Authors: Elexa Rallos and Tyler Overstreet Cromer
On August 26, 2021, the Supreme Court struck down the administration’s temporary moratorium on evictions in communities with high levels of COVID-19 infections. This moratorium suspended evictions in over 90 percent of counties across the United States. This decision jeopardizes millions of tenants who have struggled to afford housing during the COVID-19 pandemic, including older adults.
This ruling puts low-income seniors at risk by forcing them to find more crowded alternatives to housing, such as housing with relatives or shelters. These settings exacerbate risk for COVID-19 by increasing exposure to infected individuals, as well reducing ability to social distance.
As the healthcare system continues to care for older adults amidst the COVID-19 pandemic, more attention is being directed to the importance of access to housing, as well as other social determinants of health (SDOH). While many older adults currently own their own homes, it is estimated that 23 percent of this population will rent their home by 2035.
Of those who rent, 2020 data on housing demonstrate that a higher proportion of Black and Latinx renters were cost burdened during the pandemic. These groups are especially vulnerable as they face even higher risk of COVID-19-associated hospitalizations. Furthermore, new research published in the American Journal of Epidemiology, suggests that termination of eviction moratoriums during the pandemic resulted in increased incidence of COVID-19 cases, as well as increased mortality due to COVID-19. This threat to older adults, particularly for vulnerable groups within this population, accentuates the need to provide housing to older adults during the pandemic.
In response to the court’s decision, the Centers for Medicare and Medicaid Services (CMS) released a memo on August 27, titled “Reminder About Rental Support and General Supports for Living as Special Supplemental Benefits for Chronically Ill Enrollees,” offering guidance to Medicare Advantage (MA) plans. The memo cites two authorities: Special Supplemental Benefits for the Chronically Ill (SSBCI) and the Value-Based Insurance Design Model (VBID) as opportunities to offer rental supports to members.
By issuing this memo, CMS has signaled support for plans to use available authorities to support the health of their members during this unprecedented time. We know there is need, particularly in the low-income Medicare population, many of whom qualify for both Medicare and Medicaid as “dual eligible” individuals (Figure 1). There are currently 12 million dual eligible individuals and well over half of this group rents their home.
So, what exactly does this mean? Should we expect MA plans to fill the gap for rent shortfalls? The answer is that plans do have some limited authority and funding that can help with housing needs, but this is not a fix all. This is a targeted tool that can be used to alleviate some immediate, short-term needs to help improve or maintain the health and function of individuals with complex chronic illness, social determinants of health housing needs, and/or dual status. If a plan member fits these definitions, the available authorities should allow a plan to provide limited rental support. But it is a multi-step and nuanced process to add benefits, and it is yet to be seen if any plans will add these benefits to help members avoid evictions.
Both of these authorities are relatively new: Congress created SSBCI through the passage of the Bipartisan Budget Act of 2018 and MA plans first implemented SSBCI in 2020. SSBCI allow for additional flexibility to offer new, non-medical benefits in Medicare, however, recipients of these benefits must meet a three-part definition of “chronically ill”, including diagnosis of one or more complex chronic conditions. VBID was first introduced by CMS’ Innovation Center in 2017 and, similar to SSBCI, allows plans to offer new benefits to their members based on diagnosis of a chronic condition and/or (unique to VBID) socioeconomic characteristics. Benefits must have a reasonable expectation of improving or maintaining the health or overall function of the enrollee and must be paid for out of limited rebate or premium dollars.
SSBCI authority allows plans to offer new benefits that are not primarily health-related, including the benefit “General Supports for Living,” also called “Transitional Supports.” CMS’ 2019 guidance to plans on SSBCI clarified that this benefit may include “…plan-sponsored housing consultations and/or subsidies for rent or assisted living communities. Plans may also include subsidies for utilities such as gas, electric, and water as part of the benefit.”
One example of General Supports for Living, offered by Anthem MediBlue Lung Care (HMO C-SNP) of Nevada, is their “Transitional Care” benefit and is available following discharge from an inpatient stay or skilled nursing facility. The benefit allows for up 10 days at a contracted assisted living facility to serve as a transition prior to returning home. The plan’s Evidence of Coverage document also outlines additional criteria for flexibility, “such as having temporary unsafe housing, no companion, qualifying health situation/condition, and [no] substance abuse.”
Now available for two years in Plan Year 2021, more plans are choosing to offer General Supports for Living as an SSBCI. In Plan Year 2020, only 67 Medicare Advantage plans chose to offer this benefit. However, in Plan Year 2021, this number more than doubled to 150 Medicare Advantage plans. Major insurers offering this benefit in 2021 include Humana, in 77 of their Medicare Advantage products, and Geisinger Health Plan, in 42 of their plans (Figure 2).
While this growth is expected to continue into Plan Year 2022, CMS’ guidance offers plans additional flexibility to offer this benefit sooner than January 1, 2022, or the start of the new plan year. The guidance specifies that plans can utilize mid-year benefit enhancements, made available last year through the public health emergency, to offer this benefit without having to wait for the new plan year. Plans choosing to employ this authority must demonstrate that their change is related to COVID-19.
Through their guidance, CMS has signaled that MA plans may leverage available authorities to support their enrollees’ non-medical needs, specifically rental supports. As the healthcare system continues to navigate the public health emergency, especially through the emergence of the Delta variant, Medicare Advantage plans should utilize available flexibilities to support their members’ full health needs and prevent risk of infection. Providing help with rental supports and access to housing is an especially critical need, given the status of evictions. CMS should continue to support Medicare Advantage plans in their efforts to meet member needs, including needs related to social determinants of health, and provide plans the flexibility to do so.
For more information on Special Supplemental Benefits for the Chronically Ill, including ATI Advisory’s research on these, and other non-medical, benefits, see our Advancing Non-Medical Supplemental Benefits in Medicare Advantage landing page.