CMS rule seeks to curb delays in Medicare coverage, expands special enrollment periods

The Biden administration issued a final rule that seeks to make it easier for beneficiaries to enroll in Medicare and curb delays in getting coverage. 

The final rule, released Friday by the Centers for Medicare & Medicaid Services (CMS), would expand the number of special enrollment periods (SEPs) to let beneficiaries change their coverage outside of initial enrollment. It would also ensure Medicare coverage starts the month after initial enrollment to reduce any unnecessary delays. 

“For the first time, special enrollment periods will be available in traditional Medicare for individuals who were unable to enroll due to exceptional conditions, and individuals who have had a kidney transplant will now be able to receive extended Medicare coverage for immunosuppressive drugs,” CMS Administrator Chiquita Brooks-LaSure said in a statement. 

The SEPs apply to individuals who enroll in Part B if they didn’t enroll in Medicare during their initial enrollment period and not face any penalty.

Some of the new SEPs created under the rule include helping beneficiaries that missed enrollment due to a disaster or emergency and if their employer or plan “materially misrepresented information related to timely enrollment in Medicare Part B.” 

Another SEP is if an individual was incarcerated or if their Medicaid coverage was terminated after the COVID-19 public health emergency “or on or after Jan. 1, 2023 (whichever is earlier),” according to a release on the rule. 

Starting Jan. 1, Medicare will now also cover immunosuppressive drugs for people who have had a kidney transplant and otherwise would lose their coverage. 

The final rule, which implements parts of the Consolidated Appropriations Act of 2021, also seeks to simplify when a new beneficiary’s coverage starts. 

Next year, Medicare coverage will become effective the month after enrollment in an attempt to narrow a gap in coverage that could last as long as several months. 

CMS also seeks to clarify existing requirements that affect a state’s payment of Medicare Parts A and B premiums for low-income individuals in the state buy-in program. 

For instance, the rule would limit the retroactive liability that some states may face for Part B premiums. 

“From time to time, [the Social Security Act] establishes retroactive Medicare Part A entitlements for Medicaid beneficiaries as part of disability determinations,” CMS said in a fact sheet. “This action can make states liable for retroactive Part B premiums going back several years. It can also increase administrative work for providers and payers involving recoupment, billing and claims processing.”

The new rule would limit retroactive premium liability for states “to 36 months prior to the date of the Medicare enrollment determination, for full-benefit Medicaid beneficiaries beginning Jan. 1, 2024.”