New Medicare Rules for Enrollment and Coverage

Medicare continues to evolve, and some of the latest changes from the Centers for Medicare & Medicaid Services (CMS) will help provide more coverage to certain beneficiary groups. These changes come from the Consolidated Appropriations Act of 2021 (CAA), passed by Congress on December 21, 2020, and signed by President Joe Biden on December 27, 2020. Learn more about the new Medicare rules to help expand enrollment and coverage below.

What is the Consolidated Appropriations Act of 2021?

This spending bill prevents a government shutdown by combining stimulus relief for the COVID-19 pandemic with a $1.4 trillion omnibus spending bill for the fiscal year 2021. But as with many bills, there is much to dissect, including ties to new Medicare rules.

Through funding from 12 appropriation bills, the Centers for Medicare & Medicaid Services (CMS) received $4 billion, an increase of $50 million, for CMS administrative expenses. Additional revisions in the bill also help with Medicare enrollment and eligibility rules.

Does the Consolidated Appropriations Act Apply to Medicare?

Part of the Consolidated Appropriations Act of 2021 simplifies the enrollment process for Medicare and covers immunosuppressive drugs for some who are eligible. The rule proposal came from CMS as part of an ongoing effort to expand access to affordable healthcare.

The new Medicare rules can be found in the following sections within the CAA, which directly tie to your Medicare benefits:

Section 120 of Title I of Division CC of the CAA

This portion of the CAA provides change to Original Medicare. It revises the effective dates for coverage and gives the Secretary of the Department of Health and Human Services authority to establish new Medicare Special Enrollment Periods (SEPs) for seniors who qualify through exceptional conditions.

Section 402 of the CAA

The CAA is extending coverage for immunosuppressive drugs under Medicare Part B for qualifying individuals. Without other health coverage, seniors with Medicare entitlement based on end-stage renal disease (ESRD) would otherwise have their Medicare coverage end 36 months after receiving a kidney transplant.

As part of this rule, other non-CAA-related changes are finalized, including an adjustment to how enrollment forms are referenced in regulations and a technical change related to the payment of Medicare premiums by states.

Medicare Beneficiary Enrollment Simplification

CMS issued a new Medicare rule updating Medicare’s rules for enrollment and eligibility. Now, coverage is expanding by establishing the changes in the CAA. Changes that make it easier for seniors enrolling in Medicare include:

• Providing Medicare coverage the month after enrollment.
• Expanding access during Medicare Special Enrollment Periods.
• Allowing eligible seniors to enroll in Medicare Part B coverage without facing late enrollment penalties.

As said by CMS Administrator Chiquita Brooks-LaSure, “CMS is committed to ensuring that people eligible for Medicare have timely access to this vital coverage. For the first time, special enrollment periods will be available in traditional Medicare for individuals unable to enroll due to exceptional conditions.

Additionally, individuals who have had a kidney transplant will now be able to receive extended Medicare coverage for immunosuppressive drugs. Each part of this critical rule advances CMS’s strategic vision of expanding access to quality, affordable health coverage and care.”

New Rules for Medicare Exceptional Circumstances Special Enrollment Period

Thanks to Section 120 of the CAA, the Secretary is gaining the authority to establish Special Enrollment Periods for beneficiaries that meet exception conditions. If you fit the criteria, you won’t have to wait for the Medicare General Enrollment Period (GEP), nor will you be subject to a late enrollment penalty (LEP).

The goal of these changes is to close multi-month gaps in coverage and increase the eligibility for Medicare seniors. The Secretary is finalizing the following SEPs to help expand Medicare access:

SEP for Individuals Impacted by an Emergency or Disaster

Those who miss their enrollment due to an emergency or disaster declared by either federal, state, or local government officials are entitled to an a SEP.

The new Medicare rule will extend this period for six months after the emergency. It will apply if the emergency affects an area where the person authorized to make healthcare decisions on behalf of the beneficiary resides.

SEP for Health Plan or Employer Error

If you can prove that your employer or health plan misrepresented information for your Medicare enrollment, this SEP is for you. Eligible seniors will receive an extension of six months after they notify the Social Security Administration (SSA).

