(NAPSI)—If you’re enrolled in a Medicare Advantage plan, or are considering one, you will have more plan choices with a wider range of benefits to help you better manage your day-to-day health needs during this year’s open enrollment period.

Medicare’s Annual Enrollment Period, which runs from Oct. 15 through Dec. 7, gives Medicare enrollees a chance to revisit their Medicare insurance coverage, make sure it still fits their needs and make changes for the coming year.

Online health insurance broker eHealth outlines five of the most important Medicare changes to be aware of this year:

1. New benefits to help those with chronic illness. Starting in January, 2020, some Medicare Advantage Plans will include benefits for people with chronic illness that will help to support their care. A few examples include nutrition services, transportation to doctor’s appointments and home improvements like shower grips and wheelchair access. More traditional services like dental care, vision care and hearing aids also have been expanded.

2. Medicare Advantage premiums will be lower next year. The average monthly premium for Medicare Advantage plans is expected to be $23 in 2020, a decrease of 14% from an average of $26.87 in 2019, and down 28 percent since 2017. The average Medicare Advantage premium this year is the lowest it’s been since 2007.

3. Part D drug plan premiums will be lower, too. The average Medicare prescription drug plan premium for 2020 is $30, a decline of 13.5% as compared with 2019 costs. Savings on out-of-pocket costs may be available as well. A recent eHealth analysis of people using eHealthMedicare.com to compare Medicare plans found that fewer than one in ten were enrolled in the lowest cost plan for their personal prescription drug regimen. Those who switched to their optimal drug plan stood to save an average of $900 per year.

4. Seeing a doctor without leaving home will get easier. Many seniors will have access to Medicare Advantage telehealth benefits to connect with health care providers online or by phone. For 2020, more than half of all Medicare Advantage plans will offer added telehealth benefits, reaching up to about 1.7 million enrollees.

5. Medigap plan options are changing. Two of the most popular supplemental plans (so-called Medigap plans) used by those enrolled in original Medicare—Plan F and Plan C—will no longer be available to new Medicare members or those born after January 1, 1955. Fortunately, Plan G, another Medigap policy, offers the same level of coverage provided by Plan F—minus the Part B deductible—and will continue to be available after January 2020. The Part B deductible was $185 in 2019.

Even if you’re happy your Medicare coverage, eHealth recommends that you review your current coverage during open enrollment because each year plans can and do make changes in costs, physician networks or drug benefits.

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Monday, May 13, 2019

Citing the use of telehealth as a care delivery option for Medicare Advantage (MA or Part C) enrollees with the potential to “improve access to and timeliness of needed care, increase convenience for patients, increase communication between providers and patients, enhance care coordination, improve quality and reduce costs related to in-person care,” the Centers for Medicare & Medicaid Services (CMS) issued a final rule on April 5, 2019, implementing several provisions from the Bipartisan Budget Act of 2018 (Public Law 115-123), including updating the MA program by allowing MA plans to include “additional telehealth benefits” as part of the Medicare basic benefits. As a result, starting in plan year 2020, MA plans will be able to include such “additional telehealth benefits” (i.e., telehealth benefits beyond what original Medicare allows) in their bids for the basic Medicare benefits.

Traditionally, MA plans have been constrained in how they deliver telehealth services outside of the original Medicare telehealth benefit, limiting payment to specified services at eligible originating and distant sites within certain designated geographic locations. Because the government’s capitation payment historically has only included hospital and physician/outpatient services covered under original Medicare, most telehealth benefits offered by MA Plans have been offered as MA supplemental benefits, which are funded through the use of rebate dollars or supplemental premiums paid by enrollees. The new rule allows MA plans more flexibility to design their telehealth programs within the Medicare benefit package. While MA plans will still be able to offer MA supplemental benefits for those services that do not meet the requirements for coverage under original Medicare or the requirements for MA “additional telehealth benefits” (described below), the new rule will allow MA plans to provide increased access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits. 

