CMS Proposes Updates to Reduce Barriers to Coverage, Simplify Medicare Enrollment and Expand Access

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Proposed rule would create Special Enrollment Periods, reduce gaps in Medicare coverage and improve administration of the Medicare Savings Programs.

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare enrollment and eligibility rules that would expand coverage for people with Medicare and advance health equity. This proposed rule would provide Medicare coverage the month immediately after enrollment, thereby reducing the uninsured period and expand access through Medicare special enrollment periods (SEPs). It would also allow eligible beneficiaries to receive Medicare Part B coverage without a late enrollment penalty. This proposed rule would make it easier for people to enroll in Medicare and eliminate delays in coverage.

“Health care is not just about mending bones or dispensing pills. It’s about giving people peace of mind that comes with having coverage when you need it,” said U.S. Health and Human Services Secretary Xavier Becerra. “That’s why we’re proposing this rule today to help reduce delays, eliminate gaps, and expand access to care for people with Medicare. The Biden-Harris Administration will continue to strengthen Medicare and ensure our older Americans and individuals living with disabilities or End Stage Renal Disease get the affordable, quality health care they deserve.”

This is the first time that SEPs will be available for individuals who were unable to enroll due to exceptional conditions. It’s also the first time that vital coverage for immunosuppressive drugs will be provided for individuals who otherwise would be losing all Medicare coverage.  Together, these proposals not only implement important provisions of the Consolidated Appropriations Act, 2021 (CAA), but also support President Biden’s Executive Orders on Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government and Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage by eliminating confusing coverage waiting periods and allowing CMS and the Social Security Administration to remedy missed enrollment periods by permitting SEPs for exceptional conditions. Furthermore, these proposals support the Administration’s vision for CMS: to serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding access to affordable coverage and care, and improving health outcomes. 

“CMS is committed to ensuring that people eligible for Medicare have timely access to this vital coverage. This proposed rule, if finalized, will reduce the time it takes for people to receive Medicare coverage after they enroll and advances CMS’ strategic vision of expanding access to quality, affordable health coverage and care,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is grateful to Congress for allowing us to establish Special Enrollment Periods for Medicare that will help eliminate coverage gaps and late enrollment penalties for people meeting exceptional conditions.”

An SEP is an opportunity for people with Medicare to enroll in Part B if they didn’t enroll in Medicare during their Initial Enrollment Period when they were first eligible. People with coverage under Medicare Advantage and Part D can also use SEPs to make changes to their Medicare coverage when certain events happen in their lives, such as moving or losing other insurance coverage. Rules about when people with Medicare can make changes to their coverage and the type of changes they can make are different for each SEP.

Sections 120 and 402 of the CAA made two key changes to Medicare enrollment rules. First, Medicare coverage will become effective the month after enrollment for individuals enrolling in the last three months of their initial enrollment period or in the General Enrollment Period, thereby reducing any potential gaps in coverage. Currently, if individuals enroll in Medicare in the last three months of their Initial Enrollment Period or in the General Enrollment Period, they may have to wait several months for Medicare coverage to begin. Second, the proposed rule also establishes a new immunosuppressive drug program that would extend Medicare immunosuppressive drug coverage to certain individuals who have had a kidney transplant. If finalized, the proposed rule would promote accessibility to vital life-saving drugs. This rule, if finalized, would become effective January 1, 2023, and implement changes made by the CAA.

“These proposals highlight CMS’ efforts to advance health equity and improve access to Medicare,” said Dr. Meena Seshamani, Deputy Administrator of CMS and Director of the Center for Medicare. “Reducing gaps in coverage, allowing for special enrollment periods for individuals in exceptional circumstances, spending money in a smarter way on kidney transplant patients – these are meaningful changes that put people at the center of their care and improve the Medicare program.”

Finally, CMS is proposing several technical updates to improve administration of the Medicare Savings Programs. These programs help make Medicare affordable for those struggling to afford health care.

CMS encourages people who are approaching Medicare eligibility to research their Medicare coverage options and enrollment deadlines. Medicare.gov and 1-800-MEDICARE are both available to help people understand their choices and associated deadlines. In addition, personalized health insurance counseling is available at no cost from State Health Insurance Assistance Programs (SHIPs). Visit shiptacenter.org or call 1-800-MEDICARE for each SHIP’s phone number.

To view a fact sheet on the proposed rule, visit: https://www.cms.gov/newsroom/fact-sheets/implementing-certain-provisions-consolidated-appropriations-act-2021-and-other-revisions-medicare-0

To view the proposed rule, visit: https://www.cms.gov/files/document/cms-4199-p.pdf

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