ATI Contributor: Allison Rizer

Last year marked one of the most significant policy changes in the Medicare program in a very long time. In 2019, Medicare suddenly became more than the acute/post-acute, medical program it has been for more than five decades, by allowing plans to cover services that have historically been perceived as custodial and long-term care in nature. This year, the program went even further to allow social service benefits for some Medicare beneficiaries.

Spoiler alert: it was not Congress’ intent for these new services and benefits to focus on individuals dually eligible for Medicare and Medicaid (“dual eligibles”), since this population already has access to at least some of these services through their Medicaid coverage.

But Congress’ intent aside, dual eligibles still have gaps in access and not surprisingly, states are wondering how and whether to influence Medicare Advantage (MA) benefit design to fill those gaps. In particular, with budget crises and the rapidly escalating COVID19 crisis, state Medicaid agencies might look to their MA Dual Eligible Special Needs Plans (D-SNPs) to offer Medicaid-like benefits with Medicare dollars, in an effort to offload some of the pressure on the Medicaid and social service programs in a state. If not done thoughtfully, this approach could undermine the success of the new supplemental benefits and undermine state integration efforts. More detail below, but in summary: 1. states should understand MA/D-SNP benefit planning; 2. engage their D-SNP partners; and 3. inform, but not mandate, D-SNP benefit design.

What’s in the Supplemental Benefit policy details?

MA plans must cover basic benefits available in Medicare fee-for-service (FFS), but also may offer supplemental benefits: extra services not covered in FFS. Historically, supplemental benefits had to be primarily health related and non-maintenance in nature. But last year the Centers for Medicare & Medicaid Services (CMS) expanded the definition of primarily health related to include services and items that are perceived as non-skilled or custodial – benefits like in-home support services, respite care, and adult day care services. And for 2020, Congress began allowing MA plans to offer benefits that aren’t primary health related, including meals, food/ produce, rent subsidies, utilities subsidies, and non-medical transportation. These non-primarily-health-related benefits are known as “Special Supplemental Benefits for the Chronically Ill,” or SSBCI. There are guardrails around who is eligible for these new benefits and how MA plans use them, but without question, the 2019 and 2020 benefit expansions are a significant turning point in Medicare policy.

Where does Medicaid fit in?

Understandably, state Medicaid programs are interested in what these benefits mean for dual eligibles, many of whom have social and long-term services and supports needs and currently access such services through the Medicaid program. A key approach numerous states are considering is shifting some of these Medicaid services to the supplemental benefit offerings in D-SNPs.

D-SNPs require a separate contract with states, typically referred to as the “MIPPA” contract (after the legislation that mandated it) or the “State Medicaid Agency Contract” (SMAC). States have considerable latitude over the MIPPA contract with D-SNPs and can use it to limit which dual eligibles can enroll, require certain reporting and data sharing, and deploy other requirements to address a state’s Medicaid goals. And now, with the expanded opportunities available through supplemental benefits, more states are questioning whether or how to add supplemental benefit requirements to the D-SNP contract.

What should States consider?

Before state Medicaid programs add supplemental benefit requirements to their D-SNP MIPPA contracts, they need to consider the broader implications on benefit sustainability and Medicaid-Medicare integration efforts. We previously published a consensus statement on SSBCI Guiding Principles through a partnership with the Long-Term Quality Alliance (LTQA) and SCAN Foundation. And of particular importance for states: for these new supplemental benefits to succeed, they must be flexible and evolve with continuous learning as D-SNPs, providers, and members navigate this new space.

More specifically, state Medicaid agencies should keep the following five points in mind:

1.   These aren’t “new” dollars

CMS and Congress are allowing MA plans to use existing dollars in new ways – plans aren’t receiving additional funding for the new supplemental benefits. Which means MA plans and D-SNPs deploying these new benefits must take away or reduce existing benefits (e.g., traditional supplemental benefits such as dental, vision), or add a member premium (which doesn’t make sense with a dual eligible population).

2.   The scope of supplemental benefits is limited

“Value-add” is the dollar value of services offered by an MA plan, beyond Medicare FFS benefits and without an enrollee premium cost. The average value-add across MA plans and D-SNPs is small; in 2018 it amounted to $62 per D-SNP member per month and was primarily spent on vision, hearing, and dental (source). For comparison, a once-daily home-delivered meal costs nearly four times this amount, at $230 per month. Because of the limited amount of value-add dollars, supplemental benefits are just that – supplemental. They don’t replace other programs’ benefits; they complement them by filling gaps.

3.   Plans (and providers) must be able to test what works

The new supplemental benefits are an opportunity to test innovative benefit designs that address the “whole-person” – benefits that move upstream in improving an individual’s well-being (think: healthy food or socialization). But data on efficacy are limited, and data on demand and utilization are nearly non-existent. Plans need flexibility to determine what benefits are meaningful to enrollees and to understand what providers have capacity to support. And this means MA plans, including D-SNPs, may need to adjust benefits year-over-year (YOY) as they build out an evidence base for what works.

4.   D-SNPs could become less attractive than non-integrated products

States requiring DSNPs to provide specific supplemental benefits may inadvertently push dual eligibles to non-integrated products. As explained above, to afford state-mandated benefits, D-SNPs would have to reduce or eliminate other supplemental benefits that may be important to dual eligibles such as over-the-counter debit cards or dental benefits (because remember: these aren’t “new” dollars). But non-D-SNP MA plans wouldn’t be required to shuffle dollars or cut benefits, making these non-integrated products attractive to many dual eligibles. Supplemental benefits should remain flexible to ensure they can meet the needs of an MA plan’s enrollees and in the case of dual eligibles, ensure integrated D-SNP products remain competitive.

5.   Plan ability to cover benefits changes year-over-year

The amount of Medicare dollars available to MA plans (including D-SNPs) is tied to their Medicare Star Rating, county benchmark levels, prior year plan performance and other factors. The result? A D-SNP may have to reduce or eliminate benefits that enrollees have grown accustomed to. This is one reason D-SNPs may prefer cost share buy-downs to supplemental benefits, but it also speaks to the challenge of trying to mandate specific benefits.

Navigating D-SNP contracts for 2021 (and beyond)

States should not mandate specific supplemental benefits but rather, work with their D-SNPs to understand the MA benefit planning process, and determine whether there are opportunities for the D-SNPs to complement the Medicaid program specific to the individuals a D-SNP enrolls. This needs to be flexible to allow D-SNPs to meet demand and member needs, respond to the capacity of a local delivery system, and evolve as the evidence base grows.

This is an incredible turning point in Medicare policy and an amazing opportunity to provide a more holistic, person-centered set of benefits to individuals. In particular, these benefits may slow functional decline and address social need among individuals who otherwise wouldn’t have access to such services. But it’s important to remember these benefits should complement existing programs such as Medicaid and social-service programs; they cannot replace them. Collaboration and open communication between states and their D-SNP partners will be key to ensuring these benefits are successful and sustainable, and D-SNPs must maintain the ability to “test” what benefits work.

Are you curious how these new benefits are being offered? Take a look at our analysis of the 2020 benefit offerings to see which MA organizations are offering SSBCI, what new benefits are most popular, and what areas of the country are more likely to have some SSBCI coverage.

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