From here, the SSA will allow for written attestation from the affected beneficiary when documentation of misinformation by their employer or health plan is unavailable. Furthermore, this includes other sources of misinformation, including brokers and agents of health plans.

SEP for Formerly Incarcerated Individuals

The new Medicare rule for those following their release from correctional facilities allows eligible beneficiaries to enroll with an extension lasting up to 12 months post-release.

It will also allow qualifying seniors to choose between retroactive coverage back to their release date (not to exceed six months) or coverage beginning the month after their enrollment. Those choosing retroactive coverage will have to pay premiums for the retroactive period covered.

SEP to Coordinate with Termination of Medicaid Coverage

A Special Enrollment Period is coming after January 1, 2023, allowing those who have missed their Medicare enrollment period to enroll in Medicare following the termination of Medicaid eligibility.

This SEP has a new Medicare rule that is modifying the ability for individuals to choose between retroactive coverage back to the date of termination from Medicaid (but no earlier than January 1, 2023) or coverage beginning the month after the month of enrollment. Individuals that choose retroactive coverage must retroactively pay the premiums for the period covered.

SEP for Other Exceptional Conditions

There are other circumstances that may require a Special Enrollment Period which occurs on a case-by-case basis. The new Medicare rule allows the possibility to grant an enrollment period for seniors when an event outside of the qualifying individual’s control prevented enrollment during IEP, GEP, or other SEPs with a minimum 6-month extension duration.

New Medicare Rules for Immunosuppressive Drugs

While most with ESRD can enroll in Medicare, even if they are not seniors, those with kidney transplants can lose their coverage after an extension of 36 months until they are eligible due to age or disability.

A new immunosuppressive drug benefit (Medicare Part B-ID benefit) will provide better access to Medicare beneficiaries by allowing them to enroll in the new benefit past the 36-month post-transplant period. Here’s what you need to know about the new Medicare rule beginning in 2022 and allowing coverage to start as early as January 1, 2023:

• The benefit only applies to immunosuppressive drugs and will not extend to other Medicare Part B benefits or services.
• Eligible beneficiaries can enroll and disenroll at any time. There are no SEPs.
• Eligible individuals cannot be enrolled in other forms of coverage such as Medicaid, group health plans, or TRICARE, which provides benefits for immunosuppressive drugs. If a beneficiary enrolls in such coverage, they must contact the Social Security Administration within 60 days. This will, however, end their enrollment in the Medicare Part B-ID benefit).
• Your monthly premium will cost less than the standard Medicare Part B premium, and late enrollment penalties will not apply. While there is an annual deductible, enrollees only pay 20% of the Medicare-approved amount for immunosuppressive drugs after meeting the deductible.
• Your state may cover your immunosuppressive drug benefit premium if you are eligible for specific Medicare Savings Programs (MSPs). Qualified Medicare Beneficiaries (QMBs) may also have covered co-insurance, cost-sharing, and deductibles.

Medicare State Buy-In Changes

Among the new Medicare rules that are helping increase eligibility are those affecting the states’ payment for Medicare Part A and Part B premiums for low-income individuals.

Known as a “state buy-in”, it affects 10 million Medicare-eligible individuals. The new Medicare rule consolidates regulations with federal statutes, policies, and operations that have changed over the years.

This consolidation will provide more access to health coverage and increase health equity for marginalized populations. Here are the changes you need to know:

• CMS is replacing the old stand-alone agreements by specifying that a state’s Medicaid plan must include the provisions of a state buy-in agreement. This helps clarify and provide transparency for everyone involved, including beneficiaries, states, and the federal government. The move will also improve accountability for state payments of Medicare premiums for low-income persons.
• The SSA has times when it will establish retroactive Medicare Part A entitlement for Medicaid beneficiaries as part of disability determinations. This means states are liable for retroactive Medicare Part B premiums, which can go back several years and increase administrative work. Beginning January 1, 2024, by finalizing these changes, CMS will limit retroactive Medicare Part B premium liability for states to 36 months before the date of the Medicare enrollment determination for full-benefit Medicaid beneficiaries. Overall, the change will reduce the burden on providers and assist state Medicare and Medicaid programs to work in a more efficient manner.