Improving the lives of 10 million older adults by 2020 | © 2019 National Council on Aging

CONNECTING THE DOTS: MEDICARE ADVANTAGE PLANS

AND THE SDOH FRONTIER

Sharon Williams, Williams Jaxon Consulting, LLC

Lauren Driscoll, Leavitt Partners

Marisa Scala-Foley, National Association of Area Agencies on Aging

June 4, 2019

Improving the lives of 10 million older adults by 2020

Connecting the Dots: Medicare Advantage Plans and the SDoH FrontierJUNE 4, 2019

Agenda

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Medicare Advantage Plans and the SDoH Frontier

1. Medicare Advantage Financial Drivers

2. Supplemental Benefits

3. Vendor Platforms

4. Early Activity

Medicare Advantage Financial DriversSECTION 1

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Financial Drivers – Bid Terminology

Benchmark Bid

Rebate Supplemental Benefits

Star Ratings Risk Adjustment Factors

CMS’s estimated capitation rate roughly based on cost of providing Medicare FFS basic benefits (part A & B services) in a given county

A plan’s estimate of the cost to provide the Medicare basic benefits (parts A & B)

The savings achieved by the plan (the difference between the Benchmark and the Bid) adjusted by star rating factor of between 50 and 70%

Additional benefits beyond the required Basic Benefits (Parts A & B)

Quality scores that entitle higher quality plans to a 5% bonus and a higher % (65-70%) of their rebate. Conversely, lower quality rated plans receive a lower % (50%) of their rebate

Factors applied to the Benchmark and the Bid to adjust for the risk of plan’s particular population

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Financial Drivers – Bid Mechanics

MA plans submit bids in early June to CMS representing what it costs them to cover all Medicare Part A and Part B benefits, except hospice (“basic benefits”). The bid is compared to a county specific “benchmark.”• If a plan’s bid is above the benchmark, then the plan receives a base capitation rate equal to the benchmark from

CMS, and the enrollees pay a basic premium that equals the difference between the bid and the benchmark• If a plan bid falls below the benchmark, the plan receives a base rate equal to its standard bid and also receives

payment from Medicare in the form of a “rebate” - which the plan must then return to its enrollees in the form of “supplemental benefits”

Source: MedPac 2018: “The Medicare Advantage Program: Status Report”

Country Bid Mechanics

Bid Below Benchmark Bid Above Benchmark

County Benchmark

$850 $850

Plan Bid $750 $900

Savings (Premium)

$100 ($50)

Rebate % 65% n/a

Rebate $65 n/a

Comment Rebate used to enhance benefits Seniors pay premium

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Financial Drivers – Significant Variation by County

Source: KFF 2018: “A Dozen Facts About Medicare Advantage”

County economics, among other factors, drive MA penetration

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Financial Drivers - Key Take-Aways

While certain MA plans within specific markets may have similar offerings,• The lower a plans bid relative to the benchmark, the more supplemental benefit “dollars” it has to

spend

• The higher a plan’s star ratings and the more accurate the risk adjustment factors, the more successful the plan is likely to be and the higher their rebates will be – affording more supplemental benefits

• Inevitably these mechanics create a virtuous circle OR a downward spiral

Every plan chooses which supplemental benefits it will offer, given its rebate, and its view of the benefits relative value in attracting membership and managing medical costs

BOTTOM LINE: All plans are not created equal

Supplemental BenefitsSECTION 2

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Supplemental Benefits - Categories

All supplemental benefits must be “primarily health related”

• Not covered by FFS Medicare• Incurs a “non-zero medical cost”• If zero premium plan, no cost to

member• If premium, all members pay

premium and are eligible for same benefits

• Not covered by FFS Medicare• Sold as a rider to those

members who choose to purchase

Mandatory Supplemental Optional Supplemental

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Supplemental Benefits – What’s New for 2019?New, expanded definition of “primary health related” benefits• “Used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological

impact or injuries or health conditions, or reduces avoidable emergency and healthcare utilization” (vs. old definition of “prevent, cure or diminish illness or injury.”

