CMS Faces Decisions in Shaping Medicare Advantage Home Care Benefits

In a major change for the home care industry, Medicare Advantage (MA) plans have been granted new flexibility this year, which will allow them to cover non-skilled on-home services for the first time. However, it remains to be seen how much latitude the Centers for Medicare & Medicaid Services (CMS) will give insurance companies in designing these new benefits.

A new report from the Bipartisan Policy Center lays out some of the key decisions that the Centers for Medicare & Medicaid Services (CMS) still must make about how these MA changes are implemented.

One of the recent MA policy changes was announced in a call letter released by CMS in April. This allows Medicare Advantage plans to start covering non-skilled in-home services as of 2019.


But even before that April call letter came out, important Medicare Advantage policy changes had been made via the Bipartisan Budget Act of 2018, signed by President Trump on Feb. 9. These changes are the focus of the issue brief from the Bipartisan Policy Center, a nonprofit think tank based in Washington, D.C.

Specifically, the Budget Act gives MA payers more flexibility to offer non-medical health-related services and supports to people with multiple chronic conditions starting in 2020.

“This new flexibility for health plans has significant potential to provide access to non-medical health-related benefits, including those that have proved successful in keeping patients in their homes,” the issue brief states.


The goal is to short-circuit the “cycle of emergency department visits, hospital admissions, and discharges to home” that patients with multiple chronic conditions often find themselves in, which drives up costs across the health care continuum and compromises quality of life and health outcomes for these individuals.

Going forward, CMS will serve as the lead office for how provisions of this law are implemented. The Bipartisan Policy Center conducted roundtables, public events and individual interviews with current and former agency officials, Congressional staff, health plan administrators and other experts to compile its brief. These stakeholders identified a number of key questions that CMS will have to address.

One major decision point centers on the level of flexibility that MA providers will have in defining what new supplemental benefits they will offer and who is eligible for them.

“The new law opens the door to non-medical, health-related services, such as transportation, meals, and home modifications, and health plans may determine that some make economic sense and others do not,” the brief states.

CMS could collect data on costs and associated savings of providing certain supplemental benefits as part of the implementation, which would create an evidence base going forward for insurers as they design benefits packages, the brief suggests.

In terms of eligibility, CMS will have to decide whether plans will have latitude in deciding which enrollees qualify for the new supplemental benefits, or whether CMS itself will decide this.

One option would be to base eligibility on a person’s diagnoses, but insurance providers might object that this would make benefits available to people who might not need them. A more precise way to determine eligibility might be to measure a person’s ability to do activities of daily living, such as preparing meals or driving.

Despite these uncertainties about the size and scope of the new Medicare Advantage opportunity, home care companies are already taking steps to work more closely with MA insurers. For instance, major franchise company Senior Helpers recently hired a new executive to help lead its MA-related efforts.

Written by Tim Mullaney

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