Courtesy of the National Association for Home Care & Hospice (NAHC)

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule with comment period that finalizes two remaining proposals from the proposed rule titled “Medicare and Medicaid Programs; Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly”.

One provision that CMS finalized in this rule is a policy change related to service category cost sharing limits for Medicare Parts A and B services. Under this provision, CMS has adopted a requirement that Medicare Advantage (MA) plans must use cost sharing that does not exceed cost sharing in original Medicare for home health services for plans with a mandatory maximum out-of-pocket (MOOP) amount. The highest allowable MA plan cost-sharing limit for home health is 20 percent or an actuarially equivalent copayment which is limited to MA plans with a lower MOOP amount. MA plans that establish a mandatory or intermediate MOOP amount must establish $0 cost sharing for home health services. The provision is effective January 1, 2023.

CMS believes imposing limits on cost sharing for covered services is an important way to ensure that the cost-sharing aspect of an MA plan design does not discriminate against or discourage enrollment of beneficiaries who have high health care needs and who need specific services.

The National Association for Home Care & Hospice (NAHC) is grateful that CMS has finally adopted this policy. Home health agencies have had patients refuse needed home health services due to high co-pays that the beneficiary would not have been subject to under fee-for-service (FFS) Medicare.