What is a Medicare cost plan?
A Medicare cost plan is similar to a Medicare Advantage plan in that enrollees have access to a network of doctors and hospitals, and may have additional benefits beyond what’s provided by Original Medicare. But unlike Medicare Advantage plans, a cost plan offers policyholders the option...
How many people are enrolling in Medicare cost plan plans?
But there were far fewer Medicare cost plan enrollees as of 2019, due to the implementation of the Medicare Advantage competition clause. According to a Kaiser Family Foundation analysis, the total number of cost plan enrollees dropped to about 200,000 people as of 2019.
What is the Medicare Advantage beginning-of-year enrollment period?
This beginning-of-year enrollment period is a direct follow-up to AEP, which occurs near the end of every year. Insurance plans run on a calendar year basis, and Medicare Advantage beneficiaries may discover that the plan they enrolled in during AEP does not actually suit their needs.
Can I change Medicare Advantage plans during out of office periods (OEPs)?
During OEP, members of Medicare Advantage plans can make one change to their coverage. They may either switch to a different Medicare Advantage plan or return to Original Medicare. Changing plans during this time is not required.
What is the Medicare Access and CHIP Reauthorization Act of 2015?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) amends the cost plan competition requirements specified in section 1876 (h) (5) (C) of the Social Security Act (the Act).
When do transition plans have to notify CMS?
Plans are responsible for following all contracting, enrollment, and other transition guidance released by CMS. In its initial, December 7, 2015 guidance, CMS specified that transitioning plans must notify CMS by January 31 of the year preceding the last cost contract year. In its May 17, 2017 guidance, CMS revised this date to permit ...
What is cost contract?
A Cost Contract provides the full Medicare benefit package. Payment is based on the reasonable cost of providing services. Beneficiaries are not restricted to the HMO or CMP to receive covered Medicare services, i.e. services may be received through non-HMO/CMP sources and are reimbursed by Medicare intermediaries and carriers.
What is a supply file for Medicare?
To develop the supply file, extracted claims were limited to those with a starting date of service between August 1, 2016 and July 31, 2017 for beneficiaries with both Medicare Part A and B coverage at the time of their claim. The supply file is a cross-sectional database that includes information on provider and facility name, address, national provider identifier, and specialty type and is posted by state and specialty type.
What is the 90 percent coverage requirement for Medicare?
The 90 percent coverage requirement was established to align with the access standards implemented at that time by other federal programs, such as TRICARE’s standard for convenient access and Medicare Part D’s standard for retail pharmacy networks.
What is 005 in primary care?
As discussed in the Health Service Delivery Reference File, the purpose of the inclusion of 005 - Primary Care - Physician Assistants , and 006 - Primary Care - Nurse Practitioners is to inform CMS of the rare contracting with non-MD primary care providers in underserved counties to serve as the major source of primary care for enrollees. Applicants include submissions under this specialty code only if the contracted individual meets the applicable state requirements governing the qualifications for assistants to primary care physicians and is fully credentialed by the applicant as a provider of primary care services. In addition, the individuals listed under this specialty code must function as the primary care source for the beneficiary/member, not supplement a physician primary care provider’s care, in accordance with state law and be practicing in or rendering services to enrollees residing in a state and/or federally designated physician manpower shortage area.
What is RPPO in CMS?
RPPOs have the flexibility under 42 CFR 422.112(a)(1)(ii), subject to CMS pre-approval, to operate by methods other than written agreements in those areas of a region where they are unable to establish contracts with sufficient providers/facilities to meet CMS network adequacy criteri a. RPPOs that use this RPPO-specific exception must agree to establish and maintain a process through which they disclose to their enrollees in non-network areas how the enrollees can access plan-covered medically necessary health care services at in-network cost sharing rates (see 42 CFR 422.111(b)(3)(ii) and 42 CFR 422.112(a)(1)(ii)). As discussed in Chapter 1 of the MMCM, CMS expects that the RPPO-specific exception to written agreements will be limited to rural areas.
How many specialty types are there in CMS?
Currently, CMS measures 27 provider specialty types4 and 14 facility specialty types 5 to assess the adequacy of the network for each service area. CMS has created specific codes for each of the provider and facility specialty types which may be found in Appendix C and Appendix D of this document. Organizations must use the codes when completing Provider and Facility HSD Tables. Additional information on specialty types and codes is available in the current HSD Reference File posted on CMS’s website.
