Medicare Advantage plans gain expanded telehealth and ESRD enrollment

Crystal Yednak Senior Manager, Health Research Institute, PwC US May 28, 2020

Medicare Advantage plans are encouraged to expand their telehealth networks to specialty providers and enroll patients with end-stage renal disease (ESRD) under provisions of a new 2021 final rule issued by CMS on May 22.

The final rule for contract year 2021 aims to strengthen telehealth options in rural and other areas by giving Medicare Advantage plans a 10 percentage-point credit toward the percentage of beneficiaries that must reside within required time and distance standards when the plan contracts with specialty telehealth providers. Those specialties include dermatology, psychiatry, cardiology, ophthalmology, nephrology, primary care, gynecology, endocrinology and infectious diseases, according to CMS.

To boost network adequacy in some areas, Medicare Advantage plans also can reduce the share of beneficiaries from 90% to 85% that must live within those maximum time and distance standards in counties where network development can be difficult.

The rule codifies changes to payment and coverage so that people with end-stage renal disease who previously were not able to join Medicare Advantage plans can enroll starting in January 2021. Also beginning in January, kidney acquisition costs for Medicare Advantage beneficiaries will be covered by Medicare Fee for Service instead of Medicare Advantage plans, CMS said.

Most of the changes are effective January 2021, but the agency said it will address remaining issues in future rulemaking actions.

HRI impact analysis 

In the context of the COVID-19 pandemic, CMS has taken actions to help providers and plans protect high-risk populations. In particular, the agency has swept away regulations around telehealth and boosted reimbursements for visits. The telehealth changes in the final rule further encourage providers and plans to build telehealth services to protect vulnerable Medicare populations.

Under the rule, Medicare Advantage plans also gain access to a slightly larger population, as the Kaiser Family Foundation found that roughly 529,000 Medicare beneficiaries, or 0.9% of that population, with end-stage renal disease were enrolled in Medicare Part A or B in 2017. The changes mean those patients can access some of the other benefits allowed by Medicare Advantage, such as home-delivered meals, CMS notes.

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

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Crystal Yednak

Senior Manager, Health Research Institute, PwC US

Erin McCallister

Senior Manager, Health Research Institute, PwC US

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