Redefining Supplemental Benefits for Seriously Ill Patients
New Medicare Advantage Policies Are More Flexible
Medicare Advantage (MA) is moving into new terrain with its ability to customize care for the needs of patients with an advanced or serious illness. For the first time, recent regulatory and legislative policy changes to MA will give plans more flexibility around matching and reimbursing for services tailored to individual member needs.
CMS “Key Reinterpretations” include a new interpretation of the type of “supplemental benefits” that MA plans can offer, including those that act “to ameliorate the functional/psychological impact of injuries or health conditions.” Examples of the types of new supplemental benefits that will be allowable include in-home support services, support for the caregivers of enrollees, and home-based palliative care.
Going forward, plans can more effectively address the root causes of frequent readmissions and emergency department visits—the need for help at home, access to palliative care services outside of hospitals and hospices, and attention to reducing the burdens of family and other caregivers. There is clear evidence that home-based palliative care can significantly reduce total spending among seriously ill
enrollees—more than compensating for the cost of the benefits.
Moreover, CMS is redefining the “uniformity” requirement so that plans may vary benefits and the degree of beneficiary cost sharing by the different needs of subsets of enrollees, provided these variations are available and accessible to all similarly situated enrollees. Consumer protections are maintained while simultaneously enabling a more person-centered approach to benefit design.
Variation is allowed not only by disease state but also by “health status,” which is anything that can be identified through International Statistical classification of Diseases and Related Health Problems, Tenth Revision codes. This includes Z codes, which designate factors that influence health status, such as needing assistance with personal care, living alone, or living with a dependent relative.
Demonstrating Value, Meeting Needs
These changes reflect a need to address the social determinants of health (SDoH) — factors that are largely circumstantial but directly correlated to the way a member approaches an advanced or serious illness. MA plans can now introduce programs, such as Home-based Palliative Care (HBPC) to provide greater insight into SDoH issues and effectively address the issues that may be driving up utilization of healthcare serves.
Specifically, supplemental benefits will offer additional services that increase health and improve quality of life, including coverage of non-skilled in-home supports and other assistive devices. CMS is expanding the definition of “primarily health related.” Under the new definition, the agency will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.
This might include in-home support services to assist with activities of daily living, such as bathing, dressing, and toileting, as well as instrumental activities of daily living, such as shopping, cooking, and housekeeping.
This also includes support for caregivers, such as respite services, counseling, training, and, importantly, HBPC. A critical aspect of this approach includes motivational interviewing around the factors that influence end-of-life decision-making. The goal is to empower patients to make decisions about their care in congruence with their personal beliefs and values. Performing home visits and providing palliative support enables patients and their families to develop their own solutions and plans for the future based upon their preferences and values.
HBPC encompasses services to diminish symptoms of members with a life expectancy of greater than six months not covered by Medicare — for instance, palliative nursing and social work services in the home not covered by Medicare Part A.
The specific mention of HBPC is critical given that CMS explicitly acknowledges the value of palliative care. This gives MA plans permission to cover it outside of acute care settings as a formal benefit.
These changes will allow plans to compete on the quality and richness of services and provide greater transparency to consumers looking to purchase MA coverage.
Plans or provider organizations that do not have the resources or capabilities to add HBPC as a supplemental benefit can now turn to a company like Turn-Key Health which convenes, trains, and manages networks of palliative care specialists. Comprised mainly of palliative care trained nurses and social workers, the teams are also augmented by nurse practitioners and physicians, where medical intervention is needed. These teams utilize an interdisciplinary approach to manage populations, meeting weekly, and drawing in community-based resources to benefit the patient and decrease caregiver burdens.