CMS just released new guidance for Medicare Advantage plans’ annual application process. The new guidance shares that “primarily health related” supplemental benefits will be expanded to include many services offered by community-based organizations in the aging network.
What has changed?
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.
In the 2019 Medicare Advantage Call Letter, CMS announced that they will change the scope of “primarily health related” supplemental benefits to include the following items and services beginning with 2019 applications:
- 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;
- Services or items that reduce avoidable emergency and health care utilization.
Examples of newly 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
On April 27th, CMS provided additional details on newly allowable benefits. This guidance will be incorporated into Medicare Managed Care manual.
The Call Letter also reinterprets benefit uniformity rules. Beginning with 2019 applications, Medicare Advantage plans may tailor benefits for beneficiaries who are “similarly situated” and meet a set of clinical criteria. Starting with 2020 applications, CMS may offer waivers of benefit uniformity for benefits tailored to “chronically ill beneficiaries.” Read more about the changes to Medicare Advantage.
What does this mean for the aging network?
This new policy provides greater opportunities to integrate evidence-based programs and other key community-based services and supports into Medicare Advantage Plans.
Most Medicare Advantage Plans have already developed a Plan Benefit Package for their 2019 application, due to CMS on June 4th. However, now is the time to begin reaching out to local Medicare Advantage Plans to discuss supplemental benefits that could be included in their 2020 applications.
5 tips to keep in mind as you reach out to Medicare Advantage Plans about new supplemental benefits
- 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 2019. Similarly, Medicare Advantage Dual Eligible Special Needs Plans will need to submit “Model of Care” documentation, including supplemental benefits, in January or February 2019.
- 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 2020 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.
- 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.