By Young Mee Kim Jun, JD, LMSW
Effective January 2019, the Center for Medicare & Medicaid Services (CMS) made changes to Medicare rules, particularly related to Part C and Part D. Medicare Part C, also known as Medicare Advantage Plan (MA), is a Medicare coverage offered through private companies. When you join a MA plan, you receive hospital insurance (part A), Medical insurance (part B), and sometimes drug coverage (part D) from a private MA plan company not from Original Medicare.[1] Medicare Part D is a prescription drug coverage plan offered by private companies. The following are some of the notable changes being implemented in January of 2019.
Until now, CMS mandated MA plans to provide same benefit packages to the enrollees in a service area at a same premium. However as of January 1, 2019, CMS has eliminated that requirement and will allow more flexibility for MA companies to provide assortment of supplemental services not normally covered by Original Medicare. This means that as of January 2019 the MA plans will offer benefits that are not necessarily a “medical treatment”, so long as they are medically related to specific health conditions of the enrollees[2] at varied levels of premiums and the deductibles. Some of the supplemental benefits that will now be offered to eligible Medicare beneficiaries may include palliative care, meal delivery services, transportation, adult day services, medical equipment and home care services. Thus, the Medicare beneficiaries will now have an option to choose from a pool of MA plans that will offer myriad of different benefits tailored to meet their financial and specific health care needs.
Although this change was made with a worthy initiative to provide more services to Medicare beneficiaries, Medicare advocacy group[3] representatives anticipate that the increased variance of benefit packages offered by multiple MA companies may make it more difficult to navigate Plan Finders on Medicare web-portal. It may be more challenging to compare and choose from so many different plans offering multitude of services. The advocacy group cautions the enrollees to carefully read the details of the supplemental services offered by the plans and how their health conditions would affect the premiums before joining a plan.
In addition to eliminating the restrictive rules for MA plans, CMS also made changes to enable the beneficiaries to join and switch plans more easily. Until now, CMS only allowed Medicare beneficiaries to enroll and dis-enroll from MA plans during the Medicare Advantage Disenrollment Period which ran from January 1 through February 14 each year. The Medicare beneficiaries had this short window period to either enroll in a MA plan or dis-enroll from MA plan and go back to Original Medicare but were not allowed to switch to another MA plan.
As of January 2019, the Medicare beneficiaries can either go back to Original Medicare plan or switch to another MA plan if they are unsatisfied with their plan during the new Spring Enrollment Period (SEP). The SEP will run for three (3) months from January 1 through March 31 each year. CMS will now allow the beneficiaries to evaluate their current plans and make changes freely during this extended three months period each year without limitations. Any changes made during this period will be effective the following month.
For Medicare Part D enrollees receiving Extra Help, beneficiaries used to be able to switch their Part D plans as many times as necessary throughout the year. Under the new 2019 Medicare rules, these beneficiaries will be able to make changes to another Part D plan only during the Low Income Subsidy Enrollment Period (LISEP) which will run once every calendar quarter: January through March, April through June and so forth. This means that if a beneficiary switched their plan in January, he/she is not allowed to make another switch until the next quarter (i.e. April -June).
Furthermore, there are additional welcoming changes for Medicare Part D beneficiaries in 2019. Under the new Bipartisan Budget Act, the Medicare Part D coverage gap, also known as the “donut hole”, will close for brand name drugs. This means that Medicare beneficiaries on Part D will no longer pay out of pocket for increased medication cost when they hit the “donut hole”. The beneficiaries will now pay no more than an average of 25% of the cost of their drugs after meeting the deductibles. In 2020, the same changes will be made for generic drugs.
Lastly, based on the Comprehensive Addiction and Recovery Act (CARA), a Federal law signed into law in 2016, the Medicare Part D plans will establish a drug management plan. This program will be used to restrict access to medications that are determined to be Frequently Abused Drugs (FADs) to those identified as “as risk” when dangerous patterns of use are detected. However, beneficiaries on the FADs for treatment of cancer related pain, palliative care, hospice care and those in a long term care facilities, will be exempt from this program. If a beneficiary has been labeled “at risk” under this program mistakenly, the beneficiary can appeal the decision and most likely will prevail if medications are medically necessary.
The Medicare changes of 2019 are complex and can be difficult to understand. If you are currently on Medicare or will be eligible for Medicare in the near future, please make note of these important changes that affect your coverage or contact our firm at 718-238-6960 for advice and direction.
[1] https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf
[2] https://www.ncoa.org/wp-content/uploads/2019-Part-C-and-D-changes.pdf
[3] Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities. The organization helps people with Medicare understand their rights and benefits. Anyone with questions about Medicare benefits can call the national Helpline at 1-800-333-4114.