The agency that runs Medicare wants to give private organizations a chance to try administering traditional Medicare coverage.
The agency, the Centers for Medicare and Medicaid Services (CMS), has announced a two-part test for a new Geographic Direct Contracting Model.
CMS said the Geo program will let private organizations, or “direct contracting entities,” administer traditional Medicare coverage for some enrollees. CMS wants the first direct contracting entities to begin testing the Geo approach in somewhere between four and 10 communities from Jan. 1, 2022, through Dec. 31, 2024. A second Geo test period would run from Jan. 1, 2025, through Dec. 31, 2027.
Links to Geographic Direct Contracting Model program resources are available here.
An article about how U.S. health care policy might change is available here.
Any “covered entity,” or organization that has to take charge of complying with Health Insurance Portability and Accountability Act (HIPAA) personal health information privacy and date security rules, could apply to be a direct contracting entity in the Geo program, CMS officials said in the Geo program announcement.
“Covered entities include most types of provider organizations as well as health plans,” officials said.
Typical Geo applicants are likely to be health plans, or provider-run organizations that have significant experience with managing medical cost risk, such as health care provider groups or health care systems that have participated in accountable care organizations, officials said.
How Traditional Medicare Works Now
Medicare is a federal program that provides health coverage for 63 million Americans who are at least 65 years old, receive Social Security Disability Insurance benefits or have kidney disease so severe that they have either had kidney transplants or are getting kidney dialysis.
Congress created the Medicare Part A hospitalization insurance program in 1965. Congress added the Medicare Part B program, which covers physician and outpatient services, in 1983.
Medicare managers already let private organizations provide an alternative to traditional Medicare coverage through the Medicare Advantage plan program. About 25 million people use Medicare Advantage coverage or related types of coverage.
The companies that run Medicare Advantage plans often use health care provider networks that are similar to the provider networks built into commercial health coverage for people under 65. A Medicare Advantage plan might send a doctor or hospital a flat fee per month per patient, or capitation payment, to cover the cost of routine care.
The new Geo program would be part of the traditional Medicare program, which CMS calls “Original Medicare,” rather than part of the Medicare Advantage program.
CMS uses private organizations, called Medicare Administrative Contractors, or MACs, to administer Original Medicare coverage.
One set of MACs oversees Original Medicare medical coverage. A second set oversees coverage for “durable medical equipment,” such as wheelchairs.
In Arizona, California and Washington state, for example, the MAC for Original Medicare medical coverage is Noridian Healthcare Solutions LLC, an arm of Blue Cross Blue Shield of North Dakota.
The Medicare MACs are invisible to most enrollees.
Managers of Original Medicare let almost any licensed physician who accepts Original Medicare reimbursement rules and other rules treat Medicare enrollees.
Outside of test programs and other special programs, Original Medicare usually pays doctors and hospitals fees for each service provided, rather than capitation payments, or payments for bundled care.
Critics of the fee-for-service approach say it’s complicated to administer and encourages providers to offer too much care.
Ordinary Original Medicare comes with complicated deductible, co-payment and coinsurance rules, and no annual out-of-pocket limit on what an enrollee must spend on out-of-pocket costs.
Geo Test Program
A Geo contractor would manage health coverage and health care for Original Medicare enrollees in one specific region, such as Atlanta.
The contractor would make extra money if it did a good job of holding the cost of care down, while complying with Medicare care access rules and other rules. However, it would lose money if costs were high.
A contractor could use a preferred provider network to try to hold down costs. A contractor could never have an enrollee pay more out of pocket than an enrollee in Original Medicare would pay, but a contractor could reduce out-of-pocket costs for enrollees who saw in-network provider.
A Geo contractor also could provide other patient wellness and chronic condition management incentives that might be difficult for Original Medicare to offer under current rules.
A Geo contractor could offer vouchers for OTC medications, transportation, wellness and chronic condition management program memberships, electronic patient monitoring systems, vision and dental care services, and up to $75 in gift cards per year for participating in disease management programs.
A Geo contractor also could pay for home visits for care management, and it could choose to waive the Medicare rule that requires a patient to be admitted to a hospital for at least three days before Medicare will pay for convalescent care in a nursing home for that patient.
