Responding to CMS’ New COVID-19 Waivers for Medicare Advantage


Four tactical considerations to ensure your pandemic reaction is expedited, purposeful, and meaningful.

Sarah Snider, Scott Ptacek, Lindsay Knable, and Martin Graf

4 min read

Editor’s Note: The following article is part of an ongoing series offering our strategic advice and expertise on what healthcare industry stakeholders should do immediately in response to the rapidly evolving novel coronavirus (COVID-19) pandemic.

The COVID-19 pandemic is a time to focus on patients, not paperwork. On March 30, The Centers for Medicare & Medicaid Services (CMS) announced several temporary regulatory waivers. These waivers are designed to improve care access for Medicare beneficiaries and unburden providers and Medicare Advantage plans in delivering this care. CMS has retooled existing regulations or previous guidance to help better meet Medicare beneficiaries’ unique needs amidst COVID-19.

Eighty-five percent of reported COVID-19 cases nationwide involve adults over age 60, with 45 percent over age 80. CMS’ changes are a critical first step to better care for the vulnerable senior population, given that COVID-19 affects their health disproportionately. 

What Does CMS’ Announcement Mean?

We believe several aspects of the recent regulatory changes will critically shape how Medicare Advantage plans operate throughout 2020. We expect CMS will offer more detail via formal guidance to Medicare Advantage Plans in the coming days and weeks. In the meantime, changes have been focused on three key areas: benefits, audit reviews, and the Stars program.

Effective immediately, plans can introduce additional flexibility into their previously-filed benefits to foster better care access for members. This includes the ability to waive/reduce co-payments across both Parts C and D, relax refill restrictions for Part D drugs, and introduce telehealth benefits if not already offered.

CMS is also reprioritizing planned program and Risk Adjustment Data Validation (RADV) audits so plans can focus more on patient care.

Regarding the Stars program, both Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data submission requirements in 2020 have been eliminated. Instead, last year’s results will be re-used in the upcoming Stars calculations for 2021. Furthermore, the annual Health Outcomes Survey (HOS) has been delayed until at least late Summer.

An Action Plan for Medicare Advantage Plans

Two core principals underpin our recommendations on next steps for Medicare Advantage plans: (1) do the right thing to keep your members physically and mentally healthy in this tough time, and (2) shift and repurpose resources from other areas to focus on member support and prepare the business for potential challenges ahead.

Here are four tactical considerations:

  1. Re-evaluate and redirect your HEDIS and Risk Adjustment (RA) efforts considering measurement changes to amplify your response’s impact. Program changes create greater certainty around what 2021 Stars results will be and greater uncertainty for future years considering the sharp decline in in-person evaluations and encounters. Stars and RA teams are often recalibrating their efforts with the submissions calendar. Empower your leaders now to re-evaluate your position and approach given the broader business context.
  2. Mobilize a task force to rapidly assess and implement your benefit flexibility. Implementing a new telehealth program, relaxing prior authorization and refill requirements for certain Part D drugs, and making copay adjustments all require thought, financial modeling, and time to implement.  However, time is of the essence. These moves can have a big impact on members. Just like how Medicare Advantage organizations rally around fourth quarter HEDIS data collection, organizations must urgently act on new flexibilities.
  3. Lean into virtual care. As of the 2020 plan year, Medicare expanded the number and type of services Medicare Advantage plans could offer under telehealth. However, given this was the first year of that policy change, many Medicare Advantage plans had not yet taken advantage of this opportunity. The current environment, with members more wary of leaving their home – even for healthcare services – necessitates a material shift in how Medicare Advantage plans view and utilize virtual healthcare. Expanding telehealth provides a huge opportunity for preventative care, ongoing chronic disease management, early diagnoses of potentially serious acute conditions (including COVID-19), and the promotion of critical data collection needed for risk adjustment, encounter submissions, and HEDIS reporting.
  4. Communicate. The Medicare population is vulnerable in light of COVID-19, and challenges with loneliness and isolation can be particularly acute in seniors. One in four people over age 65 have no one living nearby to support them. Medicare beneficiaries are also less likely to “pull” communications or resources than their pre-65 counterparts. Creating a set of virtual resources is great but Medicare Advantage plans must bridge the digital divide to ensure these resources reach Medicare Advantage members. Multichannel communications and outreach are key – connect with members via email, text or even more “old-school” tactics like mailers, physical newsletters, refrigerator magnets, and outbound phone calls. Make all messages simple, clear, and bite-sized. Communications should be “campaign-like” rather than one-off, and speedy – this is a crisis and timely, purposeful communication is critical.

Individual Medicare Advantage is a segment driven by the customer voice in how it is sold, utilized, and rated through programs like Stars. How Medicare Advantage plans react and what they do (or don’t) say will shape impressions​, public perception, brand value, and eventually operational metrics such as HOS and CAHPS scores. Acting with a delicate balance of speed and purpose in reaction to CMS’ regulation relaxations during this time of chaos, uncertainty, and anxiety will help the industry navigate COVID-19 with grace, focus, and clarity.  

  • Sarah Snider,
  • Scott Ptacek,
  • Lindsay Knable, and
  • Martin Graf