New Uniform Flexibility benefit option• Plans may provide reduced cost sharing or additional benefits for members with certain disease states (e.g.

eye exam for diabetics)

• 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 & Bathroom Safety Devices & Modifications”

• Transportation• Over-the-Counter (OTC) Benefits

Examples provided by CMS guidance

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Supplemental Benefits – What Happened in 2019

Examples of Supplemental Benefits Categories

Number of Plans Offering Benefits

Nicotine Replacement Therapy

1,653

Caregiver Support Services 429

In-home Support & Personal Care Services

107

Social Worker Phone Line 80

Adult Day Care 26

New Supplemental Benefit Offerings in 2019

Examples of Anthem’s Additional Annual Benefits

Up to 16 home delivered “healthy’ meals per health event, or no more than 64 meals per year

Up to 60 one-way trips per year to health-related appointments or other covered services

Up to 124 hours of support from a home health aide or similar assistance

A $500 allowance for safety devices such as shower stools, reaching devices, or temporary wheelchair ramps

Up to 1 visit per week for adult day services

Up to 24 acupuncture and/or therapeutic massage visits

Examples from Anthem 2019

Source: Avalere 2018: “Medicare Advantage Beneficiaries Will See a Jump in New Supplemental Benefit Offerings in 2019”

Source: Forbes 2018: “What a Medicare Medicare Advantage Personal Care Benefit Looks Like”

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Supplemental Benefits – New for 2020

Special Supplemental Benefits for the Chronically Ill (“SSBCI”)

As long as benefit has “a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic disease,”Special Supplemental Benefits for the Chronically Ill (SSBCI)

• May also encompass benefits that are not primarily health related,• May be offered non-uniformly to eligible chronically ill enrollees

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Supplemental Benefits - SSBCI

Has one or more comorbid and medically complex chronic conditions that is life threatening or significant limits the overall

health or function of the enrollee

1

Has a high risk of hospitalization or other adverse health outcomes

Requires intensive care coordination

2

3

Examples of possible SSBCIThree Pronged Definition of “Chronically Ill Enrollee”

• Meals (beyond a limited basis)• Food and Produce• Transportation for non-medical

needs• Pest control• Indoor air quality equipment and

services• Complementary therapies• Services supporting self-direction• Structural home modifications• General supports for living

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Supplemental Benefits – Guidelines Relating to CBO’s

As pertaining to SSBCI Plans• Must coordinate with existing community services• Must incur a non-zero medical cost, and may not classify coordination of otherwise

available community services as benefits if not covered and paid for by plan• May use SDOH in determining eligibility as long as a member also meets the 3 pronged

definition of Chronically Ill

Community Organizations can also help determine if an individual meets the eligibility requirements

Vendor PlatformsSECTION 3

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Vendor Platforms

Software vendors are offering tools to plans, providers and community organizations to coordinate interventions addressing social determinants of health

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Vendor Platforms – NCOA Benefits Checkup

Early Activity SECTION 4

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Early Activity

Kaiser Permanente health plan joins forces with Unite Us to launch Thrive Local, a social health network to connect healthcare and social services providers

Blue Cross Blue Shield Institute partners with Solera Health partners to tackle social determinants nationwide

Healthfirst teams up with NowPow to connect its nearly 1.4 million members to needed social services and community-based resources

HCSC with BCBS Association launches plan to expand food delivery with foodQ in Chicago and Dallas to address social determinants

Smart on Value

www.leavittpartners.com801-538-5082

Offices in Salt Lake City, Chicago, and Washington, D.C.

@LeavittPartners

Lauren M. Driscoll, Senior AdvisorLauren.Driscoll@leavittpartners.com

Connecting the Dots: Medicare Advantage Plans and the SDoH Frontier

NCOA WebinarJune 4, 2019

Marisa Scala-FoleyDirector, Aging and Disability Business Institute

n4a

Our mission

The mission of the Aging and Disability Business Institute (Business Institute) is to successfully build and strengthen partnerships between community-based organizations (CBOs) and the health care system so older adults and people with disabilities will have access to services and supports that will enable them to live with dignity and independence in their homes and communities as long as possible.

www.aginganddisabilitybusinessinstitute.org

Our Funders Our Partners

How we help

• National resource center

• Training and technical assistance for community-based organizations (CBOs)

• CBO readiness tools

• Outreach and education to health care sector

aginganddisabilitybusinessinstitute.org

Bipartisan Budget Act of 2018 & CHRONIC Care Act• New tools and strategies to address the needs of people

with Medicare who have complex care needs

• Permanently authorizes Special Needs Plans (SNPs) which target high-need/high-risk Medicare beneficiaries (i.e., dual eligibles [D-SNPs], people with chronic health conditions [C-SNPs], people living in institutions [I-SNPs])

• Promotes integration in D-SNPs, and reduces barriers to care coordination in ACOs

• Extended and expanded the Independence at Home Demonstration, through which comprehensive primary care services are delivered at home to Medicare beneficiaries with multiple chronic conditions

• Expanded access to telehealth in Medicare Advantage plans and ACOs

Opportunities – Medicare Advantage (MA)

• Expansion of Medicare Advantage supplemental benefits• Includes flexibility to offer some types of home and

community-based services

• Called Special Supplemental Benefits for the Chronically Ill, or SSBCI

• Changes in the following areas:• Uniformity requirements

• Targeting of beneficiaries

• Definition of “primarily health-related”

2019

Changes for 2019

Old Rules New Rules

Benefit uniformity Plans must offer the same benefits to all enrollees of the same plan

Now allowed to target benefits to groups of enrollees who share certain clinical diagnoses

Supplementalbenefits

Supplemental must be “primarily health-related” which means, in part, not for the purpose of “daily maintenance”

Broader definition of the term “primarilyhealth-related”

Source: Tumlinson & Johnson. (2018). CHRONIC Care Act: Making the Case for LTSS in Medicare Advantage Supplemental Benefits. LTSS Summit, Sacramento, CA, The SCAN Foundation, 2018.