CMS officials said they believe each Geo contractor in the test program would oversee care for at least 30,000 Medicare enrollees. Officials expect each community in the test program to have three to seven Geo contractors.
A would-be Geo contractor would have to offer to cut Medicare costs for enrollees by at least about 2% to 3%, according to the program announcement.
Some of the Medicare enrollees using Geo contractor-run coverage would sign up for the coverage voluntarily. Other enrollees might end up with Geo coverage because their primary care providers are in a Geo contractor’s preferred provider network, officials said.
CMS said it would try to keep the Geo program from disrupting the risk pool for standard Original Medicare by prohibiting enrollees from opting out of the Geo program.
Officials said they expect the test Geo contractors to serve Medicare enrollees in one of 15 communities: Atlanta; Dallas; Denver; Detroit; Houston; Los Angeles; Miami; Minneapolis; Orlando, Florida; Phoenix; Philadelphia; Pittsburgh; Riverside, California; San Diego; or Tampa, Florida.
Officials show calculations suggesting that a typical test market might have about 30% to 40% of its enrollees allocated to Geo contractor-run coverage.
Non-binding letters of interest are due Dec. 21, and applications are due April 2, 2021.
Geo Test Program Challenges
Several challenges face the program. For one, the Biden administration might choose to change or kill the Geo test program.
Patient groups, health care providers or other parties could sue to block the program, or they could persuade Congress to block the program.
Insurers and health care provider organizations could stop the program by declining to become Geo contractors, and health care providers in a region could decline to join the preferred provider networks for the Geo contractors in that region.
Agents’ and Brokers’ Role
A successful Geo program could give health insurers new ways to service Medicare enrollees, but it could reduce patients’ incentive to sign up for Medicare Advantage plans or Medicare supplement insurance.
By Maria Castellucci – ModernHealthCare – November 19, 2020
The original Compare tools CMS first launched over 15 years ago will be removed from the Medicare website on December 1, replaced by a new version. CMS released in September a redesigned website that consolidates its 8 online tools intended for Medicare beneficiaries and agents to compare health care providers and settings.
The renovated site was an effort by CMS to create a more streamlined user experience. The original Compare tools forced a user to use different interfaces on the Medicare website depending on the care setting in which they were interested. Since the remodeled site was launched, CMS maintained the original compare tools as well, calling it a transition period. The remodeled site, called Care Compare, uses the same quality information as the original compare tools.
The healthcare settings available to users to compare are hospitals, nursing homes, home health, dialysis centers, long-term care hospitals, inpatient rehabilitation, physicians and hospice groups. The version for hospitals has been a point of contention because it displays quality star ratings, which have been heavily criticized by hospitals. CMS has proposed changes to the star ratings methodology but current star ratings continue to be displayed on the website.
2021 Medicare Parts A & B Premiums and Deductibles
On November 6, 2020, the Centers for Medicare & Medicaid Services (CMS) released the 2021 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.
Medicare Part B Premiums/Deductibles
Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.
Each year the Medicare premiums, deductibles, and coinsurance rates are adjusted according to the Social Security Act. For 2021, the Medicare Part B monthly premiums and the annual deductible are higher than the 2020 amounts. The standard monthly premium for Medicare Part B enrollees will be $148.50 for 2021, an increase of $3.90 from $144.60 in 2020. The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of $5 from the annual deductible of $198 in 2020.
The Part B premiums and deductible reflect the provisions of the Continuing Appropriations Act, 2021 and Other Extensions Act (H.R. 8337).
CMS is committed to empowering beneficiaries with the information they need to make informed decisions about their Medicare coverage options, including providing new tools to help them make those decisions through the eMedicare initiative. In addition to the recently released premiums and cost sharing information for 2021 Medicare Advantage and Part D plans, we are releasing the premiums and cost sharing information for Fee-for-Service Medicare, so beneficiaries understand their options for receiving Medicare benefits. As previously announced, average 2021 premiums for Medicare Advantage plans are expected to decline 34.2 percent from 2017 while plan choices, benefits, and enrollment continue to increase. The Medicare Advantage average monthly premium will be the lowest in fourteen years (since 2007). Premiums and deductibles for Medicare Advantage and Medicare Part D Prescription Drug plans are already finalized and are unaffected by this announcement.
