Proposed Benefits Manual Changes
On April 25, 2013 CMS issued a proposed update to the Benefits and Beneficiary Protections Chapter (Chapter 4) of the Medicare Managed Care Manual. The CMS cover letter provides a good summary of the changes that they are proposing to make. Most of the changes are clarifications to existing policy, for example, providing Medicare Advantage plans (MA) with the option of charging beneficiaries higher cost sharing for non-emergency out-of-network services and prohibiting MA plans from imposing policies that prevent enrollees from accessing a Part B drug administered in a physician’s office. CMS is removing the example of how total beneficiary cost-sharing (TBC) is calculated and instead stating that TBC requirements will be included in the Call Letter, as they did for 2014.
CMS is adding several items to the list of services that are not eligible to be approved as a supplemental benefit: electronic medical records and electronic data storage devices; loaner DME when rented or owned DME is being repaired since this is required under Medicare Part B; rewards and incentives used as marketing tools; brain training and memory fitness services since these services are not clinically accepted; and case management and care coordination services since these are required in all coordinated care plans.
CMS is adding two rules to ensure coordinated care that could result in new documentation requirements for some plans: (1) enrollees are informed of specific health care needs that require follow up and receive information to support and promote their own health and (2) systems are employed to identify and address barriers to enrollee compliance with prescribed treatments or regiments.
CMS is adding a definition of prior authorization and referral including a clarification that a coordinated care plan cannot require a gatekeeper referral for out-of-network dialysis. CMS is also clarifying renewal policies to allow a non-segmented plan to renew as a segmented plan or to consolidate into a segmented plan and ask to transition current enrollees to plan segments.
CMS is clarifying benefits during disasters so that CMS may use waiver authority to authorize Medicare Administrative Contractors to pay for Part C services and have the Contractors seek reimbursement from MA plans retrospectively.
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