Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and other Revisions to Medicare Enrollment and Eligibility Rules (CMS-4199-F)
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) that will simplify Medicare enrollment rules and extend coverage of immunosuppressive drugs for certain beneficiaries. Section 120 of Title I of Division CC of the CAA makes changes to Traditional Medicare by revising the effective dates of coverage and giving the Secretary of the Department of Health and Human Services (the Secretary) the authority to establish new special enrollment periods (SEPs) for individuals who meet exceptional conditions. Section 402 of the CAA extends immunosuppressive drug coverage under Part B for certain individuals whose Medicare entitlement based on End-Stage Renal Disease (ESRD) would otherwise end 36-months after the month in which they received a kidney transplant, provided they do not have certain other health coverage. This rule also finalizes other non-CAA related changes to improve state payment of Medicare premiums and a technical change related to how enrollment forms are referenced in regulations.
These changes support the Biden-Harris Administration’s vision for CMS: to serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding access to affordable coverage and care, and improving health outcomes. The changes to implement the CAA will expand coverage for people with Medicare and advance equity by reducing gaps of coverage, providing relief to individuals who miss a Medicare enrollment period due to an exceptional condition, and providing access to immunosuppressive drugs for individuals who are no longer eligible for Medicare on the basis of ESRD after a kidney transplant and have no other coverage.
The final rule (CMS-4199-F) can be downloaded from the Federal Register at:https://www.federalregister.gov/public-inspection/2022-23407/medicare-program-implementing-certain-provisions-of-the-consolidated-appropriations-act-2021-and
Section 120 of the CAA – Beneficiary Enrollment Simplification
In general, under current rules for Medicare premium Part A and Part B, the date when an individual’s coverage becomes effective depends on when they enroll:
- If an individual enrolls during any of the first three months of their Initial Enrollment Period (IEP), their coverage will start the first month of eligibility (e.g., age 65).
- If an individual enrolls during their IEP in the month they become eligible, their coverage will start the month after they enroll.
- If an individual enrolls during any of the last three months of their IEP, their coverage will start 2-3 months after they enroll.
- If an individual enrolls during the General Enrollment Period (GEP), which runs from January 1st through March 31st every year, their coverage will start July 1st.
As mandated in Section 120 of the CAA and finalized in this rule, beginning January 1, 2023, Medicare coverage will become effective the month after enrollment for individuals enrolling in the last three months of their IEP or in the GEP, thereby reducing any potential gaps in coverage.
Section 120 of the CAA also gave the Secretary the authority to establish SEPs in the case of individuals who meet such exceptional conditions as the Secretary may provide. In this rule, CMS is finalizing SEPs that will provide individuals who meet certain exceptional conditions and who missed a Medicare enrollment period, an opportunity to enroll without having to wait for the GEP and without being subject to a late enrollment penalty (LEP).
Specifically, CMS is finalizing the following SEPs:
- An SEP for Individuals Impacted by an Emergency or Disaster that will allow CMS to provide relief to those beneficiaries who missed an enrollment opportunity because they were impacted by a disaster or other emergency as declared by a Federal, state, or local government entity. This SEP is being modified in the final rule to extend the duration to six months after the end of the emergency declaration and to also allow for usage if the disaster or emergency takes place where the individual’s authorized representative, legal guardian, or person who makes health care decisions on their behalf resides.
- An SEP for Health Plan or Employer Error that will provide relief in instances where an individual can demonstrate that their employer or health plan materially misrepresented information related to enrolling in Medicare timely. The duration of this this SEP has been extended to six months after the individual notifies SSA and it will allow for a written attestation from the beneficiary when documentation of misinformation from the employer or health plan is not available and will also include brokers and agents of health plans as sources of misinformation.
- An SEP for Formerly Incarcerated Individuals that will allow individuals to enroll following their release from correctional facilities. This SEP is being modified in the final rule to extend the duration to 12 months post-release and allow individuals to choose between retroactive coverage back to their release date (not to exceed 6 months) or coverage beginning the month after the month of enrollment. If an individual selects retroactive coverage, they must pay the premiums for the retroactive covered time period.
- An SEP to Coordinate with Termination of Medicaid Coverage after January 1, 2023 that will allow individuals who have missed a Medicare enrollment period to enroll in Medicare after termination of Medicaid eligibility. This SEP is being modified in the final rule to allow individuals to choose between retroactive coverage 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. If an individual selects retroactive coverage, they must pay the premiums for the retroactive covered time period.
