Medicare Advantage (MA) Plans are seeking opportunities to enhance preventive and wellness services to improve the management of their members’ chronic conditions.
Older adults and persons living with disabilities make up the largest Medicare beneficiary population and are among the nation’s most vulnerable and costly populations affected by chronic disease.
Offering evidence-based programs can increase member awareness, support self-management activation, and build skills that address healthy diet, smoking, and physical activity.
Over the past few years, Medicare Advantage plans have been granted increased flexibility to provide targeted benefits to beneficiaries with chronic illnesses through Special Supplemental Benefits for the Chronically Ill (SSBCI). Established in 2019, the goal of SSBCI is to allow for additional services that address the social and environmental factors of health for patients and caregivers with complex needs.
The initial revision expanded “primarily health related” supplemental benefits to include many services offered by community-based organizations in the aging network. In the past, supplemental benefits were required to be “primarily health related” and only included items or services to prevent, cure, or diminish an illness or injury. The 2019 change increased the scope of “primarily health related” supplemental benefits to include the following items and services: Services or items that are used for diagnosis; services or items used to compensate for physical impairments; services or items that improve the functional or psychological impact of injuries or health conditions; or services or items that reduce avoidable emergency and health care utilization.
Examples of allowable benefits that meet this definition include:
- Adult day care services
- Home-based palliative care
- In-home support services
- Support for caregivers of enrollees
- Medically-approved non-opioid pain management
- Stand-alone memory fitness benefit
- Home and bathroom safety devices and modifications
- Over the counter drug benefits
Furthermore, beginning in 2020, plans were permitted to target "non-primarily health-related" supplemental benefits for beneficiaries with chronic illnesses. The expanded definition of SSBCI provided MA plans with more flexibility to address the environmental factors that impact health.
Examples of allowable benefits that meet this definition include:
- Complementary therapies
- Pest control
- Food and produce
- Non-medical transportation
- Structural home modifications
- Service dog support
- Social needs benefit
- Transitional/temporary supports
- Indoor air quality equipment and services
What does this mean for community-based organizations?
The revised policy provides greater opportunities to integrate key home and community-based services and supports into Medicare Advantage Plans. This is an important step toward addressing social determinants of health in vulnerable communities. As these benefits are considered, Medicare Advantage plans face the challenge of offering new options while balancing the cost of building complex infrastructure to deliver them. Community-based organizations with existing systems for receiving referrals, serving beneficiaries, and providing documentation can serve as contractors for Medicare Advantage plans to not only offer SSBCI, but also connect beneficiaries to a robust support network on an ongoing basis.
As the new benefit allowances are rolling out, uptake among Medicare Advantage plans is growing for some benefits and stagnant among others. For example, the number of plans that offered non-medical benefits such as meals, transportation, in-home support services, and acupuncture doubled from 2018-2020, but offerings like caregiver support and home-based palliative care remain low.1
For more detailed anaylsis, explore the following resources:
- Medicare Advantage Supplemental Benefits Grew in 36 out of 41 Categories for 2021
- Medicare Advantage Plans Offering Expanded Supplemental Benefits: A Look at Availability and Enrollment
- Expanding Supplemental Benefits In Medicare Advantage: Barriers To Adoption And Opportunities To Accelerate
- ATI Advisory: New Primarily Health-Related Benefits in 2021 Medicare Advantage Plans
5 tips to prepare for contracting with Medicare Advantage Plans for SSBCI
- Find local plans. Utilize the CMS Medicare Plan Finder or your state insurance bureau to identify Medicare Advantage Plans in your community, including Special Needs Plans and Managed Long-Term Services and Supports Plans.
- Understand the timeline. Medicare Advantage Plans will need to submit a “Notice to Provide Supplemental Benefits” in January of each year. Similarly, Medicare Advantage Dual Eligible Special Needs Plans will need to submit “Model of Care” documentation, including supplemental benefits, in January or February of each year.
- Be informed. Utilize the NCOA video, Improving Quality of Life and Health Care Outcomes Through Chronic Disease Self-Management Education Programs, to provide national outcomes data that supports the value of evidence-based programs to improve quality of care and quality of life metrics for aging consumers.
- Demonstrate need. Share information from your community needs assessment or annual plan to support the need for considering inclusion of specific supplemental services in plan benefit packages. Gather information about the Star Ratings for plans in your market, so you can determine how to promote your programs to address gaps for the plans. To qualify as a MA Plan, private plans and insurers must meet stringent Medicare guidelines and they must demonstrate their ability to achieve adequate Medicare star rating quality and performance metrics. For example, there are specific prevention measures that targeted health plan members living with diabetes must meet each year.
- Show satisfaction. Share satisfaction statistics from your program surveys to demonstrate the high level of consumer satisfaction for those enrolled in evidence-based programs or other applicable services. MA Plan members are surveyed annually. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is administered by independent organizations approved by CMS. Those CAHPS measures most likely to be impacted by evidence-based programs include:
- Provider support for managing chronic conditions;
- Provider/consumer communication;
- Health promotion and education;
- Falls prevention and post falls assessment/referral;
- Health status and functioning; and
- Help taking prescribed medications
1. Medicare Advantage Plans Offering Expanded Supplemental Benefits: A Look at Availability and Enrollment. Found on the internet at https://www.commonwealthfund.org/publications/issue-briefs/2021/feb/medicare-advantage-plans-supplemental-benefits