How the 1135 Waivers Impact Medicare Advantage Organizations (MAOs)


Post By:  Jan Elezian, MS, RHIA, CHC, CHPS, Director, SunHawk Consulting, LLC

Medicare is a federal health insurance program that provides health care coverage for individuals age 65 and older. The program also covers certain people under age 65 with disabilities and those with end-stage renal disease (ESRD).

Medicare consists of four parts:

  • Hospital Insurance (Part A) – This can includeinpatient care, including care received while an inpatient in a hospital, a skilled nursing facility, home health and hospice. .
  • Outpatient Medical Insurance (Part B) (Paid by the Beneficiary) – This can include outpatient care, preventive services, ambulance services, and durable medical equipment.
  • Medicare Advantage (Part C)
  • Outpatient Prescription Drug Benefit (Part D)(paid for by the beneficiary) – This includes prescription medications

“Traditional” or “Original” Medicare covers healthcare benefits under Parts A and B.  Medicare Advantage, under Part C, provides both Medicare Part A and Part B benefits to enrollees through private health plans. The Part D Medicare Prescription Drug Benefit Program refers to the voluntary outpatient prescription drug benefit that is delivered by private plans, either through a Medicare Advantage plan or as an independent prescription drug plan.

Medicare Advantage Plans must provide all enrollees, at a minimum,  all of the benefits covered under the Medicare Parts A and B. However, Medicare Advantage Plans have  more flexibility to provide additional benefits that are not normally covered under traditional Medicare such as dental coverage, eye exams and fitness memberships. Before being offered, these additional benefits must be approved through contract between the Medicare Advantage Plan and the Center for Medicare and Medicaid (CMS). CMS regularly audits Medicare Advantage Plans to ensure that all contracted benefits and no unapproved additional benefits are being provided.

In response[1] to the novel coronavirus pandemic, CMS has issued a temporary mandatory waiver of some Medicare Advantage requirements designed to: (1) ensure medical facilities have the needed capacity to treat patients, (2) remove barriers to practitioners in order to increase the healthcare system workforce; (3) expand patient access to telehealth services; (4) increase availability of at home and community-based diagnostic testing; and 5) provide temporary relief from bureaucratic paperwork, reporting and audit requirements. 

Under the temporary mandatory CMS waiver both original Medicare and Medicare Advantage Plans must cover:

  • Lab tests used to diagnose COVID-19
  • All medically necessary COVID-19 hospitalizations and outpatient services, including extended stays when a patient is placed under quarantine.
  • Temporary expansion of telehealth and related services.

If a vaccine for the COVID-19 becomes available, it will be covered under the Medicare Part D Outpatient Prescription Drug Benefit. Additional information regarding Medicare and COVID-19 may be found at

In its March 10 memo[2], CMS advised Medicare Advantage Organizations (MAOs) of special requirements and and other flexibilities available to MAOs. If the MAO chooses to offer additional benefits, for instance not charging co-pays for COVID-19 related services, they may do so without amending their contract with CMS.

MAOs must follow special requirements, as outlined in 42 CFR 422.100(m)(1) in the Federal Register, including:

  • Cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities (facilities that do not have participation agreements with Medicare)
  • Waive, in full, requirements for gatekeeper referrals where applicable. In Medicare Advantage, you typically must go to the “gatekeeper,” usually a primary care provider, who will then determine if you need to be referred for additional care.
  • Provide the same cost-sharing for enrollees as if the service was furnished at a plan-contracted facility.
  • Make changes that benefit enrollees effective immediately, without the usual 30-day notification requirements.

CMS also allows MAOs to:

  • Waive or reduce enrollee cost-sharing for COVID-19-related services, such as laboratory tests, telehealth benefits or other services to address the pandemic, as long as they do so consistently for all impacted enrollees.
  • MAOs may provide enrollees access to Medicare Part B services via telehealth in any geographic area and from beneficiaries’ homes. This flexibility is irrespective of the scope of the telehealth benefit the MA plan filed and CMS approved.
  • CMS noted that it had consulted with the Office of Inspector General (OIG), and that plans that utilized these flexibilities would satisfy the safe harbor to the federal anti-kickback statute set forth at 42 CFR § 1001.952(l). Once the pandemic has subsided, CMS will notify MAOs and Part D sponsors through the Health Plan Management System that CMS is ending its enforcement discretion with respect to such measures.

Part D sponsors are expected to relax their “refill-too-soon” edits if necessary, to ensure access to covered Part D drugs.

If enrollees cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy, plans must ensure that enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies, although enrollees will remain responsible for any cost sharing and additional charges that exceed the plan allowance, as applicable.

For enrollees that cannot physically access a retail pharmacy (e.g., because of a quarantine), Part D plans may relax any plan-imposed policies that would discourage certain methods of delivery, such as mail or home delivery, for retail pharmacies that provide such services

In the event that Part D drugs are identified to treat or prevent COVID-19, Part D sponsors may waive prior authorization, as long as they do so consistently.

If a vaccine becomes available for COVID-19, Part D plans will be required to cover the vaccine if it is a Part D drug. Otherwise, it will be covered under Medicare Part B.

Medicare Advantage members are encouraged to contact their particular health plan about coverage and costs.

Original Medicare beneficiaries may contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) for more information.

Interested readers may keep current on the novel coronavirus through these resources:

  • gov is the federal government’s source for the latest information about COVID-19 prevention, symptoms, and answers to common questions.
  • gov/coronavirus has the latest public health and safety information from CDC and for the overarching medical and health provider community on COVID-19.
  • gov has the latest information about what the U.S. Government is doing in response to the coronavirus pandemic.
    • Note: COVID-19 is the disease caused by coronavirus.

For more information about the similarities and differences between original Medicare and Medicare Advantage, please refer to the CMS booklet “Understanding Medicare Advantage” at: