CMS Updates: June 1, 2020

CMS Announces Final Payment Notice for 2021 Coverage Year

The final Notice of Benefit and Payment Parameters for the 2021 benefit year, also referred to as the 2021 Payment Notice, minimizes the number of significant regulatory changes to provide states and issuers with a more stable and predictable regulatory framework that facilitates a more efficient and competitive market. These changes further the Administration’s goals of lowering premiums, promoting program integrity, stabilizing markets, enhancing the consumer experience, and reducing regulatory burden.

To view the full press release, go to: 2021 Payment Notice Press Release.

To view the final rule, go to: 2021 Payment Notice Final Rule

To view the fact sheet on the final rule, go to: 2021 Payment Notice Fact Sheet

COVID-19 Federal Response

The federal government is taking action to protect the health and safety of our nation’s patients and providers in response to the coronavirus disease 2019 (COVID-19). There are a number of sources of information about actions being taken across the federal government.

The Center for Consumer Information and Insurance Oversight (CCIIO) COVID-19-Related Guidance

The Departments of Labor, Health and Human Services, and the Treasury issued guidance to implement requirements under the Families First Coronavirus Response Act (FFCRA), and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) that generally require private health issuers and employer group health plans to cover COVID-19 testing, the administration of that testing, and certain related items and services. This coverage must be provided for items and services that are furnished on or after March 18, 2020, with no out-of-pocket expenses, prior authorization or medical management requirements for the duration of the applicable emergency period.  Visit FFCRA and CARES Act FAQs for more information.

Prior to the FFCRA and the CARES Act, CMS released guidance that explains that essential health benefits (EHB) generally includes coverage for the diagnosis and treatment of COVID-19. However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. This guidance remains relevant for any treatment related to COVID-19, as well as diagnostic testing received before March 18, 2020. Please visit EHB Coverage for COVID-19 for more information. As noted above, under FFCRA and the CARES Act private health issuers and group health plans must now cover diagnostic services at no cost and with no prior authorization or medical management requirements

In addition, the Departments provided plans and issuers flexibility to reduce or eliminate cost-sharing for telehealth services, even in cases when a consumer may not have met their deductible. For more information, visit telehealth FAQs.

Lastly, CMS released guidance on payment and grace period flexibilities associated with the COVID-19 outbreak. CMS will exercise enforcement discretion to permit issuers of QHPs and stand-alone dental plans (SADPs) to extend payment deadlines for initial binder payments as well as ongoing premium payments during the period of the COVID-19 national emergency. Visit payment and grace period for more information.

New Guidance on Extension of Timeframes for COBRA and Coverage Appeals

On April 28, 2020, a Department of Labor notice, jointly issued with the Department of the Treasury and Internal Revenue Service, extends certain timeframes affecting participants’ rights to healthcare coverage, portability, and continuation of group health plan coverage under COBRA, and extends the time for plan participants to file or perfect benefit claims or appeals of denied claims. These extensions provide participants and beneficiaries of employee benefit plans sponsored by private sector employers additional time to make important health coverage and other decisions affecting their benefits during the coronavirus outbreak.

CMS released a guidance document concurring with the disaster relief specified by the Department of Labor, the Department of the Treasury and Internal Revenue Service and encouraging states, non-federal governmental plans (such as state and local employee health plans) and issuers offering coverage in connection with a group health plan to enforce and operate, respectively, in a manner consistent with this relief.

For a link to the Department of Labor, Treasury and Internal Revenue Service notice, visit COBRA Timeframes. Visit EBSA guidance for other guidance related to group health plans. For CMS guidance, visit the CMS website.

Economic Impact Payments and Unemployment Benefits

The CARES Act calls for the IRS to make economic impact payments of up to $1,200 per taxpayer and $500 for each qualifying child. If consumers get one of these payments, they don’t need to include it in the income they report on their application. These payments don’t impact their eligibility for financial assistance for health care coverage through the Marketplace, or their eligibility for Medicaid or the Children’s Health Insurance Program (CHIP). For more information, visit IRS Coronavirus Tax Relief information.

Unemployment benefits, including the additional $600 per week payments in the CARES Act, are taxable income included in modified adjusted gross income (MAGI). The CARES Act exempted the $600 payment increase from income calculations for purposes of eligibility for Medicaid and CHIP, but did not exempt the $600 per week payment increase for purposes of eligibility for subsidies to purchase health insurance coverage through the Marketplace. Please instruct consumers to report all unemployment payments, including the $600 per week payment increase, on their Marketplace application.

Guidance on Marketplace Coverage and Coronavirus

For more information on topics relating to Marketplace coverage and COVID-19, please visit Marketplace coverage for COVID-19. This page provides information on the following situations:

  • If I lost my job or experienced a reduction in hours due to COVID-19
  • Coverage start dates with a Special Enrollment Period due to loss in coverage
  • If I can’t pay my premiums because of a hardship due to COVID-19
  • If I’m enrolled in a Marketplace plan and my income has changed
  • If I previously qualified for a Special Enrollment Period, but missed the deadline because I was impacted by the COVID-19 national emergency
  • If I want to change my current Marketplace plan or enroll for the first time
  • If my child is now living with me after their college sent them home early
  • If I get a direct deposit or check from the IRS that is called an economic impact payment

 COVID-19 Partner Toolkit

CMS has developed a toolkit to help you stay informed on CMS and HHS materials available on the COVID-19. Please share these materials, bookmark the page, and check back often for the most up-to-date information.  To listen to the audio files and read the transcripts for the COVID-19 Stakeholder calls, visit the Podcast and Transcripts page. The link to the toolkit and more resources is available at Coronavirus Partner Tool Kit page.

Guidance on Medicaid and CHIP Coverage and Benefits Related to COVID-19

Medicaid and CHIP programs cover a broad range of benefits, which may vary by state. Some benefits are mandatory which means states are required to provide them while other benefits are optional for states to provide.  Visit benefits related to COVID-19 for more information. Specific questions regarding covered benefits should be directed to the respective state Medicaid and CHIP agency. More information is available by contacting your state.