Date: May 17, 2022
Grassroots Advocacy Forum: CMS Releases Proposed Rule Implementing Provisions of the Consolidated Appropriations Act, 2021
On April 22, 2022, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule to implement sections of the Consolidated Appropriations Act of 2021 (CAA). These provisions would simplify Medicare enrollment rules and extend coverage of immunosuppressive drugs for certain beneficiaries. Key provisions include:
Beneficiary Enrollment Simplification
Effective January 1, 2023, when an individual enrolls in Medicare Part B during their last three months of eligibility, enrollment will become effective the month after. Currently, when an individual enrolls during the last three months of eligibility, coverage becomes effective in two to three months. This new provision will reduce gaps in coverage.
Special enrollment periods (SEPs) are proposed for individuals who meet exceptional conditions and missed an enrollment period. Under this change, individuals who missed an opportunity to enroll would not have to wait until the general enrollment period (GEP). CMS proposes SEPs for the following situations:
- Individuals impacted by an emergency or disaster, as declared by a local, state, or federal entity. This includes individuals who remained covered by Medicaid during the COVID-19 Public Health Emergency (PHE) even though they became eligible for Medicare during that period but did not take actions to enroll. Individuals who will lose Medicaid coverage on January 1, 2023, or the end of the PHE, whichever is earlier, and missed a Medicare enrollment period will have a SEP.
- Health plan or employer error for individuals that can prove their employer or health plan materially misrepresented information related to timely Medicare enrollment.
- Formerly incarcerated individuals following their release.
- Enrollment in Medicare following termination of Medicaid coverage.
- Other exceptional conditions that would be determined on a case-by-case basis when an individual missed enrollment due to circumstances beyond their control.
State Payments for Medicare Premiums
CMS proposes to streamline state buy-in policies by mandating that provisions of a state buy-in agreement must be set forth in the state’s Medicaid plan.
Currently, all states are in agreements with the Secretary to facilitate payments of Part B premiums for Medicare-eligible Medicaid beneficiaries, called buy-in agreements. However, these agreements have not been amended since 1992. Rather, states have used their Medicaid state plans and state plan amendments to document state buy-in election choices and amendments. To make the buy-in process more efficient, CMS proposes to require that all buy-in provisions and agreements with the Secretary be set forth in states’ Medicaid plans. This would eliminate the free-standing buy-in agreements between states at the Secretary and instead, all changes would be effectuated through the state Medicaid plans.
Additionally, CMS is proposing to simplify situations in which the Social Security Administration 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. CMS proposes to limit retroactive Medicare Part B premium liability for states to 36 months for full-benefit dually eligible beneficiaries.
Extended Months of Coverage for Immunosuppressive Drugs
This proposal would apply to individuals with end stage renal disease (ESRD). Individuals with ESRD are generally eligible for Medicare regardless of age. The CAA mandated that an individual who does not have other health insurance coverage would be eligible to enroll in Part B beyond the 36-month post-kidney transplant period for the limited purpose of getting Part B coverage for immunosuppressive drugs. Individuals would only receive coverage for immunosuppressive drugs, not any other Part A or B benefits.
This benefit would have no enrollment period. Eligible individuals could enroll at any time. Individuals would be able to enroll in the new immunosuppressive drug benefit beginning in October with coverage beginning January 1, 2023.
CMS’s fact sheet can be found here. The unpublished proposed rule can be found here. Comments on the proposed rule are due sixty days after publication in the Federal Register.
For further questions, please contact Alexa McKinley, NRHA’s Government Affairs and Policy Coordinator, at email@example.com or another member of the Government Affairs team.