Medicare Part B Income-Related Monthly Adjustment Amounts
Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 7 percent of people with Medicare Part B. The 2021 Part B total premiums for high-income beneficiaries are shown in the following table:
Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:
Medicare Part A Premiums/Deductibles
Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.
The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,484 in 2021, an increase of $76 from $1,408 in 2020. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2021, beneficiaries must pay a coinsurance amount of $371 per day for the 61st through 90th day of a hospitalization ($352 in 2020) in a benefit period and $742 per day for lifetime reserve days ($704 in 2020). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $185.50 in 2021 ($176.00 in 2020).
Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $259 in 2021, a $7 increase from 2020. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $471 a month in 2021, a $13 increase from 2020.
For more information on the 2021 Medicare Parts A and B premiums and deductibles (CMS-8074-N, CMS-8075-N, CMS-8076-N), please visit:
Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $458 each month in 2020 ($471 in 2021). If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $458 ($471 in 2021). If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $252 ($259 in 2021).Part A hospital inpatient deductible and coinsurance
$1,408($1,484 in 2021) deductible for each benefit period
Days 1-60: $0 coinsurance for each benefit period
Days 61-90: $352 ($371 in 2021) coinsurance per day of each benefit period
Days 91 and beyond: $704 ($742 in 2021) coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
Beyond lifetime reserve days: all costs
Part B premium The standard Part B premium amount is $144.60 ($148.50 in 2021) (or higher depending on your income).
Part B deductible and coinsurance $198 ($203 in 2021). After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and durable medical equipment (dme)
Part C premium The Part C monthly premium varies by plan.
Part D premium The Part D monthly premium varies by plan (higher-income consumers may pay more).
Marketing for 2021 Annual Enrollment Period - Reminder
The 2021 Annual Enrollment Period (AEP) is just around the corner, starting on October 15th and ending on December 7th 2020. It is important to remember that The Centers for Medicare & Medicaid Services (CMS) do not allow any marketing for AEP to take place before October 1st. "Marketing" includes the following examples:
Contacting consumers to solicit an appointment.
Completing an enrollment application.
Hosting or advertising an event where 2021 plans will be discussed.
Talking about 2021 plan rates, options or benefits over the phone or during an appointment.
Obtaining a 2021 Scope of Appointment.
Sharing content regarding AEP on social media or via email.
Rule of thumb: If the purpose of the marketing activity is to eventually solicit an appointment for AEP, per CMS, it is NOT acceptable before October 1st 2020. If an agent is found to be marketing for AEP before October 1st, the agent could be penalized from the insurance carrier being marketed, or from CMS.
It is a good idea for agents to take this time before October 1st to work on certifications and becoming Ready to Sell for the 2021 AEP season. Save all marketing efforts for after October 1st.
The cost-sharing chart below covers what beneficiaries with Medicare Part D will pay for prescription coverage in each phase in 2021. This includes:
A deductible of up to $445 (this deductible varies by plan).
25% of the costs of their prescription drugs in the Initial Coverage Period (or up to $1,032.50 if they are in a plan with no deductible).
Up to $6,550 out-of-pocket expenses before the beneficiary reaches the Catastrophic Benefits Period. Once they hit this threshold, the Medicare beneficiary will pay either 5% coinsurance or $3.70 copay for generic medications, and $9.20 for brand-name drugs.
*Most Part D plans are not standard plans. This means calculating TrOOP costs during the initial deductible and ICP varies by plan. Source: 2021 Call Letter (p. 71) at: 2021 Call Letter.
CMS launched a remodeled website Thursday that consolidates its eight online consumer tools to one platform.
The redesigned site is an attempt by CMS to give users a more streamlined experience using its platform, called Compare tools.
CMS has published information online about healthcare providers and care settings for Medicare beneficiaries and their caregivers for more than 15 years. One of the elements for the hospital version to convey quality, the star ratings, has come under fire for producing inconsistent results and CMS recently proposed changes to the methodology as a result.
The eight different interfaces representing each care setting was confusing and cumbersome for users, according to CMS Administrator Seema Verma during a press call Wednesday. "The information will now be displayed in a modern streamlined design to make it as helpful as possible to users," Verma said.
