Final MA Rule Provides Insight into Special Election Periods for Hospice Beneficiaries
WASHINGTON, D.C (May 29, 2020)—The Centers for Medicare & Medicaid Services (CMS) has released the Medicare Program: Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program, with important information about the special election period for hospice beneficiaries.
In recent years, policymakers have given increased attention to current policy that has “carved” the Medicare hospice benefit out of the Medicare Advantage (MA) benefit package. In January 2019, CMS announced its intent to test inclusion of hospice as part of the MA benefit package under its existing Value-Based Insurance Design (VBID) model starting in Calendar Year 2021. MA plans were required to submit applications for the model in May of this year, and they are currently under review by CMS. It is currently anticipated that CMS will move forward with plans to start the demonstration in January 2021 as scheduled. CMS is not expected to publicize the names of the plans or locations where they anticipate offering hospice coverage until late summer, at which time contracts between CMS and the MA plans for the model will have been executed.
Given that hospice has historically been excluded from the MA benefit package and Medicare is far and away the largest payer of hospice care (roughly 90% of hospice care days are covered by Medicare), the experience hospices have to draw from is limited to primarily Medicaid managed care. However, data from the Medicare Payment Advisory Commission (MedPAC) indicates that approximately 53% of MA decedents in 2018 received hospice care. However, findings from a February 2019 study in the Journal of the American Medical Association (“Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries,” February 25, 2019, Supplemental Online Content), indicate that nearly 70% of MA beneficiaries that enter hospice either disenroll from MA (57.3%) or switch MA plans (12.5%). It is likely that some of these beneficiaries may be utilizing CMS’ policy allowing for Special Election Periods (also referred to as enrollment exceptions) when they enter hospice care. In the recently-finalized Medicare Program: Contract Year 2021 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program, CMS outlines details related to current practice for enrollment exceptions when one or more of the following factors is present:
- Extraordinary Circumstances – Circumstances beyond the beneficiary’s control that prevented him or her from submitting a timely request to enroll or disenroll from a plan during a valid enrollment period. This is inclusive of, but not limited to, a serious medical emergency of the beneficiary or their authorized representative during an entire election period, a change in hospice status, or mailed enrollment forms returned as undeliverable on or after the last day of an enrollment period.
- Erroneous Election – Situations in which a beneficiary provides a verbal or written allegation that his or her enrollment in a MA or Part D plan was based upon misleading or incorrect information provided by a plan representative or State Health Insurance Assistance Program (SHIP) counselor, including situations where a beneficiary states he or she was enrolled into a plan without his or her knowledge or consent, and requests cancellation of the enrollment or disenrollment from the plan.
- Plan Accessibility – A SEP may be warranted to ensure beneficiary access to services and where without the approval of an enrollment exception, there could be adverse health consequences for the beneficiary. This is inclusive of, but not limited to, maintaining continuity of care for a chronic condition and preventing an interruption in treatment.
The rule also notes, “CMS will review supporting details and documentation to determine eligibility for the SEP for exceptional circumstances, which, as currently implemented, can be in response to an individual beneficiary’s request for an exception to the current enrollment rules, as well as CMS’ determination that an exception is warranted for a group of beneficiaries. The SEP would take effect once CMS makes its determination and the enrollee has been notified. The effective date for an enrollment or disenrollment election using an approved enrollment exception would be based on the beneficiary’s circumstances and may either be prospective or retroactive.”
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