Dual-Eligible Medicare Advantage Beneficiaries Have Greatest Social Determinants of Health Needs

Addressing social determinants of health is especially important for Medicare Advantage (MA) beneficiaries, as they are increasingly affected by a lack of services targeting those needs, which include access to and quality of housing, food and transportation, among other socio-economic factors.

That’s according to a recent report from Avalere Health, a Washington, D.C.-based health care consulting firm.

Narrowing down even further, dually eligible Medicare and Medicaid beneficiaries are the group most affected by a lack of services, the same report suggests.


However, the expansion of supplemental benefits covered under MA may help turn things around.

As part of the Avalere study, researchers reviewed 2015 Medicare Advantage claims and ZIP code data for more than 1.8 million beneficiaries. Their findings indicate that more than 50% of dual eligible patients live in neighborhoods where the median income is less than $30,000, compared to only about 16.3% of non-dually eligible beneficiaries.

On top of that, dual-eligibles are also more likely to live in less educated neighborhoods with higher rates of poverty.


Compared to non-dually eligible patients, dual eligibles are more likely to be young, female, disabled, minorities and urbanites, according to the report.

They are also associated with higher care needs, as they’re 2.4 times more likely to suffer from Alzheimer’s disease, and between 1.5 and 2 times more likely to suffer from heart failure and stroke.

Improving care for these patients could be important to cutting health care costs, Christie Teigland, a researcher with Inovalon Inc. and author of the report, told Home Health Care News in an email.

“Certainly patients with more complex medical needs lead to higher costs, and it is true that patients with social determinants of health such as living a lifetime in poverty tend to have higher rates of chronic conditions attributed to lack of access to healthcare, medications, clean air, healthy food, and other factors,” Teigland said.

More resources to address those needs are on the way, as the Centers for Medicare & Medicaid Services (CMS) has now expanded supplemental benefits allowed under MA plans for two years in a row. The expansions have opened the door to better address social determinants of health.

“We are seeing this already,” Teigland said. “MA plans are working hard to design new benefits packages to address social determinants of health, including transportation support, housing support, in-home caregivers, cleaning services, healthy food delivery, education, non-opioid pain management and even job training.”

In 2019, Medicare Advantage plans were allowed to offer non-medical supplemental home care benefits for the first time. In 2020, plans will have further freedom to cover benefits that “have a reasonable expectation of improving or maintaining the health or overall function” of beneficiaries with chronic conditions.

However, adoption of these benefits is discretionary.

For example, in 2019, just 3% of MA plans offered in-home support services such as personal care and housekeeping, according to AARP.

Meanwhile, at least 40% of MA plans offered some type of new supplemental benefits in 2019, Avalere previously found. By 2020, that number is expected to grow to more than 50%.

Besides expanding the MA program, CMS in April announced plans give state Medicaid agencies more flexibility in how they develop programs focused on dually eligible beneficiaries.

In general, home-based care organizations have long had their attention turned to the dual-eligible market.

“The majority of our clients are dually eligible, and we see a great deal of opportunity with this population due to the continued growth of both Medicare and Medicaid eligibility,” Hometeam CEO Randy Klein previously told HHCN.

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