Defining “primarily health-related”

• Benefits must:• Diagnose, prevent or treat an injury;

• Compensate for physical impairments;

• Act to ameliorate the functional/psychological impacts of injuries or health conditions; OR

• Reduce avoidable emergency or health care utilization

• Cannot be “solely or primarily used for cosmetic, comfort, general use, or social determinant” purposes

• Benefits must be recommended by a licensed professional as part of a care plan

Examples of allowable types of supplemental benefits

• Adult day care services

• Home-based palliative care

• In-home support services

• Respite care

• Transportation (to doctor’s visits)

• Home modification (e.g., safety devices and modifications like grab bars, shower stools, stair treads)

• Support for caregivers

• (Meals excluded for 2019)

What are we seeing in 2019?

https://blog.aarp.org/2018/10/30/supplemental-benefits-in-medicare-advantage-whats-changing-in-2019-and-whats-not/

2020

Changes for 2020

• Expands supplemental benefits to allow benefits that “with respect to a chronically ill enrollee, have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits.”

• The Secretary may waive uniformity requirement for supplemental benefits to chronically ill enrollees

Defining “Chronically ill”

Defined by the Social Security Act (Section 1852(a)(3)(D)(ii) as someone who

1. has one or more comorbid and medically complex chronic conditions that is life-threatening or significantly limits the overall health or function of the enrollee (identified in section 20.1.2 of Chapter 16b of the Medicare Managed Care Manual);

2. has a high risk of hospitalization or other adverse health outcomes; and

3. requires intensive care coordination.

All three criteria must be met in order for someone to qualify for SSBCI.

What can be covered?

Plans can propose items or services that are:

• Are not covered by Original Medicare,

• Are primarily health-related, and

• Have a non-zero direct medical cost to the plan in furnishing or covering it.

Again, all three criteria must be met in order for a plan to be able to propose a service as a supplemental benefit in its plan benefit package (PBP).

Examples of allowable types of supplemental benefits

In addition to the examples from 2019, but not limited to:

• Meals (beyond limited basis)• Food and produce• Transportation for non-medical needs• Pest control• Indoor air quality equipment and services• Social needs benefits• Complementary therapies• Structural home modifications• Services supporting self-direction• General supports for living

Opportunities (and Advice) for Community-Based Organizations• Define your value proposition in terms of how

the services you offer address the plan’s needs/pain points

• Results, results, results

• Think about approaching MA plans with your existing health care partners

• If you have contracts with Medicaid/duals plans, approach their MA plans

• Don’t underestimate the value of retention

Resources• CY 2020 Final Call Letter: https://www.cms.gov/Medicare/Health-

Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html (select “2020 Announcement”, pp 188-192)

• April 24, 2019 CMS letter to MA Organizations on Implementing Supplemental Benefits for Chronically Ill Enrollees: https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/Supplemental_Benefits_Chronically_Ill_HPMS_042419.pdf)

• Webinar: The CHRONIC CARE Act: New Opportunities to Advance Complex Care Through Community-Clinical Partnerships: https://www.aginganddisabilitybusinessinstitute.org/resources/the-chronic-care-act-new-opportunities-to-advance-complex-care-through-community-clinical-partnerships/

• Webinar: CBO Partnership Opportunities with MA Plans: https://www.aginganddisabilitybusinessinstitute.org/resources/cbo-partnership-opportunities-with-medicare-advantage-plans/

• Policy Spotlight: New Federal Law and Rules Open Door for Integrated Care in Medicare Advantage https://www.aginganddisabilitybusinessinstitute.org/wp-content/uploads/2018/07/Policy-Spotlight-Integrated-Care-print.pdf

• The CHRONIC Care Act of 2018: Advancing Care for Adults with Complex Needs:https://www.thescanfoundation.org/sites/default/files/chronic_care_act_brief_030718_final.pdf

Questions?

For more information:www.aginganddisabilitybusinessinstitute.org

Marisa Scala-Foleymscala-foley@n4a.org

202-580-6021

Improving the lives of 10 million older adults by 2020 | © 2019 National Council on Aging

Any Questions?