How does CMS monitor network compliance?
CMS monitors network compliance by reviewing organizations’ networks on a triennial basis ( i.e., every three years). The triennial network adequacy review requires an organization to upload its full contract-level network into the NMM in HPMS. CMS provides organizations that are due for their triennial review at least 60 days’ notice before the deadline to submit their networks. The triennial network adequacy review cycle helps to ensure a consistent process for network oversight and monitoring. For more information, please see the Office of Management
Does CMS expect network adequacy criteria?
If an organization is offering a plan in an urban area (i.e., Large Metro or Metro county type designations), then CMS does not expect that the network adequacy criteria will warrant an Exception. The abundance of available providers/facilities in densely populated counties will usually ensure that organizations can establish a network that is consistent with, if not better than, the prevailing original Medicare pattern of care. Specifically, the high population density of Large Metro and Metro counties is accompanied by a significant number and array of available providers/facilities, including most specialists, allowing for reasonable travel times/distances for enrollees to obtain covered services – as opposed to more extended patterns of care, as might be expected in rural areas. Consequently, for CEAC, Rural, and Micro county types, organizations may need to request an Exception if the current landscape of providers/facilities does not enable the organization to meet the CMS network adequacy criteria for a given county and specialty type. See section 5.4 below for details on pattern of care rationales.
What is Medicare cost plan?
What is a Medicare cost plan? A Medicare cost plan is similar to a Medicare Advantage plan in that enrollees have access to a network of doctors and hospitals, and may have additional benefits beyond what’s provided by Original Medicare.
How many Medicare plans are there in Minnesota?
There wee 27 cost plans available in Minnesota as of 2018, and although that dropped in 2019, there are still 21 plans available in Minnesota in 2020. People who still have Medicare cost plans available in their area can still enroll, and there are cost plans available in 2020 in Colorado, Iowa, Illinois, Maryland, Minnesota, Nebraska, ...
What is the competition clause in Medicare?
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (which rebranded Medicare+Choice as Medicare Advantage) created a competition clause that banned Medicare Cost plans from operating in areas where they faced substantial competition from Medicare Advantage plans.
How many people are on Medicare in 2019?
According to a Kaiser Family Foundation analysis, the total number of cost plan enrollees dropped to about 200,000 people as of 2019.
Which states do not have Medicare?
The rest were spread across Colorado, District of Columbia, Iowa, Illinois, Maryland, North Dakota, South Dakota, Texas, Virginia, and Wisconsin; most states do not have Medicare cost plans available. But there were far fewer Medicare cost plan enrollees as of 2019, due to the implementation of the Medicare Advantage competition clause.
Who can join Medicare?
Who can join a Medicare cost plan? Eligible enrollees who live within a Medicare cost plan’s service area can join the plan when it’s accepting new members. A cost plan that is accepting new enrollees must have an annual open enrollment window of at least 30 days, although they can set an enrollment cap and close enrollment once it’s reached.
Does a cost plan have supplemental Part D?
If the cost plan offers optional supplemental Part D prescription coverage, enrollment in (or disenrollment from) the Part D coverage is limited to the normal annual open enrollment period for Part D plans. If the cost plan does not have a supplemental Part D plan available — or if it does and the enrollee would prefer a different Part D plan — ...
What is the 165 provision of MIPPA?
Section 165 of MIPPA, which revised section 1852 (a) of the Act, prohibits D-SNPs from imposing cost-sharing requirements on full benefit dual-eligible individuals and Qualified Medicare Beneficiaries (QMBs), as described in sections 1935 (c) (6) and 1905 (p) (1) of the Act, that would exceed the cost-sharing amounts permitted under the State Medicaid plan if the individual were not enrolled in the D-SNP. The effective date of this provision is January 1, 2010.
What is the 164 C of MIPPA?
Section 164 (c) (1) of MIPPA (section 1859 (f) (3) (c) of the Act) directly mandates that CMS determine the form and content of the comprehensive written statement. Regulatory language is neither a necessary nor appropriate means of effectuating this statutory directive to the agency.
What is a MA PFFS plan?