- An SEP for Other Exceptional Conditions that will, on a case-by-case basis, grant an enrollment period to an individual when circumstances beyond the individual’s control prevented them from enrolling during the IEP, GEP or other SEPs. This SEP is being modified to provide for a minimum 6-month duration.
These changes will expand Medicare enrollment opportunities and reduce multi-month coverage gaps in Medicare.
Section 402 of the CAA - Extended Months of Coverage of Immunosuppressive Drugs for Kidney Transplant Patients and Other Renal Dialysis Provisions
The majority of individuals with ESRD are eligible for Medicare, regardless of age. When an individual receives a kidney transplant, Medicare coverage extends for 36 months but is then terminated unless the individual is otherwise entitled to Medicare (based on age or disability). As mandated by Section 402 of Title IV of Division CC of the CAA, and finalized in this regulation, an individual who does not have and does not expect to have certain other health insurance coverage will be eligible to enroll in a new benefit beyond the 36-month post-transplant period. This new benefit only provides coverage for immunosuppressive drugs. CMS is referring to this benefit as the immunosuppressive drug benefit, or the Part B-ID benefit. Eligible individuals can enroll in the new immunosuppressive drug benefit beginning in October 2022 and coverage starts as early as January 1, 2023.
As outlined in this final rule, the new immunosuppressive drug benefit will have the following features:
- There will be no specific enrollment periods; if an individual is eligible, they can enroll (or disenroll) at any time.
- The benefit will only cover immunosuppressive drugs and will not include coverage for any other Part B benefits or services.
- An individual will be required to attest that they are not enrolled in, and do not expect to enroll in, certain other types of coverage (e.g., group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs) and that they will provide notification to the Social Security Administration (SSA) within 60 days if they sign up for such other coverage (thereby ending their enrollment in the Part B-ID benefit).
- The monthly premium will be less than the standard Part B premium, and enrollees will not be subject to late enrollment penalties. Enrollees will also have to pay the annual deductible. Once the deductible is met, enrollees pay 20% of the Medicare-approved amount for immunosuppressive drugs.
- Individuals eligible for certain Medicare Savings Programs (MSPs) can have states cover the immunosuppressive drug benefit premium, and for Qualified Medicare Beneficiaries (QMBs), co-insurance, deductibles and cost sharing as well.
Regulations Related to Medicare Enrollment Forms
Current regulations list every form that is used to enroll in Medicare Parts A and B and provide a brief description of the use of the form. As identifying each form in regulation makes it challenging for CMS and SSA to update forms and to quickly adapt to more efficient uses of each form; CMS is revising regulations to remove these specific references. This is an administrative change that will simplify existing regulations and will have no impact on use or availability of these forms, nor will the change affect current eligibility requirements or enrollment processes.
State Payment of Medicare Premiums
CMS is finalizing updates to the various regulations that affect a state’s payment of the Medicare Part A and B premiums on behalf of 10 million low-income individuals (often known as “state buy-in”). These changes will better align the regulations with federal statute, policy, and operations that have evolved over time. By clarifying and streamlining existing requirements, these changes will promote access to affordable health coverage and essential medical treatment and improve health equity for underserved populations.
The changes will simplify state administration by:
- Defining the State Plan as Meeting the Requirement for ‘Agreement’ with CMS. While the Secretary and all states initially signed free-standing buy-in agreements, none have been amended since 1992. Instead, CMS and states have used the Medicaid state plan and state plan amendments to document the buy-in policy in each state. CMS is finalizing changes to officially replace the old stand-alone agreements by specifying that the provisions of a state buy-in agreement shall be set forth in the state’s Medicaid state plan. Consolidating state buy-in policy in one document per state promotes clarity and transparency for states, the federal government, and beneficiaries, and enhances accountability for state payment of Medicare premiums on behalf of low-income individuals.
- Limiting Retroactive Liability of States. From time to time, SSA establishes retroactive Medicare Part A entitlement for Medicaid beneficiaries as part of disability determinations. This action can make states liable for retroactive Part B premiums going back several years. It can also increase administrative work for providers and payers involving recoupment, billing, and claims processing. CMS is finalizing changes to limit retroactive Medicare Part B premium liability for states to 36 months prior to the date of the Medicare enrollment determination, for full-benefit Medicaid beneficiaries beginning January 1, 2024. This change will reduce burden on providers and will help state Medicaid programs and the Medicare program run more efficiently.