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Medicare Advantage Organization (MAOs) Response to National Emergency Legislation

By Jan Elezian, Michael Kotch, & Kristine Tomzik


Background. When President Trump declared a national emergency under the National Emergencies Act (March 13, 2020) the Health and Human Services (HHS) Secretary then declared a public health emergency under Section 319 of the Public Health Service Act. These declarations put into motion Section 422.100(m) of the Federal Register, which specifies special requirements that Medicare Advantage Organizations (MAO’s) must follow during a declared disaster or emergency.

In response to the Novel COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) has issued a temporary mandatory waiver of some Medicare Advantage requirements designed to:

  • Ensure medical facilities have the needed capacity to treat patients,

  • Remove barriers to practitioners in order to increase the healthcare system workforce;

  • Expand patient access to telehealth services;

  • Increase availability of at home and community-based diagnostic testing; and

  • Provide temporary relief from bureaucratic paperwork, reporting and audit requirements.

See March 10, 2020 CMS Memo for additional actions.


These actions only apply during the national emergency and end when any of the following occur:

  • The President declares an end,

  • The HHS Secretary declares an end of the public health emergency, or

  • Thirty days have elapsed since the declaration of the public health emergency, and no end date was identified. Currently the end date is set for May 15, 2020 but that could be extended.


Under the temporary mandatory CMS waiver both original Medicare and Medicare Advantage Plans 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.


SNF Coverage Special Requirements. One of the more complicated special requirements for MAOs, such as gatekeeper referrals (i.e., prior authorization), are waived in full, this includes the Skilled Nursing Facility (SNF) 3-day rule. Traditional Medicare requires a 3-day acute inpatient stay before a beneficiary qualifies for SNF coverage. This is generally consistent with most Medicare Advantage Plans, which also require a clinician “gatekeeper” to monitor medical necessity before a step down unit placement for their enrollees.


Telehealth flexibilities. In addition to Special Requirements, waiver flexibilities are available to MAOs to 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 is also now allowing MAOs to submit diagnosis for risk adjustment payments that are identified during any sessions.


Operationally, the mechanism for payment will differ, based on negotiated contracts with providers, for each MAO Plan. Auditing is likely to occur post the national emergency to determine whether coding and modifiers were submitted accurately, and MAOs should anticipate further review and reconciliation of any discrepancies.


Additional Information. CMS continues to monitor the evolution of the COVID-19 outbreak and is taking action to protect the health and safety of our nation. A toolkit has been developed by CMS and is available here. to help you stay informed on CMS and HHS materials available on the COVID-19. Please bookmark the page and check back often for the most up-to-date information.


Additional, up-to-date information for original Medicare enrollees is available here.

Medicare Advantage members, including those enrolled in Special Needs Programs (SNPs), should continue to contact their health plans for updates and instructions.

[1] https://www.cms.gov/outreach-education/partner-resources/coronavirus-covid-19-partner-toolkit [2] https://www.medicare.gov/medicare-coronavirus







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