“Additional telehealth benefits” are defined as services i) available under Medicare Part B, but not payable under the original Medicare telehealth benefit and ii) identified by the MA plan as clinically appropriate to furnish through electronic exchange when the physician or practitioner providing the services is not in the same location as the enrollee. See 42 CFR 422.135(a); 42 CFR 410.78. CMS broadly defines “electronic exchange” as electronic information and telecommunications technology and permits MA plans to furnish such “additional telehealth benefits” provided the plan meets the following requirements:

1. the plan provides in-person access to the specified Part B services(s) at the election of the enrollee;
2. the plan advises each enrollee that he/she may receive the specified Part B services through an in-person visit or through electronic exchange;
3. the plan complies with the Medicare provider selection and credentialing requirements and, when providing additional telehealth benefits, ensures through its contract with the provider that the provider meets and complies with applicable state licensing requirements and other applicable laws for the state in which the enrollee is located and receiving the services; and
4. the plan makes information about coverage of additional telehealth benefits available to CMS upon request, including but not limited to statistics on use or cost, manner or method of electronic exchange, evaluation or effectiveness, and demonstration of regulatory compliance.

See 42 CFR 422.135(c). 

Additionally, an MA plan furnishing “additional telehealth benefits” may only do so using contracted providers. CMS requires that the MA plan review and certify the qualifications and compliance of such providers to ensure that telehealth services are furnished in accordance with clinically appropriate standards of care and that all licensure and credentialing requirements are met. Coverage of benefits furnished by a non-contracted provider through electronic exchange may only be covered as a supplemental benefit. See 42 CFR 422.135(d).

If an MA plan fails to comply with the requirements of 42 CFR 422.135, the MA plan may not treat the benefits provided through electronic exchange as “additional telehealth benefits.” (The plan may treat them as supplemental benefits, but subject to CMS approval.)

Further, because CMS deems the delivery of a Part B service via electronic exchange as inherently different (e.g., in modality and required infrastructure) from in-person delivery, MA plans offering “additional telehealth benefits” may maintain different cost-sharing for the specified Part B services furnished through an in-person visit versus furnished through electronic exchange. See 42 CFR 422.135(f).

Under this final rule, CMS envisions that MA enrollees will have additional opportunities to receive health care services from places like their homes, rather than being required to go to a health care facility. And MA plans will now have broader flexibility than is currently available in how they pay for telehealth benefits to meet the needs of their enrollees. ©2019 Greenberg Traurig, LLP. All rights reserved.

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The Centers for Medicare & Medicaid Services (“CMS”) has published a final rule that will expand access to telehealth services for Medicare Advantage (“MA”) plan enrollees.^[1]CMS Administrator Seema Verma characterized the agency’s latest policymaking efforts as “a historic step in bringing innovative technology to Medicare beneficiaries” and a way for the agency to provide “greater flexibility to Medicare Advantage plans, [so] beneficiaries can receive more benefits, at lower costs and better quality.”^[2]

Traditionally, MA plans have been limited to providing, as part of their Medicare benefit packages, solely those telehealth services covered under original Medicare, as defined at Section 1834(m) of the Social Security Act (“Act”). MA plans seeking to offer a broader scope of telehealth services only could do so as MA supplemental benefits, which were funded through use of rebate dollars or supplemental premiums paid by enrollees. Section 1834(m) of the Act limits payments for Medicare telehealth services to specified services provided using a real-time, interactive audio and video telecommunications system between the Medicare beneficiary and practitioner. Also, this section of the Act limits the locations where beneficiaries may receive Medicare-covered telehealth services (e.g., rural and authorized health care facilities).

Under the Bipartisan Budget Act of 2018 (P.L. 115-123) (“BBA”), which was signed into law by President Trump in February 2018, Congress amended the Act to enable MA plans to offer telehealth services beyond the Part B-covered telehealth services traditionally covered as part of the MA basic benefit package. Section 50323 of the BBA created a new Section 1852(m) of the Act which allows MA plans to provide “additional telehealth benefits” starting in 2020 and to treat them as basic benefits (also known as “original Medicare benefits” or “benefits under the original Medicare FFS program option”). The term “additional telehealth benefits” is defined in the final rule as “services—(1) for which benefits are available under Part B, including services for which payments not made under section 1934(m) of the Act due to the conditions for payment under such section; and (2) that are identified for the applicable year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician or practitioner providing the service is not at the same location as plan enrollee.”^[3] This change will benefit both plans and enrollees by enabling plans to fund much of the cost of such benefits through the government-paid capitation without relying on rebate dollars or additional premium charges.

