The Centers for Medicare and Medicaid Services (CMS) and the Office of Personnel Management (OPM) issued guidance to their contracting carriers on various issues surrounding the novel coronavirus or COVID-19.  These guidance documents remind carriers of their contractual obligations as well as give carriers flexibility in the administration of their benefit plans during this crisis.

Coronavirus; OPM

CMS Guidance to Medicare Advantage Organizations and Part D Sponsors

▪ Medicare Advantage Organizations

CMS reminds MA organizations of their obligations under 42 C.F.R. § 422.100(m) when there is a state of disaster.

These obligations include:

  • Covering Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities subject to § 422.204(b)(3).
  • Waiving, in full, requirements for gatekeeper referrals where applicable.
  • Providing the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.
  • Making changes that benefit the enrollee effective immediately without the 30-day notification requirement at 42 C.F.R. § 422.111(d)(3).

MA organizations may also take any of the following actions:

  • Waive or reduce enrollee cost-sharing for their Medicare enrollees who are impacted by the outbreak. Any such waivers must be on a uniform basis for all similarly situated plan enrollees.
  • Provide enrollees access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes.
  • Waive plan prior authorization requirements that otherwise would apply to tests or services related to COVID-19 at any time.

CMS will exercise enforcement discretion with respect to the above deviations from CMS-approved plan benefit packages.  In addition, CMS has confirmed with the HHS Office of the Inspector General that the cost-sharing waivers and increased telehealth benefits would satisfy the Anti-Kickback Statute safe harbor for increased coverage, reduced cost-sharing amounts, or reduced premium amounts offered by health plans at 42 C.F.R. § 1001.952(l).

▪ Part D Sponsors

Part D sponsors may also take the following actions to ensure pharmacy access during a disaster or state of emergency resulting from COVID-19:

  • Relax “Refill-Too-Soon” edits and provide maximum extended day supply.
  • Reimburse enrollees for prescriptions obtained from out-of-network pharmacies.
  • Relax any plan-imposed policies that may discourage certain methods of delivery, such as mail or home delivery, for retail pharmacies that choose to offer these delivery services.
  • Waive prior authorization requirements at any time that they otherwise would apply to Part D drugs used to treat or prevent COVID-19, if or when such drugs are identified.

Office of Personnel Management Guidance to Federal Employees Health Benefits Program Carriers

In Carrier Letter 2020-02, OPM directs FEHB carriers to review their plan benefits to minimize barriers to testing and treatment for FEHB members who are affected by the COVID-19 outbreak.  This includes:

  • On a case-by-case basis, in consultation with the public health authorities and OPM, relaxing referral or pre-authorization requirements to provide benefits for COVID-19 testing, care at specialized centers, medical ambulance transportation reimbursement and early refills of prescription medications for displaced individuals.

In addition, OPM encourages carriers to consider:

  • Contracted medical transportation providers are equipped to handle the transport of potentially infectious patients.
  • Members who require treatment for COVID-19 disease have access to needed services in-network or to consider authorizing access to out-of-network services with in-network cost sharing.
  • Implementing solutions so that out-of-pocket costs are not a barrier to enrollees seeking testing for COVID-19, including waiving cost sharing for testing and telemedicine/ telehealth visits.

In the event that new treatments or vaccines become available (e.g., FDA approval of new drugs or vaccines, or peer-reviewed publications demonstrating the effectiveness of existing anti-viral medications), OPM expects carriers to rapidly review and approve these therapeutics consistent with other existing OPM guidance.

Be safe!

For more legal insights visit our Coronavirus (COVID-19) page.