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Latest news and updates about the Medicare and pharmacy industries.

Medicare Advantage: What’s Changed for 2021

Posted on August 27, 2020 by Amplicare Team

Over the past few months, the Centers for Medicare and Medicaid Services (CMS) have released updates to the Medicare Advantage (MA) and Part D programs for the upcoming year. MA plans have become more popular among patients in recent years with enrollment increasing about 9% between 2019 and 2020. These plans now account for about 36% of all Medicare beneficiaries. 

The recent updates from CMS cover new flexibilities driven by the current health climate as well as other changes designed to provide better care to patients. With the Medicare Open Enrollment period up ahead, understanding what has or will be changing next year is important for pharmacists helping patients navigate their options this fall. Below, we outline some of the major plan changes this year.

COVID-19 Updates

As COVID-19 spread across the U.S., CMS made updates to some of its rules to help MA plans better address patient needs during the crisis. For instance, plans were able to expand telehealth services (which will be discussed later) and waive or reduce cost sharing for these services. MA plans are required to cover the cost of COVID-19 laboratory tests in full for patients and will also waive cost sharing for a vaccine and the administration of a vaccine once it becomes available. In addition, plans are allowed to expand or offer additional benefits such as transportation or meal delivery service coverage to help patients maintain social distancing during the pandemic. 

Telehealth Services

Last year, CMS expanded telehealth coverage for seniors, but the effects of the pandemic have led to an even greater expansion this year. In fact, Forrester estimates that there will be more than 1 billion virtual healthcare visits in the U.S. this year with 900 million due to COVID-19. The convenience of these services make them a good option for patients adhering to social distancing measures or in areas with limited access to healthcare professionals. 

As a result, CMS has implemented measures to improve access to telehealth services for Medicare beneficiaries. Specifically, patients enrolled in MA plans can access additional benefits not provided under Medicare-Fee-for-Service, which allows patients to receive healthcare services from home. MA plans can also cover a wider range of telehealth services than before, including specialists for primary care, psychiatry, cardiology, and dermatology. 

Benefits for ESRD Patients

Starting in 2021, patients with End-Stage Renal Disease (ESRD) will be able to enroll in Medicare Advantage plans under the 21st Century Cures Act requirements. Currently, these patients may only enroll in MA plans under limited circumstances. CMS noted that the new rule will provide patients with ESRD “access to more affordable Medicare coverage choices and extra benefits such as transportation and home-delivered meals.”

Supplemental Benefits for Chronic Conditions

CMS also finalized a modification to its Special Supplemental Benefits for the Chronically Ill (SSBCI) guidance. For the 2021 contract year, CMS is loosening the restrictions around what chronic conditions a patient must have in order to be eligible under SSBCI. Medicare plans will be able to target other chronic conditions that may not meet the definition outlined in the Medicare Managed Care Manual. 

Options for Rural Residents

In addition to increasing telehealth options for Medicare beneficiaries, CMS has also finalized other rules targeted to improving care for those living in rural areas. It reduced the required percentage of beneficiaries that must reside within maximum time and distance standard to 85%. The requirement was previously 90%. The change would help MA plans build networks in rural areas and expand options for beneficiaries. 

Targeting Opioid Use

The opioid crisis continues to be an issue in the U.S., even as attention this year has shifted to addressing the novel coronavirus pandemic. Data from the CDC earlier this year showed that drug overdose deaths in the U.S. reached 72,000 in 2019, and had risen 13% year-over-year by July of this year. As part of its efforts to fight the opioid crisis, CMS is requiring Part D plans to educate patients on the risks of opioids, alternative pain treatments, and how to safely dispose of medications. It also expands drug management and medication therapy management programs. 

Aside from the benefits listed above, CMS has also made notable changes to data collection requirements, Star Ratings for 2021 and 2022, as well as providing additional flexibility for Medicare appeals. 

When helping patients compare plans this upcoming Open Enrollment, knowing the major changes to the plans can help with guiding patients toward a more informed decision. Amplicare can help you perform comprehensive plan comparisons for patients that take into consideration medication history, doctor networks, and formulary changes. To learn more about Amplicare’s plan comparison platform, don’t hesitate to reach out to us


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