evekhm/cms_iom_500 huggingface dataset:
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enrollees from MMPs to DSNPs does not address our need to stem the proliferation and growth of DSNP look- alikes now, as summarized earlier in this section and discussed in more detail in the February 2020 proposed rule (85 FR 9018 through 9021). Comment: A commenter encouraged CMS to continue efforts to reduce incentives for non-SNP plans to focus enrollments efforts on dually eligible individuals. A commenter suggested that CMS continue to monitor and evaluate any non DSNP plan where dually eligible individuals make up the majority of the covered lives to ensure the plan is not engaged in deceptive marketing practices. Another commenter recommended that CMS contemplate requiring Medicare to inform beneficiaries when they are enrolling in a non-integrated model where an integrated model exists. Response: We appreciate the comments and agree with concerns about the potential proliferation of D SNP look-alikes that are not required to comply with the requirements for D SNPs and that may undermine our goals of encouraging and furthering integrated coverage options for dually eligible individuals. As described in the June 2020 final rule at 85 FR 9020, we stated that the prevalence of DSNP look- alikes has led to instances of misleading marketing by brokers and agents that misrepresent to dually eligible individuals the characteristics of such look-alike plans, especially where the plans have marketed themselves as being special Medicaid-focused plans. We sought to reduce that prevalence through finalizing the DSNP look-alike contracting limitations at  422.514(d). Also in the June 2020 final rule, we codified at  422.2262(a)(1)(xvi) a prohibition on MA organizations, with respect to their non-DSNP plans, from marketing their plan as if it were a D SNP, implying that their plan is designed for dually eligible individuals, targeting their marketing efforts exclusively to dually eligible individuals, or claiming a relationship with the State Medicaid agency, unless a contract to coordinate Medicaid services for that plan is in place. We will continue to monitor the level of dually eligible enrollment among non- SNP MA plans. This comment is out of scope for this rulemaking, but we will consider ways to monitor non-DSNP plans for deceptive marketing practices and contemplate for future
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level of dually eligible enrollment among non- SNP MA plans. This comment is out of scope for this rulemaking, but we will consider ways to monitor non-DSNP plans for deceptive marketing practices and contemplate for future rulemaking a requirement to inform beneficiaries upon enrolling into a non-integrated model where an integrated model exists. Comment: A commenter noted that the unforeseen loopholes reinforced their concerns about the overly complex nature of MA contracting and the opportunities that complexity brings for abuse, which led to the need for DSNP look-alike regulations. This commenter emphasized that complexity hampers transparency as shown by the MA plan segment issues and recommended that CMS take a hard look at its contracting and oversight of MA plans to ensure the system is more straightforward, accountable, and transparent. Response: We welcome this perspective. While this comment is out of scope for this rulemaking, we will consider it for future rulemaking and oversight opportunities. After considering the comments we received and for the reasons outlined in the proposed rule and our responses to comments, we are finalizing revisions to  422.503(e), 422.504(a)(19), 422.510(a)(4), and 422.514(g) as proposed. B. Part D Special Enrollment Period Change Based on CAA Medicare Enrollment Changes ( 423.38) Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108173) established a Part D Voluntary Prescription Drug Benefit program for Medicare-eligible individuals. The MMA added section 1860D1(b)(3)(C) of the Act, which authorized the Secretary to establish Part D special enrollment periods (SEP) for Medicare-eligible individuals to enroll in a Part D plan based on exceptional conditionsthat is, an individual may elect a plan or change his or her current plan election when the individual meets an exceptional condition as determined by the Secretary. In 2020, we codified a number of exceptional condition SEPs, including the SEP for Individuals Who Enroll in Part B During the Part B General Enrollment Period (GEP) (85 FR 33909). This SEP, as codified at  423.38(c)(16), allowed individuals who are not entitled to premium-free Part A and who enroll in Part B during the
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(85 FR 33909). This SEP, as codified at  423.38(c)(16), allowed individuals who are not entitled to premium-free Part A and who enroll in Part B during the GEP for Part B (JanuaryMarch) to enroll in a Part D plan. This SEP begins April 1st and ends June 30th, with a Part D plan enrollment effective date of July 1st. This SEP effective date aligns with the VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00016 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222135 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations entitlement date for Part B for individuals who enroll in Part B during the GEP. Prior to January 1, 2023, when an individual enrolled in Part B during the GEP, their Part B enrollment entitlement date was July 1st, regardless of when during the GEP they enrolled. Division CC, title I, subtitle B, section 120 of the Consolidated Appropriations Act, 