From pet food to carpet shampooing — and even rides to church or a grocery store — Medicare Advantage plans, or plans that provide Medicare benefits through a private-sector health insurer, began offering nontraditional, non-health related benefits for the chronically ill on January 1 of this year.
Medicare has long covered the cost of caring for the nation’s elderly and disabled individuals — paying for surgeries, hospital stays, and prescription drugs — but new rules now allow these private-sector plans to offer benefits targeted at keeping people out of the hospital altogether.
Though it’s still too soon to know whether the benefits are leading to better health outcomes or lower overall costs, researchers say this new approach presents an important opportunity to examine links between services and outcomes.
“Anyone who has cared for a sick relative or tended to a chronic illness knows that health depends on a lot more than medical care,” said Arielle Mir, Vice President of Complex Care at Arnold Ventures. “If those wraparound services, like transportation to check-ups or home modifications to prevent falls, can help prevent avoidable hospitalizations or emergency department visits, Medicare stands to benefit.”
Arnold Ventures is partnering with Health Management Associates Inc. to study the rollout of the new benefits. The research will document plan offerings and the experiences of beneficiaries, community organizations, and health plan officials.
“We really want to bring perspective to the market response,” said Jon Blum, the managing principal of Health Management Associates. “If Congress and the public want Medicare to better coordinate with social service benefits, the ultimate question will be: Is this the best way to do it?”
Medicare Advantage plans, which currently cover about one-third of total Medicare enrollees, have historically appealed to patients primarily due to their low premiums and inclusion of hearing, dental, vision, and prescription drug benefits, none of which are included in traditional Medicare. Since they were first introduced in the late ’90s, Medicare Advantage plans were required to provide the same benefits to all plan enrollees, no matter their health status.
If Congress and the public want Medicare to better coordinate with social service benefits, the ultimate question will be: Is this the best way to do it?Jon Blum Managing Principal, Health Management Associates
The past two years saw fundamental changes to the program. In 2018, the Centers for Medicaid and Medicare Services adopted new rules that allowed plans more flexibility in the “primarily health related” supplemental benefits they could offer certain enrollees. And the CHRONIC Care Act, adopted by Congress through the Balanced Budget Act of 2018, declared that plans could offer non-medical services to members with chronic conditions beginning in 2020. The latter, called SSBCI supplemental benefits, were defined as those “that have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee.” Both of these changes opened the door for Advantage plans to begin targeting beneficiaries with a range of new benefits.
Late last year, CMS projected some 250 plans would offer SSBCI supplemental benefits in 2020, reaching an estimated 1.2 million enrollees. But CMS has not yet released updated data, and experts say that number is likely far lower.
David Lipschutz, the associate director of the Center for Medicare Advocacy, said insurers are largely still figuring out the new landscape. Plans have broad discretion in determining the types of items and services they may offer as SSBCI, as well as what is considered “a reasonable expectation.”
While coverage for a broader array of services may be seen as a net positive, patient advocates are warning beneficiaries that they are not necessarily immediately eligible for a benefit once enrolled. Information on Medicare.gov’s “Plan Finder” may not even include the full details of a benefit, and agents, brokers, or anyone else representing a plan cannot guarantee that a beneficiary will be eligible before enrollment.
“The patient has to actually call the plan to have them confirm their diagnosis to know if a service or benefit is available for them,” said Ann Kayrish, Medicare expert for the National Council on Aging.
As researchers await updated CMS data about the new benefits soon, Mir said emerging research will continue to shed light on the relationship between social service benefits and health outcomes.
“There is still a big gap between the belief that social needs impact health and a clear understanding of the most effective ways to finance and deliver social services,” she said.