MA plans choosing to offer additional telehealth benefits may maintain different cost sharing for specified Part B services furnished through in-person visit and those Part B services furnished via electronic exchange.^[4] CMS has required that for every MA additional telehealth benefit, the MA plan also must provide access to the same service via an in-person visit, thereby giving the MA plan enrollee the ultimate choice in how to access such services. CMS has chosen not to define which services will be considered “clinically appropriate” to offer in this manner, instead extending to the provision of such additional telehealth benefits the existing requirement at Section 422.504(a)(3)(iii) that the MA organization to agree to provide all benefits covered by Medicare “in a manner consistent with professionally recognized standards of health care.” CMS will defer to MA plans to independently determine, for each plan year, which services are clinically appropriate to furnish using electronic information and telecommunications technology.  MA plans that choose to cover additional telehealth benefits must do so through contracted providers; such benefits as provided by non-contracted providers would need to be covered as MA supplemental benefits.

The final rule also will allow MA plans to continue to separately offer as “MA supplemental benefits” those telehealth services that do not meet the requirements for coverage under original Medicare or to be considered MA additional telehealth benefits. For example, an MA plan may offer, as an MA supplemental benefit, a videoconference dental visit to assess dental needs because services primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth are not currently covered Part B benefits and thus would not be allowable as MA additional telehealth benefits.

Importantly, the final rule will allow MA enrollees to receive certain health care services via telehealth (e.g., ESRD-related, stroke-related) from places other than an authorized health care facility, such as beneficiaries’ homes.

While the final rule ensures that MA plans will have greater flexibility in providing a broader range of telehealth-delivered services and services in more locations, a plan’s choice to offer such benefits remains optional. The final rule may create widely varying offerings between otherwise comparable MA plans, as well as hesitation among MA plans to offer these additional telehealth benefits, for example, due to the requirement that only certain provider-types may provide these services. For plan year 2017, CMS reported that 219 MA plans (or 8 percent of plans) covered remote patient monitoring services and that 2,115 plans MA plans (or 77 percent of plans) covered “remote access technologies” (a term broadly describing services such as e-mail, two-way video, and nurse call-in telephone lines).^[5] How many MA plans will take advantage of this new flexibility, how far they will go, and how these utilization numbers may change, remains to be seen. CMS’s hope is that the change in how MA additional telehealth benefits are financed will encourage MA plans to offer them which, in turn, will improve access for more MA enrollees in need of such benefits.

[1] See 84 Fed. Reg. 15680 (Apr. 16, 2019).

[2] Centers for Medicare & Medicaid Services, Press Release, CMS Finalizes Policies to Bring Innovative Telehealth Benefit to Medicare Advantage (Apr. 5, 2019).

[3] 84 Fed. Reg. 15680, 15684 (Apr. 16, 2019).

[4] However, MA plans may not use differential cost sharing to limit enrollee choice by steering or inhibiting enrollee access to services.

[5] The Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy, ch. 16 (Mar. 2018), at 483, available at http://www.medpac.gov/. In this March 2018 report, MedPAC stated that the Commission “supports expanding telehealth coverage in MA beyond the current level” and made recommendations related to a proposed two-phase plan for expansion. Id. at 499. ©2019 Epstein Becker & Green, P.C. All rights reserved.

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Providers will be able to offer more telemedicine services to seniors in private Medicare plans, thanks to changes announced Friday. But nursing home advocates are pushing for more, hoping the technology can help ease the industry’s ongoing staffing challenges.

Under the final rule starting in plan year 2020, nursing facility patients on Part C plans will be able to receive telehealth services from a physician or other advanced practitioner, if a Medicare Advantage plan decides to incorporate those services into its basic benefits. The National Association for the Support of Long Term Care applauded this policy change Monday, but was disappointed that the final rule did not expand the definition of telehealth provider to also include physical and occupational therapists, and speech language pathologists.

“This rule is a step in the right direction for ensuring patients in skilled nursing facilities have access to the broadest array of services that they need, delivered in ways that are effective, efficient and cost-effective,” Cynthia Morton, executive VP of NASL, told McKnight’s. “We are eager for Congress to do more to help patients by taking action to allow therapy providers to provide telehealth services as part of the additional telehealth benefits.”

She did note, however, that MA plans will also be able to incorporate nurse practitioner services, as well as registered dietitians, via telehealth.

“NASL believes that this is a positive move and good for nursing facility residents who are covered by a MA plan and are not in a rural area,” she added.