2021 (CAA) Public Law 116260 modified section 1838(a)(2) of the Act, to address the beginning of the entitlement for individuals enrolling during their GEP pursuant to section 1837(e) of the Act. As added by the CAA, section 1838(a)(2)(D)(ii) of the Act requires that, for an individual who enrolls in Part B during the GEP on or after January 1, 2023, entitlement begins the first day of the month following the month in which the individual enrolled. For example, if an individual enrolls in Part B in February 2023 (during the GEP), their Part B coverage will begin on March 1st. Based on Medicare enrollment statutory changes made by the CAA described previously, we proposed to modify  423.38(c)(16) to provide that on or after January 1, 2023, an individual who is not entitled to premium-free Part A and who enrolls in Part B during the GEP is eligible to use the SEP for Individuals Who Enroll in Part B During the Part
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provide that on or after January 1, 2023, an individual who is not entitled to premium-free Part A and who enrolls in Part B during the GEP is eligible to use the SEP for Individuals Who Enroll in Part B During the Part B GEP to request enrollment in a Part D plan, and that this SEP will begin when the individual submits the application for Part B, and will continue for the first 2 months of enrollment in Part B. Further, we proposed to modify  438.38(c)(16) to provide that where an individual uses this Part D SEP to request enrollment in a Part D plan, the Part D plan enrollment would be effective the first of the month following the month the Part D plan sponsor receives the enrollment request. These proposed revisions are needed to align the timeframe for use of this Part D SEP based on new Part B GEP enrollment effective date parameters. Because an individual may elect a Part D plan only during an election period, Medicare Part D sponsors already have procedures in place to determine the election period(s) for which an applicant is eligible. Finalizing this SEP will not add to existing enrollment processes, so we believe any burden associated with this aspect of enrollment processing would remain unchanged from the current practice and will not impose any new requirements or burden. All information impacts of this provision have already been accounted for under OMB control number 0938 1378 (CMS10718). We do not believe finalizing this SEP will adversely affect individuals requesting enrollment in Medicare plans, the plans themselves, or their current enrollees. Similarly, we do not believe finalizing this SEP will have any impact to the Medicare Trust Funds. We received a number of comments on this proposalthose comments and our responses follow. Comment: All commenters supported our proposal to align the timeframe for use of this SEP based on the revised GEP effective date parameters established by the CAA. One commenter stated that they support beneficiaries access to affordable, quality health coverage, and that this change would reduce potential coverage gaps. Another commenter agreed that this change would help alleviate potential coverage gaps, and added that it would simplify the process for beneficiaries and their caregivers, as it will align the effective date of Part D coverage with the effective date for other Part D SEPs. Another commenter stated that they support policies that support enrollment alignment across Medicare Parts A, B, C and
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and their caregivers, as it will align the effective date of Part D coverage with the effective date for other Part D SEPs. Another commenter stated that they support policies that support enrollment alignment across Medicare Parts A, B, C and D. Response: We thank the commenters for their support of this proposed revision to align the timeframe for use of this SEP with the new parameter for GEP effective dates established under the CAA. Comment: One commenter supported the proposal, but stated that current eligibility criteria do not require checking Part A status of payment, and requested clarification on whether CMS intends to require plans to validate Part A Entitlement Status Code in the Medicare Advantage Prescription Drug (MARx) system as part of eligibility verification for use of this SEP. Response: CMS did not propose any change to the criteria for use of this SEP, only the timeframe for its use, and the effective date of the coverage. Therefore, the actual enrollment process will not change. Per current procedures outlined in the CMS Plan Communications User Guide, Part D sponsors must verify Part D eligibility/Medicare entitlement by either the Batch Eligibility Query (BEQ) process or the MARx online query (M232 screen) or its equivalent for all enrollment requests except enrollment requests from a current enrollee of a PDP who is requesting enrollment into another PDP offered by the same parent organization with no break in coverage (that is, switching plans). CMS systems are updated within two business days of SSA processing new or changed Part A or Part B entitlement for a Medicare beneficiary. If the plan needs to validate the individuals Part A entitlement status, that code/ information can be found in the Part A Entitlement Status column on the M257 screen in MARx. Comment: One commenter stated that the individuals premium-Part A entitlement is a necessary component if one were to use the SEP to apply for Part D. They further stated that, the window for applying for premium-Part A in the 14 group-payer states is limited to the GEP, so, group-payer states can delay the individuals ability to take advantage of the proposed Part D SEP. Response: We thank the commenter, but the parameters for applying for premiumPart A in group-payer states are outside of the scope of this rule. After considering the comments we
