CMS Releases Proposed Medicare Eligibility and Coverage Changes

This week, CMS published in the Federal Register a proposed rule entitled, Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules. The Notice of Proposed Rulemaking (NPRM) includes proposed changes to Medicare eligibility, including elimination of the Medicare coverage waiting period under specific circumstances, as well as new Special Enrollment Periods (SEP). The NPRM also proposes extending months of immunosuppressive drugs for kidney transplant patients, simplification of Medicare enrollment forms and proposes to update various regulations that affect a state’s payment of the Medicare Part A and B premiums on behalf of low-income individuals (often known as “state buy-in”). These changes could better align the regulations with federal statute, policy and operations that have evolved over time.

Enrollment in Medicare must happen during certain periods of eligibility specific to the beneficiary. When a beneficiary becomes eligible for Medicare, they have various opportunities to enroll. Currently, these opportunities correspond with different effective dates. CMS is proposing consistency in effective dates to ensure gaps in coverage are reduced and access to care is enhanced. Under the new proposal, all beneficiaries will receive coverage effective the first of the month following their enrollment. In some cases, this will reduce waiting periods by up to three months.

A beneficiary can also access Medicare through SEPs. CMS is proposing five new SEPs for:

The SEP for Other Exceptional Conditions provides the Secretary with the ability to grant an SEP to an individual on a case-by-case basis when circumstances beyond an individual’s control prohibit them from enrolling during normal enrollment periods.

Most individuals with ESRD are eligible for Medicare, regardless of age. When an individual receives a kidney transplant, Medicare coverage extends for 36 months but is then terminated unless the individual is otherwise entitled to Medicare (based on age or disability). CMS proposes that an individual who does not have other health insurance coverage would be eligible to enroll in Part B beyond the 36-month post-transplant period to maintain Part B coverage for immunosuppressive drugs. CMS is referring to this benefit as the Part B-ID benefit. If the proposed policy is finalized, eligible individuals can enroll in the new immunosuppressive drug benefit beginning in October 2022 and coverage would start as early as January 1, 2023.

Current regulations list every form that is used to enroll in Medicare Parts A and B and provide a brief description of the use of the form. Identifying each form in regulation makes it challenging for CMS and SSA to update forms and to quickly adapt to more efficient uses of each form. To address these challenges, CMS is proposing to revise regulations to remove these specific references. This is an administrative change that would simplify existing regulations and would have no impact on the use or availability of these forms, current eligibility requirements or enrollment processes.

CMS is proposing to update the various regulations that affect a state’s payment of the Medicare Part A and B premiums on low-income individuals (often known as “state buy-in”). These changes would better align the regulations with federal statute, policy, and operations that have evolved over time. By clarifying and streamlining existing requirements, these proposals would promote access to affordable health coverage and essential medical treatment and improve health equity for underserved populations. Specific proposals include: 

AHCA will be commenting on each of these provisions. If you have questions or would like to be in included in comment development, please contact AHCA at covid19@ahca.org.