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Medicare Heads Up: May 27, 2020

A round-up of the state and national Medicare news that matters to consumers

Beginning in 2021, insurers participating in the Medicare Part D Senior Savings Model will be required to lower co-pays for all Part D insulins to $35 a month, after the deductible is met. | Image: RFBSIP / stock.adobe.com

Reviewed by our health policy panel.

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:

House bill would require all health insurers to cover full cost of COVID-19 treatment

On May 15, the U.S. House of Representatives passed the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act. If enacted into to law, the bill would require all health insurers – including Original Medicare and Medicare Advantage – to cover the full cost of coronavirus treatment during the public health emergency.

Medicare Part D and Medicare Advantage Prescription Drug (MAPD) plans would also have to cover any medications used to treat coronavirus. Insurers couldn’t have prior authorization requirements or other coverage limits on these medications.

The HEROES legislation is the fourth coronavirus economic relief bill to be considered by Congress. Although some form of additional stimulus legislation is expected to pass, the current version of this legislation is not expected to pass the Senate, and the White House opposes the bill.

Other provisions included in the HEROES Act:

  • As of April 27, Medicare providers had received about $100 billion in advance payments from Medicare to help them financially during the crisis. The HEROES Act would give non-hospital providers two years before the amounts are recouped – affording medical practices more time for their finances to stabilize before repaying CMS.
  • The legislation would also support hospitals by increasing the amount Original Medicare reimburses them for treating coronavirus patients.
  • The HEROES Act would create a special enrollment period (SEP) for Medicare Part B enrollment. The SEP would start July 1 and continue for the remainder of the crisis.

CMS announces special enrollment period for Medicare Advantage, Part D

On May 5, the Centers for Medicare and Medicaid Services (CMS) announced a special enrollment period (SEP) for Medicare beneficiaries impacted by the COVID-19 health emergency. Under the SEP, beneficiaries have until June 30, 2020 to:

  • enroll in or change Medicare Advantage plans;
  • enroll in or change Part D plans;
  • move from Original Medicare to Medicare Advantage (or vice versa)

CMS is granting the SEP under its authority to aid beneficiaries whose attempts to enroll were hindered by a FEMA-declared weather-related emergency or major disaster. Beneficiaries are eligible for this SEP if they qualified to change their Medicare coverage earlier in the year, but the coronavirus crisis prevented them from making changes. (Every Medicare Advantage beneficiary was eligible to change their coverage during the Medicare Advantage open enrollment period, and some beneficiaries may have also qualified for other reasons.) Beneficiaries are also eligible for this SEP if they would have normally had a family member help them change their Medicare coverage, but that person was unavailable because of the coronavirus crisis.

CMS gives beneficiaries extra time to sign up for Part B

CMS is giving beneficiaries extra time to enroll in Part B or premium-free Part A if they were unable to sign up during their initial enrollment period (IEP), general enrollment period (GEP), or special enrollment period (SEP) because Social Security offices were closed during the crisis. In order to be eligible, beneficiaries need to have qualified for and missed an enrollment opportunity between March 17 and June 17, 2020. (Beneficiaries can also decline Part B enrollment if they were automatically signed up during their IEP.)

A CMS FAQ document indicates that a beneficiary’s effective date will be “the month that would have been granted had the application been filed at the time of the individual’s original” enrollment period. But depending on when a beneficiary enrolls during an enrollment period, Medicare’s effective date could occur in multiple different months. We have asked CMS for clarification, but it may help to clearly state the month Part B coverage should begin when making this request (although there is no guarantee CMS will grant a specific start date).

Although many individuals qualify for additional time to enroll, those who previously declined Part B and changed their mind about it will not receive extra time.

Major telehealth provider now accepting Part B patients

An estimated 40 million Original Medicare beneficiaries will be able to access telehealth services now that a large telehealth provider is accepting Medicare Part B. Doctor on Demand is the first major telehealth vendor to offer services to Original Medicare beneficiaries – and will be providing a variety of medical services, including screening and treatment for COVID-19. This is good news for beneficiaries with Original Medicare, whose access to telehealth has been more limited than Medicare Advantage or commercial insurance policyholders.

Prior to the coronavirus, Medicare Part B only covered telehealth for rural beneficiaries who communicated with their provider from a medical facility (as opposed to using a smartphone at home). But this changed in March 2020, when Medicare’s telehealth coverage was opened to all beneficiaries and visits were allowed to take place at home. Coverage was expanded again in April, when Medicare began reimbursing telehealth visits at in-person rates. Although these changes are supposed to be temporary, Doctor on Demand is counting on at least some of them being permanent.

Part D savings program expected to cut insulin costs significantly

CMS announced that more than 1,750 Part D and Medicare Advantage Prescription Drug (MAPD) plans will be offered through the Medicare Part D Senior Savings Model. Beginning in 2021, participating insurers will be required to lower co-pays for all Part D insulins to $35 a month, after the deductible is met. CMS expects beneficiaries who enroll in these plans to pay $229 in annual out-of-pocket insulin costs, which is significantly lower than the $675 paid currently.

The program applies only to “enhanced” Part D plans, which provide additional coverage beyond the “basic” Part D benefit defined in the law. In 2020, the average premium for this type of Part D plan is $49.32, or $17 more than the average basic Part D plan’s cost of $32.09. The model will change the cost of injected insulin – which is covered by Medicare Part D. But it won’t affect the price paid for insulin administered through a pump – which is covered by Part B. Beneficiaries must enroll in a Part D Senior Savings Model plan to receive lower costs. If the model is successful, CMS may expand it to other types of expensive medications.

Insurers are participating in the Part D Senior Savings Model in all 50 states, Washington, DC, and Puerto Rico. CMS will release premiums and other costs for Part D and MAPD plans – including those in the model – in September.

CMS broadens eligibility for Medicare Advantage chronic conditions program

Beginning in 2021, CMS will allow Medicare Advantage plans to offer Special Supplemental Benefits to the Chronically Ill (SSBCI) to any enrollee who meets the law’s definition of having a chronic condition – even if they don’t have one of the diseases specified by CMS. Prior to 2018, supplemental benefits in Medicare Advantage had to be primarily health-related, but that changed when CMS began allowing insurers to cover expenses that aren’t medical in nature.

CMS reports that about 500 Medicare Advantage plans are offering primarily health-related supplemental benefits – such as adult day programs and caregiver supports – to about 2.6 million beneficiaries in 2020. An additional 250 plans offer non-medical benefits such as home meal delivery and therapeutic massage. The regulation means insurers can make these benefits available to even more policyholders in 2021.


Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated 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.

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