ATI Contributors: Tyler Cromer and Elexa Rallos
Medicare Advantage plans can now offer a wide range of diverse benefits to address the needs of the aging population, through newly expanded supplemental benefits. This expansion gives plans more flexibility to meet member needs for non-medical supports and services and to address social determinants of health. This year (2020) marks the first time that all pathways to benefit flexibility have been fully implemented. ATI will follow new developments and share our learnings and insights.
There are two main pathways available for plans to offer non-medical supplemental benefits. The pathway a plan chooses depends on 1) the type of service offered as a benefit and 2) who is eligible for the benefit. Below we describe the two pathways, what each pathway allows, and how these flexibilities create new opportunities in the Medicare program.
Pathway #1: Expansion of Primarily Health-Related Supplemental Benefits
Medicare Advantage plans have always had the flexibility to offer additional supplemental benefits that are exclusive to Medicare Advantage (i.e., not offered under traditional Medicare fee-for-service); however, these benefits can only be offered if they are “primarily health related.” Previously, the definition of primarily health related was limited to “an item or service whose primary purpose is to prevent, cure, or diminish an illness or injury.” Items largely intended for daily maintenance or comfort were restricted from being offered as a supplemental benefit under the previous definition.
In 2018 (to go into effect for Calendar Year 2019), the Centers for Medicare and Medicaid Services (CMS) expanded the scope of “primarily health related” to services that:
1. diagnose, prevent, or treat an illness or injury,
2. compensate for physical impairments,
3. act to ameliorate the functional/psychological impact of injuries or health conditions, or
4. reduce avoidable emergency and healthcare utilization
This new, expanded definition allows Medicare Advantage plans to offer supplemental benefits that are not strictly health related in nature, including services like adult day care services, home-based palliative care, in-home support services, and support for caregivers of enrollees. While this expanded definition offers new opportunities for plans, its scope is limited; most significantly, benefits must be offered uniformly to similarly situated enrollees (e.g., if a plan member with diabetes is offered a transportation benefit, that same benefit must be offered to other plan members with diabetes). Moreover, this new definition does not allow plans to offer services that are for social determinant purposes, like pest control or transportation to non-medical locations.
Pathway #2: Special Supplemental Benefits for the Chronically Ill (SSBCI)
In 2018, Congress passed the CHRONIC Care Act in the Bipartisan Budget Act of 2018, which created a new supplemental benefit category in statute. In addition to the expansion of primarily health-related supplemental flexibility (described above), Medicare Advantage plans now have even greater flexibility to offer a new set of benefits to chronically ill enrollees called “special supplemental benefits for the chronically ill,” or SSBCI.
Available for the first time in Calendar Year 2020, these benefits are unique from other supplemental benefits in that they can be non-primarily health related. This means that, for the first time, Medicare Advantage plans can cover services such as pest control, social needs benefits, indoor air quality equipment and services, and other social determinants in their benefit packages. In contrast to the expansion in primarily health related supplemental benefits, CMS has interpreted the law so that SSBCI can be offered non-uniformly (i.e., plans can tailor benefits specifically to an enrollee’s needs). While plans have broad discretion to offer a vast range of benefits under this authority, services must still “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee” and plans must be lear in how they decide which services are appropriate for an enrollee’s needs.
What Does This Mean for Medicare Advantage Plans?
These new flexibilities, expanded primarily health-related supplemental benefits and SSBCI, enable Medicare Advantage plans to:
1. Serve the needs of the complex care, aging population. By offering benefits that meet beneficiaries’ broader social needs, Medicare Advantage plans can provide holistic, high-value care to this population
2. Evaluate whether these services deliver better health outcomes. Because many of these services are new, Medicare Advantage plans can generate new evidence on the impact of health-related or non-health-related services on health. As evidence of these benefits grows, more plans may be encouraged to offer these types of benefits.
3. Form new partnerships with service providers. As plans consider which of these new benefits to offer, they have the opportunity to engage with community-based organizations and other service providers to build new relationships outside of traditional healthcare providers.
The Future of Supplemental Benefit Flexibility in Medicare Advantage
Preliminary analysis of publicly available benefit data released by CMS and press releases from major health plans reveal that a number of plans are on the bleeding edge of this new flexibility, offering brand new, innovative services for Calendar Year 2020. Nevertheless, there is limited financing available for these services within the rebate, and new benefits compete with plan dollars that are used to buy down premiums and provide the typical services many Medicare Advantage enrollees are used to receiving, like dental and vision coverage. Many plans are waiting to see what happens in this first year before they jump in.
Anne Tumlinson Innovations (ATI) is excited to see how these new supplemental benefits will be implemented in Calendar Year 2020 and to see how these benefits will continue to evolve over time. We anticipate CMS’ data release of which plans are offering these new special supplemental benefits for the chronically ill. In recognition of the need to create a foundation around the implementation of these new benefits, ATI and the Long-Term Quality Alliance convened a working group to develop a set of principles to guide implementation of SSBCI. These principles center around the core principle of meeting an individual’s needs and highlight the necessity for collaboration as these SSBCI are introduced. Read more: ‘Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill.’
For more information on Medicare Advantage supplemental benefits, contact us at firstname.lastname@example.org.