Prior to MIPPA, the statute defined an MA PFFS plan as an MA plan that pays providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk; does not vary the rates for a provider based on the utilization of that provider's services; and does not restrict enrollees' choice among providers who are lawfully authorized to provide covered services and agree to accept the plan's terms and conditions of payment. Section 162 (b) of MIPPA added that although payment rates generally cannot vary based on utilization of services by a provider, an MA PFFS plan is permitted to vary the payment rates for a provider based on the specialty of the provider, the location of the provider, or other factors related to the provider that are not related to utilization. However, this section of MIPPA allowed MA PFFS plans to increase payment rates for a provider based on increased utilization of specified preventive or screening services. Section 162 (b) of MIPPA was effective at the time of publication of the September 18, 2008 IFC.
What is MIPPA 162(a)(2)?
Section 162 (a) (2) of MIPPA amended section 1852 (d) of the Act by adding a new requirement for employer/union sponsored PFFS plans. For plan year 2011 and subsequent plan years, MIPPA required that all employer/union sponsored PFFS plans under section 1857 (i) of the Act meet the access standards described in section 1852 (d) (4) of the Act only through entering into written contracts or agreements in accordance with section 1852 (d) (4) (B) of the Act, and not, in whole or in part, through establishing payment rates meeting the requirements under section 1852 (d) (4) (A) of the Act. We revised § 422.114 (a) in the September 2008 IFC to reflect this statutory change. Specifically, the changes to § 422.114 (a) set forth how an MA organization that offers a PFFS plan must demonstrate to CMS that it can provide sufficient access to services covered under the plan. We stated in the September 18, 2008 IFC ( 73 FR 54226) that, in order to meet the access requirements beginning plan year 2011, an employer/union sponsored PFFS plan must establish written contracts or Start Printed Page 54611 agreements with a sufficient number and range of health care providers in its service area for all categories of services in accordance with the access and availability requirements described in section 1852 (d) (1) of the Act. An employer/union sponsored PFFS plan will not be allowed to meet access requirements by establishing payment rates for a particular category of provider that are at least as high as rates under Medicare Part A or Part B. We also stated that while an employer/union-sponsored PFFS plan must meet access standards through signed contracts with providers, providers that have not signed contracts can still be deemed to be contractors under the deeming procedures in 1852 (j) (6) of the Act that currently apply.
What is a special needs plan?
Congress authorized special needs plans (SNPs) as a type of Medicare Advantage (MA) plan designed to enroll individuals with special needs. The three types of special needs individuals eligible for enrollment in a SNP identified in the MMA include— (1) Institutionalized individuals (defined in § 422.2 as an individual continuously residing, or expecting to continuously reside, for 90 days or longer in a long term care facility); (2) individuals entitled to medical assistance under a State Plan under title XIX of the Act; or (3) other individuals with severe or disabling chronic conditions that would benefit from enrollment in a SNP.
Can MA organizations market health care products?
Section 422.2268 (g) states that MA organizations cannot market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to the appointment.
When was Medicare Part D enacted?
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) ( Pub. L. 108-173) was enacted on December 8 , 2003. The MMA established the Medicare prescription drug benefit program (Part D) and made revisions to the provisions in Medicare Part C, governing what is now called the Medicare Advantage (MA) program (formerly Medicare+Choice). The MMA directed that important aspects of the new Medicare prescription drug benefit program under Part D be similar to and coordinated with regulations for the MA program. Start Printed Page 54227
What is Medicare C?
The Balanced Budget Act of 1997 (BBA) ( Pub. L. 105-33) established a new “Part C” in the Medicare statute (sections 1851 through 1859 of the Social Security Act (the Act)) which provided for a Medicare+Choice (M+C) program. Under section 1851 (a) (1) of the Act, every individual entitled to Medicare Part A and enrolled under Medicare Part B, except for most individuals with end-stage renal disease (ESRD), could elect to receive benefits either through the original Medicare program or an M+C plan, if one was offered where he or she lived.
What is section 163(b)(2)?
Section 1852 (e) (3) (A) (ii) had provided for CMS to establish separate regulatory requirements for MA regional plans relating to the collection, analysis, and reporting of data that permit the measurement of health outcomes and other indices of quality and also provided that these requirements for MA regional plans could not exceed the requirements established for MA local plans that are PPO plans . Furthermore, section 163 (b) (3) amended Section 1852 (e) (3) (iii) of the Act by adding that MA regional plans are subject to the data collection requirements under Section 1852 (e) (3) (A) (i) of the Act only to the extent that data are furnished by providers who have a contract with the MA regional plan. This provision is effective for plan years beginning on or after 2010 and allows for consistent data collection requirements between MA local plans that are PPO plans and MA regional plans.