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ability to take advantage of the proposed Part D SEP. Response: We thank the commenter, but the parameters for applying for premiumPart A in group-payer states are outside of the scope of this rule. After considering the comments we received and for the reasons outlined in the proposed rule and our responses to comments, we are finalizing the SEP for Individuals Who Enroll in Part B During the Part B GEP to request enrollment in a Part D plan at  423.38(c)(16) without modification. C. Alignment of Part C and Part D Special Enrollment Periods With Medicare Exceptional Condition Enrollment ( 422.62 and 423.38) Section 1851(e)(4)(D) of the Act authorizes the Secretary to create special enrollment periods (SEPs) for an individual to disenroll from an MA plan or elect another MA plan if the individual meets an exceptional condition provided by the Secretary. This authority was originally codified at  422.62(b)(4) in the June 1998 interim final rule as a general SEP for CMS to apply on an ad hoc basis. (63 FR 35073) As noted previously, section 1860D 1(b)(3)(C) of the Act authorizes the Secretary to establish Part D SEPs for Medicare-eligible individuals to enroll in a Part D plan if they meet certain exceptional conditions. This authority was originally codified at  423.38(c)(8)(ii) (70 FR 4529). The MMA also added section 1860D 1(b)(1)(B) of the Act which provides that in adopting the Part D enrollment process, the Secretary shall use rules similar to (and coordinated with) the rules for enrollment, disenrollment, termination, and change of enrollment with an MAPD plan under the following provisions of section 1851. As required by section 1851(a)(3) of the Act (for the MA program) and section 1860D1(a)(3)(A) of the Act (for the Part D program) and described in  422.50(a)(1) and 423.30(a)(1)(i), eligibility for MA or Part D plan enrollment requires that an individual first have Medicare Parts A and B for MA eligibility and either Part A or B for VerDate
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and 423.30(a)(1)(i), eligibility for MA or Part D plan enrollment requires that an individual first have Medicare Parts A and B for MA eligibility and either Part A or B for VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00017 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222136 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations Part D eligibility. Division CC, title I, subtitle B, Section 120 of the CAA established section 1837(m) of the Act to authorize the Secretary to establish Part B SEPs for individuals who are eligible to enroll in Medicare and meet such exceptional conditions as the Secretary provides. Per section 1818(c) of the Act, the provisions of section 1837 of the Act, excluding subsection (f) thereof, applies to the premium Part A program. This authority to adopt exceptional conditions SEPs for premium Part A and Part B was effective January 1, 2023. CMS finalized new exceptional condition SEPs under section 1837(m) of the Act in 42 CFR 406.27 and 407.23 for Medicare parts A and B, respectively, in a final rule that was published in the Federal Register on November 3, 2022, titled Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules (87 FR 66454). These SEPs are available to individuals who have missed an enrollment period due to an exceptional condition that is specified in the final rule. Specifically, individuals who miss an IEP, GEP, or another SEP, such as the Group Health Plan SEP, due to an exceptional condition, would be eligible to enroll in Medicare premium Part A or Part B using the new SEPs. Based on Medicare enrollment changes made by the CAA described previously, we proposed to add corresponding exceptional condition SEPs for MA and Part D enrollment, as authorized under sections 1851(e)(4)(D) and 1860D1(b)(3)(C) of the Act, to align with the new Medicare premiumPart A and B exceptional condition SEPs that
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as authorized under sections 1851(e)(4)(D) and 1860D1(b)(3)(C) of the Act, to align with the new Medicare premiumPart A and B exceptional condition SEPs that CMS has finalized in 42 CFR 406.27 and 407.23. We proposed at  422.62(b) to redesignate current paragraphs (26) as (27) and add a new paragraph (26) to provide an SEP for individuals to enroll in a MA plan or MA plan that includes Part D benefits (MAPD plan), when they use a Medicare exceptional condition SEP to enroll in premium Part A and/or Part B. We also proposed at  423.38(c) to redesignate current paragraph (34) as (35) and add new paragraph (34) to provide an SEP for individuals to enroll in a stand-alone Part D prescription drug plan (PDP) when they use a Medicare exceptional condition SEP to enroll in premium Part A or Part B. The proposed new MA SEP would begin when the individual submits the application for premium Part A and Part B, or only Part B, and would continue for the first 2 months of enrollment in Part A (premium or premium-free) and Part B. Similarly, the proposed new Part D SEP would begin when the individual submits their premium-Part A or Part B application and would continue for the first 2 months of enrollment in premium Part A or Part B. The MA or Part D plan enrollment would be effective the first of the month