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 Health Programs, Medicare. For subscription information visit: https://bplc.cssny.org/home/subscription_options.
Changes in Requirements for Accessing Benefits
CORONAVIRUS TESTING – Molecular PCR and Antigen Tests
Medicare Part B covers the full cost of a Molecular PCR test and rapid antigen when the test is performed by a laboratory, pharmacy, doctor, or hospital, and when a doctor or other authorized health care professional orders it. A Medicare beneficiary can also get up to one lab-performed test a year without an order, with no out-of-pocket cost.
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.
Those in Medicare Advantage plans have no out-of-pocket costs for these services, similar to Original Medicare.
While many individuals with private health insurance have coverage of at-home rapid antigen tests, these tests are not covered by Original Medicare. Beneficiaries in Medicare Advantage plans can contact their plans to see whether their plan covers rapid at-home tests.
CORONAVIRUS VACCINE and Booster
In 2022, the administration of the COVID vaccine and boosters are covered under Medicare Part B for those with Original Medicare, and by the plan for those in Medicare Advantage plans. (In 2021, costs associated with both the administration of the vaccine and booster were covered by Original Medicare.) There is 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 Health Programs, Medicare, Medicare Covered Services, Covered Services – Medicare Part A, Benefit Period
The flexibilities regarding SNF coverage during the Public Health Emergency specify that it can be used only by people who experience “dislocations or are otherwise affected by COVID-19.” See page 19 of this CMS document for more information.
Medicare had generally only covered telehealth services in limited situations. During the COVID-19 emergency Medicare 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. Medicare permanently expanded the use of telehealth for mental health services.
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 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. Page 22 of this document provides documentation stating that occupational therapists (OTs), physical therapists (PTs), and speech language pathologists (SLPs) can perform initial and comprehensive assessments for all patients via telehealth.
MEDICARE PART D
Among other changes, Medicare Part D plans must cover formulary drugs at out-of-network providers, cover up to a 90-day supply of prescription drugs, and make other needed changes to ensure beneficiaries can access their medication.
The following rules apply to all Part D plans, whether standalone plans that work with Original Medicare or Medicare Advantage plans that include Part D coverage, must cover 90-day refills of prescriptions (except in cases of a safety concern).
Part D plans are required to do this during a Public Health Emergency. See this link and this link for more information on this provision. If you are a Benefits Plus subscriber, for additional information on Medicare Part D, refer to, Health Programs, Medicare, Medicare Part D. For subscription information visit: https://bplc.cssny.org/home/subscription_options.
Part D plans must:
- Cover formulary Part D drugs filled at out-of-network pharmacies
- Part D plans must do this when beneficiary cannot be expected to get covered Part D drugs at an in-network pharmacy.
- Cover up to 90-day supply of the prescription (or the length of the prescription, whichever is shorter) at the beneficiary’s request
- During the emergency, all Medicare Advantage and Part D stand-alone plans must cover up to a 90-day supply of a drug, as long as they have a prescription for that amount, when a beneficiary asks for it.
- Plans cannot use quantity limits on drugs that would prevent a beneficiary from getting a 90-day supply, if they have a prescription for that amount.
- However, some safety limits are still in place to prevent unsafe doses of opioids.
- Make other needed changes to ensure beneficiaries can access their medication without interruption
- Plans have different options for how to do this, such as lifting restrictions that prevent a beneficiary from filling a prescription too soon.
Medicare has also given plans the flexibility to make optional changes. These optional changes include:
- Removing prior authorization requirements for certain services
- Relaxing restrictions on home or mail delivery of prescription drugs
- Relaxing restrictions on refilling prescriptions too soon
- Making mid-year changes that would provide more generous coverage (lower cost-sharing) or adding additional benefits
- Not disenrolling beneficiaries who:
- Fail to pay premiums
- Live outside of plan service area for more than six months
- No longer qualify for specialized type of plan known as Special Needs Plan (SNP)
Every Medicare Advantage and Part D stand-alone plan is different. Beneficiaries should contact their plan directly to learn about how it covers services related to coronavirus.
Changes in Medicare Enrollment Procedures
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 (Extra Help) 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. This CMS memo reinforces these requirements.