The remodeled site, available on Medicare.gov, can now access users' location and a drop-down menu allows the consumer to select what type of provider they are looking for. Options are hospitals, nursing homes, home health, dialysis centers, long-term care hospitals, inpatient rehabilitation, physicians and hospice groups. A user can compare up to three providers using information about costs, location and quality data. The site is also compatible for use on smartphone and tablets.
CMS is seeking feedback from users about the upgraded platform. There is an online survey available on Medicare.gov for users. CMS will also seek feedback from provider stakeholders who treat Medicare beneficiaries.
Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries
Today, under the leadership of President Trump, the Centers for Medicare & Medicaid Services (CMS) is calling for a renewed national commitment to value-based care based on Medicare claims data that provides an early snapshot of the impact of the coronavirus disease 2019 (COVID-19) pandemic on the Medicare population. The data shows that older Americans and those with chronic health conditions are at the highest risk for COVID-19 and confirms long-understood disparities in health outcomes for racial and ethnic minority groups and among low-income populations.
“The disparities in the data reflect longstanding challenges facing minority communities and low income older adults, many of whom face structural challenges to their health that go far beyond what is traditionally considered ‘medical’,” said CMS Administrator Seema Verma. “Now more than ever, it is clear that our fee-for-service system is insufficient for the most vulnerable Americans because it limits payment to what goes on inside a doctor’s office. The transition to a value-based system has never been so urgent. When implemented effectively, it encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life.”
The data released today includes the total number of reported COVID-19 cases and hospitalizations among Medicare beneficiaries between January 1 and May 16, 2020. The snapshot breaks down COVID-19 cases and hospitalizations for Medicare beneficiaries by state, race/ethnicity, age, gender, dual eligibility for Medicare and Medicaid, and urban/rural locations. The new data show that more than 325,000 Medicare beneficiaries had a diagnosis of COVID-19 between January 1 and May 16, 2020. This translates to 518 COVID-19 cases per 100,000 Medicare beneficiaries. The data also indicate that nearly 110,000 Medicare beneficiaries were hospitalized for COVID-19-releated treatment, which equals 175 COVID-19 hospitalizations per 100,000 Medicare beneficiaries.
Blacks were hospitalized with COVID-19 at a rate nearly four times higher than whites. The disparities presented in the snapshot go beyond race/ethnicity and suggest the impact of social determinants of health, particularly socio-economic status.
Other key data points:
End-stage renal disease (ESRD) patients (individuals with chronic kidney disease undergoing dialysis) had the highest rate of hospitalization among all Medicare beneficiaries, with 1,341 hospitalizations per 100,000 beneficiaries. Patients with ESRD are also more likely to have chronic comorbidities associated with increased COVID-19 complications and hospitalization, such as diabetes and heart failure.
The second highest rate was among beneficiaries enrolled in both Medicare and Medicaid (also known as “dual eligible”), with 473 hospitalizations per 100,000 beneficiaries.
Among racial/ethnic groups, Blacks had the highest hospitalization rate, with 465 per 100,000. Hispanics had 258 hospitalizations per 100,000. Asians had 187 per 100,000 and whites had 123 per 100,000.
Beneficiaries living in rural areas have fewer cases and were hospitalized at a lower rate than those living in urban/suburban areas (57 versus 205 hospitalizations per 100,000).
The snapshot also shows that besides higher hospitalization rates, beneficiaries enrolled in both Medicaid and Medicare have a higher infection rate of COVID-19, with 1,406 cases per 100,000 beneficiaries. By comparison, the coronavirus infection rate for beneficiaries enrolled only in Medicare is 325 cases per 100,000. The rate of COVID-19 cases for dual eligible individuals is higher across all age, sex, and race/ethnicity groups. Previous research has shown that these individuals experience high rates of chronic illness, with many having long-term care needs and social risk factors that can lead to poor health outcomes.