Centers for Medicare & Medicaid officials said the changes, first proposed in October, are part of a larger push to modernize Medicare Advantage, an option that is becoming increasingly popular among seniors.

Meanwhile on the Congressional front, LeadingAge is recommending several changes to fee-for-service Medicare policy to further expand access to telehealth. Those suggestions come in response to a request for information from the Congressional Telehealth Caucus.

In an April 1 letter to the caucus, the advocacy group recommended including waiving certain statutory Medicare telehealth requirements, such as rural site restrictions, and allowing the patient’s home to be an eligible originating site for administering such offerings.

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By Meredith Parnell on April 9, 2019h

Last week the Centers for Medicare & Medicaid Services (CMS) announced significant policy changes for Medicare Advantage (MA) and Part D programs. On April 1, 2019, CMS released the calendar year 2020 Rate Announcement and Call Letter, and on April 5, 2019, CMS release the unpublished version of a final rule revising the MA and Part D program regulations for 2020 and 2021 (scheduled to be published April 16, 2019). These documents include many important policy changes for MA plans—including opportunities to offer broadened supplemental benefits packages and expanded telehealth services.

Supplemental Benefits for the Chronically Ill

Traditionally, CMS has interpreted section 1853(a) of the Social Security Act to allow MA plans to offer supplemental benefits (items or services not covered by original Medicare) when they are “primarily health related,” offered uniformly to all enrollees, and result in the MA plan incurring a non-zero direct medical cost. “Primarily health related” means an item or service that is “used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and healthcare utilization.” For 2019, CMS introduced new flexibility into the uniformity requirement by allowing MA plans to offer supplemental benefits to some—but not all—vulnerable enrollees.

In the Bipartisan Budget Act of 2018, Congress amended section 1852(a) of the Social Security Act to allow MA plans to offer chronically ill enrollees supplemental benefits that are neither primarily health related nor uniformly offered. As amended, a chronically ill enrollee is an individual who: (i) has “one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee;” (ii) has a “high risk of hospitalization or other adverse health outcomes;” and (iii) requires “intensive care coordination.” Congress also specified that supplemental benefits must provide a reasonable expectation of improving or maintaining a chronically ill person’s health or overall functioning before they can be offered.

CMS will allow MA plans to offer supplemental benefits to individuals identified by their plan as meeting the statutory definition of chronically ill beginning in 2020. Supplemental benefits may include (but are not limited to) meal delivery, transportation for non-medical needs, pest control, indoor air quality equipment and services, benefits to address social needs, and structural improvements such as ramps or the widening of hallways. Initially, CMS will consider any enrollee with a chronic condition described in section 20.1.2 of Chapter 16b of the Medicare Managed Care Manual to qualify as having a “comorbid and medically complex” condition as required by statute. A technical advisory panel will be formed to periodically update this list for future years. MA plans will have broad discretion to determine which supplemental benefits provide a reasonable expectation of improving or maintaining a chronically ill person’s health.

Expanded Telehealth Services

Historically, telehealth services were only available through original Medicare to seniors living in rural areas. That changed this year when seniors living in urban and rural areas gained the option to pay for virtual check-ins with their doctors.

Compared to original Medicare, MA plans have always had the ability to offer comparatively more telehealth services to enrollees through supplemental benefits packages. The Bipartisan Budget Action of 2018 created new section 1852(m) of the Social Security Act which empowers MA plans to offer “additional telehealth benefits” as part of their basic Medicare benefits package, rather than solely as a supplemental benefit. The statute limits these additional telehealth benefits to those available through Medicare Part B.

In the final rule released last week, CMS leveraged this new statutory authority to grant MA plans broader flexibility around telehealth services. Beginning in 2020, MA plans can offer Part B telehealth benefits as part of their basic benefits package. Plans cannot replace in-person visits with telehealth visits—if a plan offers a Part B services as an additional telehealth benefit, it must provide access to the service through in-person visits as well. Additionally, MA plans can continue to offer supplemental telehealth benefits for services that don’t qualify for this expanded coverage either because they aren’t covered under Part B or original Medicare.

This push for more access to telehealth services reflects CMS’s intent to foster more innovation and competition into MA plans’ offerings. CMS expects this flexibility to result in more plans offering expanded telehealth services, regardless of what part of the country enrollees live in.

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