Health Plans: Mixed Messages, Lack of Clarity Hinder MA Change Adoption

Despite high levels of interest, several roadblocks are preventing a bigger, broader rollout of new supplemental benefits, including ones related to home care, soon to be available under Medicare Advantage (MA) in 2019.

Those roadblocks, according to MA plans, include a general lack of regulatory clarity, mixed messages from federal policymakers and a tight deadline. The Centers for Medicare & Medicaid Services (CMS) first announced that certain non-skilled in-home care services would, come next year, be allowed as supplemental benefits through MA plans in April.

In the past, the Medicare Advantage program has only allocated federal dollars to private insurers offering MA plans covering standard Medicare benefits, plus a limited number of extras, such as vision or dental. The expanded benefits in 2019, however, can include services that help compensate for physical impairments, reduce the impact of health conditions or curb avoidable emergency room utilization.


For example, many of the health plans affiliated with Anthem, Inc. (NYSE: ANTM) will cover up to 124 hours annually of an in-home health aide for respite care, home-based chores and assistance with activities of daily living.

MA plans highlighted the biggest challenges they face in moving forward with the newfound supplemental benefits flexibility as part of a Long-Term Quality Alliance survey (LTQA). Released Tuesday, the survey features insights from seven different MA organizations and presents recommendations for improvement in 2020.

Washington, D.C.-based LTQA is an association of groups aimed at improving outcomes and quality of life for individuals managing functional limitations stemming from chronic health conditions. Launched in 2010, LTQA previously operated as part of now industry association LeadingAge.


AARP, Aetna, Anthem, Medicare Rights Center and the National Hospice and Palliative Care Organization are among LTQA’s diverse members.

MA plans that took part in the LTQA survey reported being enthusiastic about the opportunity to add benefits that could provide greater non-medical supports and services for members with complex care needs, according.

Regardless of whether they submitted a bid with flexible supplemental benefits for 2019, all surveyed plans reported doing or planning to do the work necessary to prepare benefits for possible inclusion in 2020 bids, according to LTQA.

Top challenges for MA plans

Only 3% of MA plans will offer in-home support services such as personal care and housekeeping in 2019, according AARP.

Three of the seven MA plans surveyed by LTQA are including flexible supplemental benefits in their 2019 bid. The plans reported offering benefits in 2019 as a pilot effort to test both the value of the new types of benefits and their capacity to target the benefits to subgroups of members.

All surveyed plans reported that the compressed timeframe for including a flexible supplemental benefit in bids for 2019 was a major challenge.

CMS issued a final call letter and final rule on April 2, providing guidance on the reinterpretation of the MA supplemental benefit provisions on April 27. MA plans had to submit bids to CMS for 2019 on June 8.

Plans that are not offering benefits in 2019 cited a lack of overall clarity as an obstacle, as well as contradictory actions taken by CMS. Indeed the rejection by CMS of benefits plans proposed based on criteria they seemingly used in preliminary discussions or in bid reconciliation was more restrictive than what was implied in the guidance documents, plans reported in the survey.

Uncertainty about how to communicate details of supplemental benefits to plan members was also a concern. Additionally, MA plans often do not maintain networks of non-medical service providers, a fact that also presented hurdles.

Plans that did include flexible supplemental benefits in their 2019 bids ended up with “fairly conservative approaches,” according to LTQA. That meant limited personal care and homemaker services, meal delivery for members transitioning from institutions, adult day services and non-emergency transportation to covered benefits.

Suggestions for 2020

One in three Medicare beneficiaries — about 20.4 million people — was enrolled in a Medicare Advantage plan for 2018, according to Kaiser Family Foundation data.

Medicare Advantage enrollment will to continue to grow over the next decade, with plans including about 42% of beneficiaries by 2028, the Congressional Budget Office projects.

MA enrollment varies greatly from state to state, with most enrollment occurring in Florida, Hawaii, Minnesota and Oregon. More than 60% of MA enrollees have access to dental benefits, while nearly 70% have access to fitness benefits, statistics that demonstrate the rising value of benefits not covered by traditional Medicare.

Also in the LTQA survey, MA plans outlined things they would like to see happen in 2020 to streamline the crafting of Medicare Advantage supplemental benefits. For instance, with more lead-time for CMS to communicate criteria in the 2020 cycle, plans would like to see detailed guidance earlier.

Plans would like to have more opportunity for creativity in structuring supplemental benefits.

Moreover, a focus on medical diagnoses as a condition for receiving non-medical services leaves out a population with functional limitations, MA plans pointed out in the survey. CMS should see if there is a better way to incorporate functional limitations to ultimately broaden scope of populations that can be served, they argued.

Medicare beneficiaries with both multiple chronic conditions and functional impairments are twice as expensive to the Medicare program than individuals who have multiple chronic conditions alone, recent data from Anne Tumlinson Innovations found.

The Bipartisan Budget Act of 2018 will further expand supplemental benefits beginning calendar year 2020, but only for enrollees with chronic conditions.

Written by Robert Holly