enrollment in Medicare Advantage Special Needs Plans (SNPs) – a type of plan for specific categories of individuals such as those with both Medicare and Medicaid – is also expected to rise 16 percent, after increasing 12 percent in 2019.

Medicare Advantage home care benefit could support more beneficiaries in 2021

Some home health providers plan to expand services to more Medicare beneficiaries once Medicare Advantage’s home care benefit – Special Supplemental Benefits for the Chronically Ill (SSBCI) – includes care for more people at risk of hospitalization or recovering from a disease. Home health agencies and other stakeholders expect SSBCI to cover a greater portion of Advantage beneficiaries and possibly even include COVID-19-related illnesses in 2021, according to Home Health Care News.

The Medicare Advantage home care benefit includes non-medical transportation, meal support, home modifications, and other “general supports for living” for patients with at least one of 45 chronic conditions. Coronavirus Disease 2019 (COVID-19) is not currently recognized as an eligible condition.

Medicare will pay more for some coronavirus lab tests

CMS announced on April 15, 2020 that Medicare will pay a rate of $100 for COVID-19 clinical diagnostic lab tests that use “high-throughput technologies.” These tests can be processed more quickly than previous ones. The change is intended to help providers who aim to test for coronavirus in nursing home residents and others for whom COVID-19 is particularly dangerous. Original Medicare payments for other COVID-19 tests vary regionally but average $51. Medicare is also paying a specimen collection fee to facilitate testing of non-hospital and homebound patients unable to travel to a lab.

Social Security is allowing Americans to fax Medicare enrollment forms

The Social Security Administration is allowing Americans to submit Medicare enrollment forms using fax. Many people used to visit a local Social Security office to sign up for Medicare, and these offices are closed because of the coronavirus. Social Security has posted the Part B enrollment form and the request for employment information form for those needing to use the Part B special enrollment period (SEP) on its website. Social Security’s fax number is 1-833-914-2016, and these forms can also be mailed to your local Social Security office. (You can use this tool to find the right address.) You can also enroll in Medicare online if you don’t need to use the Part B SEP and don’t already have Part A.

CMS is allowing freestanding emergency departments in some states to bill Medicare and Medicaid

CMS announced on April 21, 2020 that it will allow independent freestanding emergency departments (IFEDs) in Colorado, Delaware, Rhode Island, and Texas to enroll in and bill Medicare and Medicaid. These facilities provide basic care like imaging services, CT scans, ultrasounds, and laboratory services, but aren’t normally eligible to bill Medicare or Medicaid. Until now, IFEDs have only been able to treat commercially insured or cash-paying patients. The temporary change is intended to increase access to treatment during the coronavirus emergency.

CMS allows new appeals flexibility

CMS has said it will allow Medicare and insurers to give beneficiaries extra time to appeal coverage denials during the coronavirus emergency. Original Medicare claims processors, Medicare Advantage, and Part D plans are allowed – but not required – to grant extensions to appeals deadlines. (CMS hasn’t outlined how this will work.) Normally beneficiaries can request extra time to appeal if special circumstances keep an appeal from being filed on time.

Medicare claims processors and insurers are also allowed to process an appeal even if it’s missing information, and can make a decision based on information provided. These flexibilities are optional, and advocates have worried that not all carriers will implement them, or they won’t do so uniformly.

Medicare Advantage plans to get pay boost in 2021

Payments to insurers offering Medicare Advantage will increase 1.66% next year. CMS initially proposed a smaller increase of 0.93% for these insurers. Medicare Advantage plans will actually be paid 3.64% more, when accounting for higher payments insurers receive due to enrollees’ medical conditions.

CMS asks Medicare Advantage and Part D insurers not to disenroll certain members

While people make most changes to their Medicare coverage on their own, Medicare Advantage and Part D insurers also sometimes make changes without being asked. This can include the involuntarily disenrollment of a person from their health plan for reasons such as nonpayment of their  premium.

• Encouraging insurers to delay disenrollments for nonpayment of premiums – CMS is urging Medicare Advantage and Part D insurers not to disenroll members who are unable to pay premiums during the coronavirus emergency. Insurers are allowed to disenroll people who don’t pay premiums after a minimum 2-month long grace period. CMS is asking insurers who won’t stop disenrolling past due members to at least extend the amount of time to pay past premiums. Disenrollment from a Medicare plan can be difficult for somebody with health care needs. Medicare Advantage enrollees can receive health coverage through Original Medicare if they’re disenrolled from their Advantage plan, but people disenrolled from Part D lose their prescription drug coverage altogether, and must wait until the next open enrollment period to re-enroll (with a late enrollment penalty, depending on the circumstances).
• Delayed disenrollment for being out the service area – Medicare plans have set geographic areas where enrollees can live. Under normal circumstances, insurers must disenroll members who stay outside the service area for more than 6 months. CMS will not penalize insurers for letting enrollees keep their plan, through the end of 2020, if a member stays outside the service area for more than 6 months due to the coronavirus.
• Delayed SNP disenrollment for being no longer eligible – Medicare Advantage SNPs must disenroll members when they are no longer eligible to be in the plan (e.g. their Medicaid status changes or they no longer have certification from a health provider regarding the diagnosis that makes them eligible for the SNP). Because this information may be delayed due to coronavirus, CMS is allowing SNPs to let enrollees whose recertification is delayed stay in their plan until the end of 2020, or until the insurer is informed the enrollee is no longer eligible, whichever happens later.

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Josh Schultz has a strong background in Medicare and the Affordable Care Act. He managed a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients on Medicare and Medicaid issues.

Tags: coronavirus, in-home care, Medicare Heads Up, Medicare trust fund