What is a MA PFFS plan?
Prior to MIPPA, the statute defined an MA PFFS plan as an MA plan that pays providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk; does not vary the rates for a provider based on the utilization of that provider's services ; and does not restrict enrollees' choice among providers who are lawfully authorized to provide covered services and agree to accept the plan's terms and conditions of payment. Section 162 (b) of MIPPA added that although payment rates cannot vary based solely on utilization of services by a provider, an MA PFFS plan is permitted to vary the payment rates for a provider based on the specialty of the provider, the location of the provider, or other factors related to the provider that are not related to utilization.
What is the MIPPA 164?
Section 164 of MIPPA adds a new clause (ii) to section 1852 (e) (3) (A) of the Act and a new paragraph (6) to section 1857 (d) of the Act. Section 1852 (e) (3) (A) (ii) of the Act now mandates that, beginning on a date specified by the Secretary (but in no case later than January 1, 2010), data collected, analyzed, and reported as part of the plan's quality improvement program must measure health outcomes and other indices of quality at the plan level with respect to the model of care as required in section 1859 (f) (2-5). As a Medicare Advantage plan, each SNP must implement a documented quality improvement program for which all information is available for submission to CMS or for review during monitoring visits. The focus of the SNP quality improvement program should be the monitoring and evaluation of the performance of its model of care (see § 422.101 (f)). The program should be executed as a three-tier system of performance improvement. The first tier consists of data on quality and outcomes that is collected and analyzed to enable beneficiaries to compare and select from among health coverage options. In calendar year (CY) 2008, CMS required the submission of thirteen HEDIS measures and three structure and process measures to pilot the development of comparative measures to facilitate beneficiary choice. We continue to work on this initiative and will issue guidance to SNPs on collecting comparative measures for submission using CMS required tools in CY 2009.
What is a SNP?
The Congress first authorized special needs plans (SNP) to exclusively or disproportionately serve individuals with special needs. The three types of special needs individuals eligible for enrollment identified by the Congress include (1) institutionalized individuals (defined in § 422.2 as an individual residing or expecting to reside for 90 days or longer in a long term care facility), (2) individuals entitled to medical assistance under a State plan under title XIX, and (3) other individuals with severe or disabling chronic conditions that would benefit from enrollment in a SNP.
What is the IFC for Medicare Advantage?
This interim final rule with comment period (IFC) revises the regulations governing the Medicare Advantage (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost plans. This IFC makes conforming changes to the MA regulations to reflect new statutory requirements regarding special needs plans (SNP), private-fee-for-service plans (PFFS), regional preferred provider organizations (RPPO) plans, Medicare medical savings accounts (MSA) plans, and new statutory provisions governing cost-sharing for dual-eligible enrollees in the MA program prescription drug pricing, coverage, and payment processes in the Part D program. In addition, this IFC sets forth new requirements governing the marketing of Part C and Part D plans which by statute must be in place at a date specified by the Secretary, but no later than November 15, 2008. Both the conforming changes to the regulations to reflect new statutory provisions and the new marketing requirements are based on provisions in the Medicare Improvements for Patients and Providers Act (MIPPA), which became law on July 15, 2008.
Why was OEP created?
This beginning-of-year enrollment period is a direct follow-up to AEP, which occurs near the end of every year. Insurance plans run on a calendar year basis, and Medicare Advantage beneficiaries may discover that the plan they enrolled in during AEP does not actually suit their needs.
What changes can be made during OEP?
This enrollment period applies to you only if you are enrolled in a Medicare Advantage plan. If you are enrolled in a Medicare Advantage plan, you have one opportunity to:
OEP vs. OEP-New
The Medicare Advantage Open Enrollment Period is yearly and only for three months, but there is another open enrollment period called OEP-New. This period is not tied to any specific dates, but is different for every individual.
OEP Recap
The Medicare Advantage Open Enrollment Period (OEP) is new in 2019. It happens January 1 - March 31. During OEP, members of Medicare Advantage plans can make one change to their coverage. They may either switch to a different Medicare Advantage plan or return to Original Medicare. Changing plans during this time is not required.