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CMS Announces Proposed Rule Implementing Important Medicare Enrollment Changes

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This week, the Centers for Medicare and Medicaid Services released a much-anticipated proposed rule implementing important changes implemented by the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act, key provisions of which were included in the Consolidated Appropriations Act, 2021 (CAA), which was signed into law on December 27, 2020. That law, which was championed by the Medicare Rights Center and enjoyed broad support among beneficiary advocacy organizations, established modernized timelines for effectuating Part B enrollment and also established authority for CMS to create Special Enrollment Periods (SEPs) to account for “exceptional circumstances” that might cause a person to miss or make a mistake around their Initial or other enrollment period.

The proposed rule updates existing rules to reflect the CAA’s changed timelines for coverage when people enroll in the later months of their Initial Enrollment Period (IEP) or during the General Enrollment Period (GEP). Starting in 2023, Medicare coverage will be effective the month after enrollment for people who enroll in the last three months of their IEP or during the GEP, reducing or eliminating gaps in coverage. The rule also proposes several SEPs for people who meet “exceptional conditions” and missed a Medicare enrollment period including:

  • An SEP for individuals impacted by an emergency or disaster
  • An SEP for Health Plan or Employer Error that constitutes “material misrepresentation” of information related to enrolling in Medicare timely
  • An SEP for Formerly Incarcerated Individuals
  • An SEP to coordinate with the termination of Medicaid eligibility
  • An SEP on a case-by-case basis for other exceptional conditions where circumstances beyond the individual’s control prevented them from using another enrollment period.

These absolutely essential enrollment flexibilities will expand Medicare enrollment opportunities, reduce coverage gaps, and relieve the burden of lifetime penalties.

The rule also contains provisions that implement another change included in CAA – the creation of a new limited Medicare coverage for people who have received a kidney transplant but whose full Medicare coverage as a result of end-stage renal disease (ESRD) has terminated 36 months after the transplant. The law establishes a right to continued coverage of immunosuppressant medications for individuals in this situation who do not have other health insurance coverage. CMS has named this coverage “the immunosuppressive drug benefit, or the Part B-ID benefit.” The benefit covers immunosuppressant drugs only and does not include coverage for any other Part B benefits or services, and people must attest that they do not have and do not expect to enroll in certain other coverage. There will be a premium, which will be lower than the standard Part B premium, and people who are eligible for the Medicare Savings Programs, including QMB, can access cost sharing.

The rule also makes important, but largely administrative, updates to the functioning of the Medicare Savings Programs, including limiting the premium liability of states in situations where a person is awarded retroactive Medicare enrollment and is eligible for both Medicare and Medicaid.

Read a fact sheet about the proposed rule here.

Read more about the BENES Act.

Read about the BENES 2.0 Act which would further simplify Medicare enrollment.

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