Given the complexity of these disparities, any solution requires a multi-sectoral approach that includes federal, state, and local governments, community based organizations, and private industry. One piece of this is the increased implementation of a value-based system that rewards providers for keeping patients healthy and gives consumers the information about disease prevention and outcomes needed to help make healthcare choices on the basis of quality. Additionally, CMS is encouraging states to double down on efforts to protect low income seniors and look at the data and determine what resources are available, both locally and federally, to improve this disparity of health outcomes. CMS has identified a range of operational opportunities for states to improve care for dually eligible individuals and a variety of models that states can participate in that focus on improving the quality and cost of care for individuals who are concurrently enrolled in Medicaid and Medicare.
The Center for Medicaid and Children’s Health Insurance Program (CHIP) Services is developing guidance for states on new opportunities to adopt innovative, value-based payment design and implement strategies to address social determinants of health for their beneficiaries, including those who are dually-eligible for Medicare and Medicaid. In addition to these ongoing efforts and programs, the CMS Office of Minority Health will be holding a series of listening sessions with key stakeholders responsible for providing care to racial and ethnic minorities. These listening sessions are intended to help refine the ongoing outreach and work by CMS to improve future efforts on this issue.
CMS typically releases Medicare claims information on an annual basis when there are more complete claims and encounter data. However, as part of the agency’s efforts to provide data transparency during the pandemic and ensure the public has this vital information as soon as it is available, CMS is releasing this preliminary data now. The data will be updated on a monthly basis as more claims and encounter records are received. CMS anticipates releasing similar information on Medicaid beneficiaries in the future.
President Trump Announces Lower Out of Pocket Insulin Costs for Medicare’s Seniors
Across the nation, 88 Part D Sponsors applied to the Part D Senior Savings Model to offer enhanced plans with a maximum $35 copay for a broad set of insulins beginning in 2021.
Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) announced that over 1,750 standalone Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the Part D Senior Savings Model for the 2021 plan year. Across the nation, participating enhanced Part D prescription drug plans will provide Medicare beneficiaries access to a broad set of insulins at a maximum $35 copay for a month’s supply, from the beginning of the year through the Part D coverage gap. The model follows on the Trump Administration’s previously announced 13.5 percent decline in the average monthly basic Part D premium since 2017 to the lowest level in seven years.
Currently, Part D sponsors may offer prescription drug plans that provide lower cost-sharing in the coverage gap; however, when they do, the Part D sponsor accrues costs that pharmaceutical manufacturers would normally pay. These costs are then passed on to beneficiaries in the form of higher premiums. The new insulin model directly addresses this disincentive by doing two things: 1) allowing manufacturers to continue paying their full coverage gap discount for their products, even when a plan offers lower cost-sharing; and 2) requiring participating Part D sponsors’ plans, in part through applying manufacturer rebates, to lowering cost-sharing to no more than $35 for a month’s supply for a broad set of insulins.
Under President Trump’s leadership, for the first time, CMS is enabling and encouraging Part D plans to offer fixed, predictable copays for beneficiaries rather than leaving seniors paying 25 percent of the drug’s cost in the coverage gap. Both manufacturers and Part D sponsors responded to this market-based solution in force and seniors that use insulin will reap the benefits.
Based on CMS’s estimates, beneficiaries who use insulin and join a plan participating in the model could see average out-of-pocket savings of $446, or 66 percent, for their insulins, funded in part by manufacturers paying an estimated additional $250 million of discounts over the five years of the model. With a robust voluntary response from Part D sponsors, CMS anticipates beneficiaries will have Part D plan options in all 50 states, the District of Columbia, and Puerto Rico, through either a standalone prescription drug plan (PDP) or a Medicare Advantage plan with prescription drug coverage. Beneficiaries will be able to enroll during Medicare open enrollment, which is from October 15, 2020 through December 7, 2020, for Part D coverage that begins on January 1, 2021.
“President Trump has forged partnerships with pharmaceutical manufacturers and plans to deliver lower priced insulin to our nation’s seniors,” said CMS Administrator Seema Verma. “This market-based solution, in which insulin manufacturers and Part D sponsors compete to provide lower costs and higher quality for patients, will allow seniors to choose a Part D plan that covers their insulin at an average 66 percent lower out-of-pocket cost throughout the year.”
The Part D Senior Savings Model – which was announced on March 11, 2020 – is a voluntary model that tests the impact on insulin access and care by participating Part D enhanced alternative plans offering lower out-of-pocket costs, at a maximum $35 copay for a month’s supply, for a broad range of insulins.
