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HHS Gets Emergency Medicare Advantage Provider Network Change Authority

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Alex Azar II testifies at a House Education and the Workforce hearing on HHS priorities. (Photo: House Education and the Workforce Committee) Alex Azar II testifies at a House Education and the Workforce hearing on HHS priorities. (Credit: House Education and the Workforce Committee)

The head of the U.S. Department of Health and Human Services (HHS) now has the authority to let a Medicare Advantage plan’s enrollees seek care out of network, if he believes that’s necessary to help an area cope with the Covid-19 pneumonia outbreak.

President Donald Trump included a provision giving HHS Secretary Alex Azar II that authority today, in the new proclamation declaring a national emergency concerning severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes Covid-19.


The main effect of the proclamation is to give the HHS secretary the emergency powers described in Section 1135 of the Social Security Act (SSA).

SSA Section 1135 gives the HHS secretary the authority to waive many different federal requirements to make sure that people in Medicare, Medicaid and other government programs can get health care in an area affected by a national emergency.

Most of the provisions of SSA Section 1135 relate to the federal programs’ relationships with the providers.

One provision, for example, lets the HHS secretary ease Health Insurance Portability and Accountability Act (HIPAA) health information privacy rules.

Another provision lets the HHS secretary have federal programs pay licensed health care providers for services delivered outside the providers’ states of licensure.

One provision affects administration of the Medicare Advantage program.

Section 1135(b)(6) lets an HHS secretary temporarily let Medicare Advantage plan enrollees in an emergency area get health care items and services out of network.

“To extent possible, given the circumstances, the secretary shall reconcile payments made on behalf of such enrollees to ensure that the enrollees do not pay more than would be required had they received services from providers within the network of the plan,” according to the provision text.

The provision may simply reflect what would have happened in hard-hit areas, anyway: Many health insurers have already said that they plan to ease provider network rules for Medicare plan enrollees seeking SARS-CoV-2 testing and care.

— Read State Regulators, Health Insurers Muster for Coronavirus Fight, on ThinkAdvisor.

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