Information Related to Coronavirus Disease 2019 - COVID-19
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Guidance to Medicare Advantage Organizations, Part D Sponsors, and Medicare-Medicaid Plans on obligations and permissible flexibilities during the COVID-19 emergency, including coverage, cost-sharing, telehealth, pharmacy access, and business continuity.
No material clinical or coverage changes in this revision.
COVID-19 Coverage and Operational Criteria
COVID-19 coverage and operational criteria
Permissive and required actions for plan sponsors during COVID-19 emergencies include coverage at non-contracted facilities, cost-sharing waivers/reductions, telehealth expansion, pharmacy access measures, and vaccine coverage.
ALL of the following
- Cover Medicare Parts A and B services and supplemental Part C benefits furnished at non-contracted facilities subject to Medicare participation agreement requirements.
- Waive, in full, gatekeeper referral requirements where applicable.
- Provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.
- Make changes that benefit the enrollee effective immediately without the 30-day notification requirement (e.g., reductions in cost-sharing, waiving prior authorizations).
Cost-sharing flexibilities
- Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for beneficiaries impacted by the outbreak (for example, for COVID-19 lab tests, telehealth, or other services).
- CMS will exercise enforcement discretion regarding administration of MA benefit packages when organizations voluntarily waive or reduce cost-sharing for similarly situated enrollees; HHS OIG advised such waivers/reductions would satisfy the Federal anti-kickback statute safe harbor at 42 CFR 1001.952(l).
Telehealth and prior authorization flexibilities
- MA organizations may provide Part B telehealth in any geographic area and from beneficiaries' homes, and may expand telehealth coverage beyond approved benefits for similarly situated enrollees; CMS will exercise enforcement discretion while necessary.
- MA organizations may waive plan prior authorization requirements for tests or services related to COVID-19 at any time, consistent with existing flexibilities.
Pharmacy access and Part D operational flexibilities
- Part D sponsors may relax 'refill-too-soon' edits if disruption in access to drugs is reasonably expected and may allow affected enrollees to obtain the maximum extended day supply available under their plan; sponsors may relax edits even absent declarations when appropriate.
- Part D sponsors must ensure enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies when network access is not reasonable; enrollees remain responsible for plan cost-sharing and any excess usual/customary charges.
- Part D sponsors may voluntarily relax plan-imposed policies that discourage mail or home delivery when disasters impede retail pharmacy access or enrollees are quarantined.
Vaccine and Related Code Coverage
| If a COVID-19 vaccine becomes available, Medicare will cover it; all Part D plans must cover it if it is a Part D drug. |
Provider and Plan Operational Actions
Waive prior authorization and implement immediate enrollee‑benefit changes
When special requirements are in effect, plans may waive prior authorization requirements for services and for Part D drugs related to COVID-19 and may make beneficiary-benefit changes that take effect immediately without the usual 30‑day notification requirement. Any waivers or immediate changes must be applied uniformly to similarly situated enrollees affected by the disaster or emergency.
- Waive prior authorization for services and Part D drugs related to COVID-19.
- Implement beneficiary‑benefit changes that benefit enrollees effective immediately without the 30‑day notification requirement.
- Provide waivers and changes uniformly to similarly situated enrollees affected by the disaster or emergency.
Regulatory Definitions and CMS Discretion
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