Part D sponsors that participate in the model will offer beneficiaries Part D prescription drug plans that provide supplemental benefits for a broad range of insulins, including both pen and vial dosage forms for rapid-acting, short-acting, intermediate-acting, and long-acting insulins. Participating pharmaceutical manufacturers will continue to pay their current 70 percent discount in the coverage gap for their insulins that are included in the model, and based on the model’s waiver of current regulations, those manufacturer discount payments will be calculated before the application of supplemental benefits under the model – which will reduce the out-of-pocket cost of insulin for Medicare beneficiaries.
One in every three Medicare beneficiaries has diabetes, and over 3.3 million Medicare beneficiaries use one or more of the common forms of insulin. For some of these beneficiaries, access to insulin is a critical component of their medical management, with gaps in access increasing risk of serious complications, ranging from vision loss to kidney failure to foot ulcers to heart attacks. Unfortunately, the costs of insulin can be a major barrier to appropriate medical management of diabetes.
A beneficiary’s out-of-pocket costs for insulin in Medicare’s Part D prescription drug benefit can fluctuate from one month to the next, in part due to the different rules applying for each phase of the Part D benefit. This can be challenging for beneficiaries when budgeting for their drug costs. These challenges can in turn lead to beneficiaries not being able to afford their medicine or resorting to medication rationing, resulting in worse health outcomes over time. The model aims to address this with stable, predictable costs for insulin that beneficiaries know up front by staying in or choosing a model-participating plan during open enrollment.
Part D sponsors that applied must submit their calendar year 2021 plan benefits to CMS by June 1, 2020 to designate their participation in the model. CMS anticipates releasing the premiums and costs for specific Medicare health and drug plans for the 2021 calendar year in September 2020, including final information on the model.
Beneficiaries will be able to find a Part D plan participating in the Part D Senior Savings Model in the 2021 plan year through the Medicare Plan Finder on Medicare.gov during the annual open enrollment period, which begins on October 15, 2020 and ends December 7, 2020. CMS will enhance the Medicare Plan Finder to include a filter to identify plans that will offer capped out-of-pocket costs for insulin in the model so beneficiaries can easily find those plans during open enrollment in the Fall. The Medicare Plan Finder, which was upgraded for the first time in a decade last year, is the most used tool on Medicare.gov and allows users to shop and compare Medicare Advantage and Part D plans.
The Part D Senior Savings Model builds on steps the Trump Administration has already taken to strengthen Medicare and improve the quality of care for patients with diabetes. CMS has taken the following actions to address the needs of beneficiaries with diabetes:
Providing coverage for therapeutic continuous glucose monitors (CGM) for patients who synchronize their insulin devices with their smartphones, when used in conjunction with a durable CGM receiver.
Allowing Medicare Advantage plans to offer a broader range of supplemental benefits tailored to a patient’s chronic disease. For an enrollee living with diabetes for example, a plan could provide transportation to a doctor’s appointment, diabetes education programs, or time with a nutritionist.
To respond to the coronavirus disease 2019 (COVID-19) public health emergency, CMS has taken additional actions to ensure that beneficiaries with diabetes have access to treatment and care by:
Implementing statutory requirements for Medicare Part D prescription drug sponsors and MA plans with a prescription drug benefit to allow enrollees to obtain prescription fills or refills of covered Part D drugs—including insulin—for up to a three-month supply in most instances.
Providing additional flexibility to Part D sponsors to give beneficiaries more options for delivery of their medications – including their diabetes supplies -- such as mail or home delivery through retail pharmacies.
Expanding telehealth so that people with diabetes, nationwide, can still maintain access to their doctor.
Expanding access to therapeutic continuous glucose monitors for patients with diabetes as determined medically appropriate by practitioners. Previously, patients were required to meet certain clinical criteria to qualify for coverage of a therapeutic continuous glucose monitor under Medicare. During the COVID-19 public health emergency, CMS will not enforce the clinical indications in Local Coverage Determinations for therapeutic continuous glucose monitors in an effort to give practitioners the flexibility to allow more of their diabetic patients to better monitor their glucose and adjust insulin doses from home.