following the month the MA or Part D plan receives the enrollment request. Because an individual may elect an MA or Part D plan only during an election period and when eligible, MA organizations and Part D sponsors already have procedures in place to determine the election period(s) for which an applicant is eligible. Finalizing these coordinating SEPs will not add to existing enrollment processes, so we believe any burden associated with this aspect of enrollment processing will remain unchanged from the current practice, and will not impose any new requirements or burden. Consequently, finalizing these SEPs will not have added impact. All burden impacts of these provisions have already been accounted for under OMB control number 09381378 (CMS10718). We do not believe finalizing these SEPs will adversely impact individuals requesting enrollment in Medicare plans, the plans themselves, or their current enrollees. Similarly,
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under OMB control number 09381378 (CMS10718). We do not believe finalizing these SEPs will adversely impact individuals requesting enrollment in Medicare plans, the plans themselves, or their current enrollees. Similarly, we do not believe the finalized SEPs will have any impact to the Medicare Trust Funds. We received a number of comments on this proposalthose comments and our responses follow. Comment: All commenters supported our proposal to add corresponding exceptional condition SEPs for MA and Part D enrollment to align with the new Medicare premium Part A and B exceptional condition SEPs that CMS has finalized in 42 CFR 406.27 and 407.23. A few commenters expressed that the availability of these SEPs would reduce potential coverage gaps and help prevent late enrollment penalties. Another commenter stated that they support the timely access to prescription drugs, and these new SEPs would allow vulnerable beneficiaries access to prescription drug coverage to become effective the first of the month following the month the plan sponsor receives the enrollment request. One commenter stated that they support policies that promote enrollment alignment across Medicare Parts A, B, C and D. Another commenter stated that their priority is to improve beneficiary experience by reducing confusion and to align program dates within Medicare or between Medicare and Medicaid. They further stated that this will provide Medicare beneficiaries with the opportunity to learn about and enroll in MA special needs plans (SNPs). The commenter added that an ongoing issue for beneficiaries and stakeholders is the lack of understanding of the availability of SNPs, and that this will provide another opportunity for CMS to provide beneficiaries with the very important choice of fee-for-service vs. MA, and MA vs. SNPs. Response: We thank the commenters for their support of our proposal to add corresponding exceptional condition SEPs for MA and Part D enrollment to align with the new Medicare premium Part A and B exceptional condition SEPs. Comment: One commenter expressed that, under the new requirements, a Part D plan would not know the date the applicant submitted their application to the SSA. Accordingly, they requested CMS to clarify how the start of the SEP factors into a plan processing an enrollment request using the SEP. Response: Per current practice, the MA or Part D plan would need to confirm that the individual had enrolled in premium Part A and/or Part B, as applicable,
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start of the SEP factors into a plan processing an enrollment request using the SEP. Response: Per current practice, the MA or Part D plan would need to confirm that the individual had enrolled in premium Part A and/or Part B, as applicable, prior to the individuals MA or Part D enrollment effective date. The SSA will have to first process the individuals premium Part A and/or Part B application and submit that information into SSA systems, which, in turn, would be populated in the CMS enrollment systems, for an MA or Part D plan to have access to that enrollment information. For MA enrollment, the SEP begins when the individual, using an exceptional condition SEP, submits their application for ++ PremiumPart A and Part B; or ++ Part B only, if the individual is already entitled to Part A, (or enrolls in premium-free Part A within the timeframe for use of this SEP). For Part D enrollment, the SEP begins when the individual, using an exceptional condition SEP, submits their premiumPart A or Part B application. We note that the timeframe for use of both of these SEPs extends two months beyond the premiumPart A and/or Part B entitlement date, which will be visible to plans. Comment: A commenter stated that, although they support CMS policy intent with this proposal, with increased prescription coverage for beneficiaries, this will likely exacerbate current reimbursement challenges at the pharmacy counterwhere pharmacies are being paid below costs for many of the prescriptions they purchase and dispense. Another commenter suggested VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00018 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222137 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations that CMS consider creating an SEP that would allow cancer patients to switch back to Original Medicare, in the case where a patient in an MA plan receives a cancer diagnosis and is unable to access needed treatment in a timely manner. The commenter also recommended that CMS create an ongoing open enrollment window for patients diagnosed with cancer,