What Changes When a Plan Replaces Original Medicare

Answer first: the benefit floor is fixed, and the delivery rules are not

The basic-benefits regulation states the floor without qualification. Each MA organization must provide coverage of, by furnishing, arranging for, or making payment for, "all services that are covered by Part A and Part B of Medicare" — or by Part B alone for someone entitled only under Part B — that are available to beneficiaries residing in the plan's service area. Services may be provided outside the service area if they are accessible and available to enrollees.

The definition of basic benefits in the general requirements section says the same thing from the other direction: basic benefits are all items and services, other than hospice care and, beginning in 2021, coverage for organ acquisitions for kidney transplants, "for which benefits are available under Parts A and B of Medicare," including additional telehealth benefits offered consistent with the applicable rules.

So the answer to "does the plan cover less" is that the plan cannot cover less than Parts A and B in terms of the items and services included. What differs is everything around that: who may deliver the service, whether a referral is required, what the cost sharing is, and what supplemental benefits are added on top.

The regulation also binds the plan to the same coverage-decision architecture as traditional Medicare. An MA organization must comply with CMS's national coverage determinations, with the general coverage and benefit conditions in traditional Medicare laws unless superseded by laws applicable to MA plans, and with the written coverage decisions of local Medicare contractors with jurisdiction in the geographic area. The regulation names examples — inpatient admission payment criteria, the inpatient-only designations, and the requirements for skilled nursing, home health and inpatient rehabilitation payment.

The plan types are not interchangeable

The regulation's taxonomy is narrower than the marketing vocabulary. An MA plan may be a coordinated care plan, a combination of a medical savings account plan with a contribution into that account, or a private fee-for-service plan.

A coordinated care plan is defined as a plan that includes a network of providers under contract or arrangement with the organization to deliver the CMS-approved benefit package. The network itself is approved by CMS to ensure that access and availability, service area and quality requirements are met. Coordinated care plans "may include mechanisms to control utilization, such as referrals from a gatekeeper for an enrollee to receive services within the plan, and financial arrangements that offer incentives to providers to furnish high quality and cost-effective care."

Under that umbrella sit health maintenance organizations, provider-sponsored organizations, regional or local preferred provider organizations, and other network plans. A preferred provider organization plan is defined by three features: a network of providers that have agreed to contractually specified reimbursement, reimbursement for all covered benefits "regardless of whether the benefits are provided within the network of providers," and, for one narrow quality-assurance purpose, an organization not licensed or organized under State law as an HMO.

Special needs plans are a subset rather than a separate type. A specialized MA plan for special needs individuals "includes any type of coordinated care plan" that meets CMS's requirements and exclusively enrolls special needs individuals, and the regulation requires National Committee for Quality Assurance approval of the plan's model of care. Chronic-condition special needs plans may focus on one severe or disabling chronic condition or on an approved grouping, and the regulation lists the permitted groupings explicitly — including diabetes mellitus with chronic heart failure, diabetes mellitus with cardiovascular disorders, and chronic kidney disease with post-transplantation status.

What the network rules require the plan to do

The access regulation permits a coordinated care plan to specify the networks from whom enrollees may obtain services, but only "if the MA organization ensures that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan." It then lists what accomplishing that requires.

The organization must maintain and monitor a network of appropriate providers supported by written agreements and sufficient to provide adequate access to covered services for the population served, and that network "must include providers that specialize in behavioral health services." It must also "arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollee's medical needs."

It must establish a panel of primary care providers from which the enrollee may select. Where the organization requires a referral in most situations before a specialist visit, it must either assign a primary care provider for the purpose of making the needed referral or make other arrangements to ensure access to medically necessary specialty care. It must give women enrollees the option of direct access to a women's health specialist within the network for routine and preventive care provided as basic benefits.

The regulation sets minimum appointment wait time standards, and requires the organization to monitor access continuously and take corrective action. For primary care and behavioral health services the minimums are: urgently needed services or emergency care immediately; services that are not emergency or urgently needed but where the enrollee requires medical attention, within 7 business days; and routine and preventive care within 30 business days.

The general requirements section adds the out-of-network payment rule. An MA organization must make timely and reasonable payment for a listed set of services obtained from a non-contracting provider, including ambulance services dispatched through 911, emergency and urgently needed services, maintenance and post-stabilization care, renal dialysis furnished while the enrollee was temporarily outside the service area, and services for which coverage was denied and later found on appeal to be services the enrollee was entitled to.

What the plan must tell you, and when

The disclosure regulation requires an MA organization to disclose specified information "in clear, accurate, and standardized form" to each enrollee electing a plan, at the time of enrollment and at least annually thereafter by the first day of the annual coordinated election period.

The required content is unusually detailed. It includes the service area and any enrollment continuation area; the benefits offered with their conditions, limitations, premiums and cost sharing; and — this is the provision worth knowing about — "for purposes of comparison," the benefits offered under original Medicare. A dual eligible special needs plan must additionally provide each prospective enrollee, before enrollment, with a comprehensive written statement describing the cost sharing protections and benefits the individual is entitled to under Medicare and under the State Medicaid program.

The access disclosure is equally specific: the number, mix and distribution of providers from whom enrollees may reasonably be expected to obtain services, each provider's cultural and linguistic capabilities including languages offered by the provider or a skilled medical interpreter, any out-of-network coverage, and any point-of-service option with its supplemental premium.

The regulation also requires disclosure of the availability of the Medicare hospice option and approved hospices in the service area, including any the organization owns, controls or has a financial interest in.

When the choice can be made or unmade

The election regulation defines the windows. The initial coverage election period begins three months before the month the individual is first entitled to both Part A and Part B and ends on the later of the last day of the second month after that first month of entitlement, or the last day of the individual's Part B initial enrollment period.

Beginning in 2011, the annual coordinated election period for the following calendar year runs October 15 through December 7. During it, an individual eligible to enroll may change from a plan to Original Medicare, from one plan to another, or from Original Medicare to a plan; someone moving to Original Medicare may also elect a stand-alone drug plan.

For 2019 and later there is a separate open enrollment period for people already in a plan: once during the first three months of the year, an enrollee may switch to another plan or disenroll to obtain Original Medicare, with a coordinating Part D election permitted. A newly eligible individual enrolled in a plan gets a comparable one-time change during the period beginning the month of entitlement to both parts and ending on the last day of the third month. Institutionalized individuals are not limited in the number of elections they may make, with a defined end point once they cease to reside in a qualifying long-term care setting.

Special election periods exist outside those windows. The regulation lists them, beginning with contract terminations and plan discontinuations, and covering an individual who becomes ineligible to remain enrolled because of a change of residence out of the service area — while excluding terminations resulting from failure to make timely premium payment or from disruptive behavior. A further special election period, requiring CMS approval before use and a CMS-operated election mechanism, is available where the individual demonstrates that the organization substantially violated a material provision of its contract in relation to that individual, including failure to provide medically necessary covered services on a timely basis or failure to provide services in accordance with applicable quality standards.