On April 5, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates the Medicare Advantage (MA or Part C) and Medicare Prescription Drug Benefit (Part D) programs by promoting innovative plan designs, improved quality, and choices for patients.
CMS took significant action to increase MA plan choices for the 2019 plan year and aims to continue to expand opportunities so that patients have access to MA plans that meet their unique health needs. In continuing the efforts to increase plan flexibility and plan choices for patients, CMS is finalizing additional flexibilities that will provide patients with more MA options and new benefits.
This fact sheet discusses the major provisions of the final rule (CMS-4185-F) that will implement certain provisions of the Bipartisan Budget Act of 2018, improve MA and Part D program quality and accessibility, and clarify program integrity policies. The final rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/.
Implementing the Bipartisan Budget Act of 2018 Provisions
CMS is implementing several sections of the Bipartisan Budget Act of 2018 (Public Law 115-123):
- Section 50323 allows MA plans to offer “additional telehealth benefits” as part of the government-funded “basic benefits”;
- Section 50311 requires increased integration of Medicare and Medicaid benefits and appeals and grievance processes for MA Dual Eligible Special Needs Plans (D-SNPs); and
- Section 50354 requires the Secretary to establish a process to allow Part D plan sponsors to request standard extracts of Medicare Parts A and B claims data regarding their enrollees.
Medicare Advantage Plans Offering Additional Telehealth Benefits
The Bipartisan Budget Act of 2018 allows MA plans to include “additional telehealth benefits” (telehealth benefits beyond what Original Medicare allows) in their bids for the basic Medicare benefits, starting in plan year 2020. Under this final rule, MA enrollees may have great opportunities to receive healthcare services from places like their homes, rather than being required to go to a healthcare facility. MA plans will now have broader flexibility than is currently available in how they pay for coverage of telehealth benefits to meet the needs of their enrollees.
These changes will provide MA plans with the ability to offer expanded telehealth coverage to meet the needs of their patients. Patients in MA plans have always been able to receive more telehealth services than those in original Medicare, and with the final rule there is an even greater likelihood that these patients will have access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas.
Integration Requirements for D-SNPs
CMS is finalizing new minimum criteria for Medicare and Medicaid integration in D-SNPs for contract year 2021 and subsequent years. Pursuant to the requirements in the Bipartisan Budget Act of 2018, we will require that D-SNPs meet the integration criteria either by, at a minimum, (1) covering Medicaid long-term services and supports and/or behavioral health services through a capitated payment from a state Medicaid agency; or (2) notifying the state Medicaid agency (or its designee) of hospital and skilled nursing facility admissions for at least one group of high-risk full-benefit dual eligible individuals, as determined by the state Medicaid agency.
Unified Grievance and Appeals Procedures for D-SNPs
CMS is finalizing rules to unify Medicare and Medicaid grievance and appeals processes for certain D-SNPs and affiliated Medicaid managed care plans. The processes will apply to D-SNPs with fully aligned enrollment and the affiliated Medicaid managed care organization, where one organization is responsible for managing Medicare and Medicaid benefits for all enrollees. In such D-SNPs, enrollees will have simpler, more straightforward grievance and appeals processes. The Bipartisan Budget Act of 2018 requires compliance with unified grievance and appeal procedures beginning in contract year 2021.