Standard coverage and cost-sharing rules still apply for both inpatient (Medicare Part A) and outpatient (Medicare Part B) care. Medicare has allowed an expansion of the use of telehealth services, reduced coverage requirements for skilled nursing facility (SNF) care, opened up their enrollment procedures, and Medicare Advantage plans must allow beneficiaries to receive health care services with out-of-network providers, among other changes.
If you are a Benefits Plus subscriber, for additional information on Medicare, refer to Benefits Plus, Health Programs, Medicare. For subscription information visit: https://bplc.cssny.org/home/subscription_options.
Changes in Requirements for Accessing Benefits
Coronavirus testing and associated provider expenses are covered under Medicare Part B with no cost sharing. Medicare is not requiring an order from the treating practitioner to receive COVID-19 testing; instead, tests may be covered when ordered by health care professional authorized to do so under state law. In addition, beneficiaries can get tested at “parking lot” test sites operated by pharmacies and other entities consistent with state requirements. Medicare is also covering certain antibody tests.
There is currently no vaccine for coronavirus. If a coronavirus vaccine is developed, it will be covered under Medicare Part B. There will be no cost-sharing (deductible, coinsurance, or copayment) for the vaccine.
SKILLED NURSING FACILITY (SNF) CARE
Medicare Part A generally only covers SNF care if someone was a hospital inpatient for three consecutive days before entering the SNF. During the COVID-19 emergency, Medicare has removed the three-day hospital stay requirement for beneficiaries who are affected by this emergency, including beneficiaries who:
- Need to be transferred to a SNF, for example, due to nursing home evacuations or to make room at local hospitals
- Need SNF care as a result of the COVID-19 emergency, regardless of whether they were previously in the hospital
Medicare is also changing other SNF coverage requirements. Typically, Medicare Part A covers up to 100 days of SNF care each benefit period. During the COVID-19 emergency, beneficiaries who cannot start a new benefit period can get another 100 days of covered SNF care without having to begin a new benefit period. For more information about benefit periods, refer to Benefits Plus, Health Programs, Medicare, Description of Medicare, Benefit Package – Medicare Part A, Benefit Period.
Medicare generally only covers telehealth services in limited situations. During the COVID-19 emergency Medicare has temporarily expanded coverage and access and will cover hospital and doctors’ office visits, behavioral and mental health counseling, preventive health screenings, and other visits via telehealth services for all beneficiaries. Limited telehealth services can also be delivered using only audio. These services include counseling and therapy provided by an opioid treatment program, behavioral health care services, and patient evaluation and management.
CMS is waiving limitations on the types of clinical practitioners that can offer Medicare telehealth services; other practitioners, such as physical therapists, occupational therapists, and speech language pathologists, can now provide such services.
Standard Medicare cost-sharing may apply, but a provider can choose not to charge for the cost-sharing for these services. If a beneficiary has a Medicare Advantage Plan, they should contact their plan to learn about its costs and coverage rules.
During the COVID-19 emergency, some of the requirements for home care coverage by Medicare have been changed.
- Homebound Requirement: Someone will can be considered homebound if their physician certifies that the beneficiary cannot leave their home because they are at risk of medical complications if they go outside, or if they have a suspected or confirmed case of COVID-19.
- In addition to a doctor, other health care providers, such as nurse practitioners, physician assistants can also prescribe home care. The face-to-face visit requirement can be met through telehealth services.
- Home health care agencies can provide more services via telehealth.
Changes in Medicare Enrollment Procedures
EQUITABLE RELIEF: BENEFICIARIES WHO MISSED A MEDICARE ENROLLMENT PERIOD
During the week of May 4th, the CMS announced it is providing “equitable relief” to allow individuals who missed a Medicare enrollment period extra time to enroll in Medicare without penalty. Specifically, individuals who could have enrolled in Medicare between March 17th and June 17th during either their initial enrollment period (IEP), Medicare’s general enrollment period (GEP), or a special enrollment period (SEP), have until June 17, 2020 to enroll and not be penalized.
While certain individuals could be eligible for coverage immediately, many will have to wait until July or later for their coverage to become effective.
SPECIAL ENROLLMENT PERIODS
CMS also announced a Special Enrollment Period (SEP) for Medicare beneficiaries that will allow them to change their Medicare Advantage plans (MA) and Part D prescription drug plan (PDP) enrollment if they did not make a change during the MA Open Enrollment Period or another SEP due to the coronavirus emergency. This SEP is available until July 13th.
The Medicare Advantage Open Enrollment Period is only for Medicare beneficiaries who are enrolled in a Medicare Advantage plan as of January 1st of the current calendar year and runs through March 31st. It allows the beneficiary to switch to a different Medicare Advantage plan, or disenroll from their Medicare Advantage plan and return to Original Medicare.
To use this SEP, a beneficiary must have been entitled to use another enrollment period between March 17 and July 17. To make a change, a beneficiary should call 1-800-MEDICARE (633-4227). They do not have to prove that they were impacted by the public health emergency. This SEP can only be used once.
Beneficiaries who switch to Original Medicare during this period have a choice of enrolling or not enrolling in a stand-alone Part D plan, regardless of whether they had Part D coverage with their Medicare Advantage plan.
FIRST TIME ENROLLEES
Beneficiaries within three months of age 65 or older and not ready to start their monthly Social Security benefits yet, can use SSA’s online retirement application to sign up just for Medicare and wait to apply for retirement or spouses benefits later.
See “How to Apply for Medicare Online” – https://www.ssa.gov/pubs/EN-05-10531.pdf.
Applications for the Low-Income Subsidy can also be completed online.
Changes for Medicare Advantage Plans
During the COVID-19 emergency, Medicare Advantage Plans must work to maintain access to health care services and prescription drugs for plan members. Medicare Advantage Plans must:
- Allow beneficiaries to receive health care services at out-of-network doctor’s offices, hospitals, and other facilities
- Charge in-network cost-sharing amounts for services received out-of-network
- Waive referral requirements
- Suspend rules requiring the beneficiary tell the plan before getting certain kinds of care or prescription drugs, if failing to contact the plan ahead of time could raise costs or limit access to care
This requirement applies whenever there is a declaration of a disaster, emergency or public health emergency.