The Medicare open enrollment for the 2019 plan year is October 15 through December 7th, 2018. For the first time we may see additional home care benefits offered by Medicare Advantage (MA) Plans. Two (2) recent pieces of legislation led to CMS’ recent approval of expanded MA benefits that can include private duty personal home care in 2019 and palliative care in 2020. These services represent a real opportunity for accredited private duty organizations to pursue contracted Network provider status, as well as palliative care services that earn CHAP certification in 2019.
A review of some basics about MA plans and CMS oversight illustrate the importance of these changes, and how these opportunities may present themselves to providers.
Medicare Advantage (MA) Basics:
- Medicare Advantage (MA) health plans are approved by CMS to serve a geographic area each year, as are the benefits and plan products (e.g. HMO) to be offered, the premiums they will charge, and marketing materials they will use.
- However, CMS oversight of MA plans is based on regulations that extend their responsibility beyond the annual proposal review and approval process.
- Based on quality measures, including beneficiary satisfaction, CMS awards stars to health plans each year that can equate to plan bonus payments.
- CMS also has day-to-day oversight that includes responding to beneficiary complaints and as indicated, requesting plans of correction if the MA plan is found out of compliance with federal regulation. CMS can also take overt action such as stopping a Plan’s ability to market to new enrollees.
- MA plans are paid PMPM (per member per month). The payment is based on where the member lives and their acuity established by a physical examination.
- Note, PMPM means that all MA plans carry full financial risk for the cost of care. CMS does not pay an additional amount if the cost of care is higher than anticipated in any one year – such a particularly bad influenza season.
- PMPM also means that should they spend less than anticipated, the MA plan keeps the difference.
- Both elements of risk provide a clear incentive to keep enrollees healthy.
- At a minimum, each MA plan must provide benefits equivalent to that of Medicare Fee-for-Service (FFS).
- Each MA plan can also offer “supplemental benefits” or care not covered by Medicare that is “primarily health related” and approved by CMS. These benefits must be uniform, available to all enrollees equally, and can require additional premiums and co-pays.
A good example is Anthem Blue Cross/Blue Shield’s “Essential Extras” that allow beneficiaries to buy dental and vision coverage for an additional premium each month.
What Changes in 2019 and 2020?
Greater Flexibility in MA Supplemental Benefits Offered 2019:
- As of the 2019 plan year (Jan-Dec) the definition of “primarily health related” supplemental benefits is expanded to include items and services that:
- Focus directly on an individual member’s healthcare needs.
- Are medically appropriate.
- Are recommended by a licensed provider in the Network; physician orders are not required by CMS-but the plan may require these from a Network physician, APRN, or PA.
- MA plans can now target supplemental benefits to particular beneficiary populations.
- The 2019 CMS approved MA supplemental benefits can:
- Compensate for physical impairments
- Lessen the functional and psychological impact of injuries or health conditions
- Or work to reduce avoidable emergency healthcare utilization
|Examples of Expanded 2019 MA Supplemental Benefits|
Each MA plan designs the supplemental benefits to be offered within these guidelines. Not all expanded benefits will be available in all areas that a MA plan offers coverage. Not only is insurance still state-based, the Plan also needs to consider which benefits offer the greatest opportunity to improve beneficiary health based on the profile of their enrollees.
2019 is the first year these benefits may be offered. However, CMS clarification about the change was delayed, and many MA plans may not have had the time to develop and submit the expanded benefits for CMS approval for 2019. Expect more plans to offer these in 2020.
One MA plan that secured CMS approval for 2019 is Anthem Blue Cross Blue Shield of Indiana. Below is an example of expanded benefits offered to MA enrollees.
Anthem Essential Extras Offered with 2019 MA Plan HMO Products
2020 – Supplemental Benefits Expand to Include Chronically Ill and Specific Disease States
- MA plans may target supplemental benefits to chronically ill members or those with a specific disease state for plan year Jan-Dec 2020. This further allows MA plans to target expenditure and intervention to enrollees who have greater acuity.
- The plans can submit targeted disease state benefits in 2020 proposals due to CMS in Spring 2019. CMS provides the following guidance to MA plans for 2020, and additional guidance may be forthcoming.
- Selected diagnosis(es) will need to be confirmed by an in-network practitioner
- Benefits must be medically appropriate
- Benefits offered must have the reasonable expectation of improving or maintaining health or overall function of chronically ill members, examples include:
- Delivery of home meals targeted to diabetics.
- Or palliative care to members with advanced heart disease or cancer.
The home care services paid for by MA plans in 2019 and 2020 are essentially unregulated, with limited, if any, licensure. Voluntary accreditation offers MA plans evidence that private duty organization or palliative care program has demonstrated compliance with national standards, and accountability for services that includes evaluation of care being provided to members, as well as home visits and interviews of enrollees receiving the service.
Accreditation represents a unique statement of accountability as these services emerge as providers in a changing healthcare system.