The Health Ethics Trust is pleased to continue its series of briefings addressing compliance issues related to the COVID-19 crisis.
We thought it would be useful to set out some of the recent guidance provided by OIG, CMS, OCR, and the CDC, among others, to assist you in navigating the laws, rules and regulations with which your organizations have to comply.
We are grouping the guidance by the type of organization to which it applies (hospitals, home health, health plan, etc.), although some of the guidance may apply across organization types.
These guidance documents are not meant to cover every issue or all guidance involving a particular organization type, but may serve as a helpful starting point for the compliance issues related to COVID-19.
These guidance documents are prepared with the support of Lynn Barrett, Esq., CHC, CCP a private practice attorney and former CCO who speaks at many Trust programs and is active in Compliance Resource Group, Inc.
This guidance applies to Medicare Advantage plans and plans of other related types. Read the Medicare Advantage plan guidance at https://healthethicstrust.com/category/covid-19/
Medicare Advantage Organizations
Generally, Medicare Advantage Organizations (MAOs) maintain provider networks and either limit an enrollee’s ability to obtain Medicare-covered services from out-of-network providers or charge enrollees more when they receive services from out-of-network providers.
On March 10, 2020, CMS released guidance for MAOs (as well as for Part D sponsors) regarding certain obligations as well as permitted flexibilities related to disasters and emergencies resulting from COVID-19.
1. Special Requirements:
The following requirements are imposed on MAOs from the time the Governor of a state or territory makes a public health emergency declaration until the end date stated in the declaration or 30 days, if no end date is contained in the declaration.
The National Association of Governors (NAG) has compiled the states and territories that have made such a declaration (which appear to be all states and territories, as well as the District of Columbia).
Once a declaration has been made, MAOs are required to:
- Cover Medicare Part A and B services and supplemental Part C plan benefits furnished at non-contracted facilities subject to §422.204(b)(3), which requires that facilities that furnish covered Medicare Part A/B benefits have participation agreements with Medicare;
- Waive, in full, requirements for gatekeeper referrals, where applicable;
- Provide the same cost-sharing for the enrollees as if the services or benefits had been furnished at a plan-contracted facility; and
- Make changes that benefit the enrollee effective immediately without the required 30-day notification (§422.111(d)(3)), including potential changes such as waiving prior authorizations, as set forth below under “Permitted Actions.”
CMS notes that these changes must be made uniformly to similarly situated enrollees who are affected by the disaster or emergency.
2. Permitted Actions:
- In addition to the noted requirements, CMS is allowing MAOs to:
- Waive or reduce enrollee cost-sharing for COVID-19 lab tests, telehealth benefits or other services to address the epidemic if the MAO waives or reduces cost-sharing for all similarly situated plan enrollees on a uniform basis;
- Provide all similarly situated enrollees impacted by the outbreak of COVID-19 access to Medicare Part B services via telehealth in any geographic area and from a number of places, including the beneficiary’s home; and/or
- Waive plan prior authorization requirements that otherwise would apply to tests or services related to COVID-19.
Importantly, CMS has consulted with the OIG who indicated that (i) if the MAO voluntarily waives or reduces cost-sharing as approved by CMS (option (i) above), and/or (ii) expands coverage of telehealth benefits (option (ii) above), then the waivers or reductions and/or the additional telehealth coverage would each satisfy the safe harbor to the federal Anti-Kickback Statute (42 CFR 1001.952(l)).
There a number of additional considerations for MAOs and health plans, which we plan to publish in a later guidance document.
In the meantime, please do not hesitate to contact us should you have any questions or if you need assistance to help ensue your facilities maintain compliance with the ever-changing laws, rules, regulations related to COVID-19.
We can be reached at 703-683-7916 or firstname.lastname@example.org.
Upcoming Course & Conferences
Washington Executive Certification Course
May 18 – 19, 2020 – Online
Compliance Certification Intensive Course
August 5 – 7, 2020 – Boca Raton, FL
Annual Best Compliance Practices Forum
October 19 – 21, 2020 – Washington, DC
Compliance Program Assessors Course
October 21, 2020 – Washington, DC