6 Steps Home Care Providers Must Take to Succeed in Medicare Advantage

The recent rule changes to Medicare Advantage (MA) from Centers for Medicare & Medicaid Services have created a level of flexibility and creativity for home care participation that is nearly unchecked.

For example, the final call letter for MA plan year 2020 notes that “MA organizations have broad discretion” in determining what’s called the “Special Supplemental Benefits for the Chronically Ill.” Among the examples of benefits: pest control.

In other words, home care’s place in MA is limited only by providers’ and payers’ imagination.


But that flexibility brings new challenges — namely in operations, relationship building and technological demands. The new HHCN report, “The New Medicare Advantage Opportunity in Home Care,” reveals the six steps home care providers must take to succeed in MA.

1. Take both a top-down and bottom-up approach to connect with payers

Most MA plans come from major insurers, yet the plans themselves vary zip code to zip code. That means in order to connect with payers, providers must take both a top-down and bottom-up approach.

Top-down can be tricky for smaller providers without national, executive-level contacts. And bottom-up is time-intensive: There were 3,100 individual MA plans in 2018, 3,700 in 2019 and there should be more in 2020.


To make these connections, Denver-based Homewatch CareGivers, a franchiser with 200 locations in six countries, built a three-pronged approach to help it serve as facilitator between its franchisees and MA plans:

— Use national contacts to learn payers’ big-picture strategies and gain national contracts

— Talk to local plans with supplemental benefits related to home care

— Talk to local plans that serve their home care clients

While the specific plan decisions must be made at the local level, the national offices can give a valuable 30,000-foot view. Homewatch’s executive team uses existing relationships in the c-suite to learn more about a given plan’s overall level of interest in home care partnerships.

They also use their institutional knowledge to guide their franchisees through existing contracts to locate the slivers of information relevant to a provider’s clients. Homewatch views handling this process as part of its value proposition to its franchisees, for whom the task of is challenging, whether due to having little to no experience working with insurers, struggles with the often opaque process of finding plans or staffing bandwidth.

2. Be prepared to educate payers on home care vs. home health care

This might sound silly, but according to a number of home care providers, major payers still struggle to understand the difference between home care and home health.

“I didn’t realize how big of a learning curve there actually was for these payers,” Kerin Zuger, vice president of business development at Right at Home, told HHCN.

To combat this problem, Zuger and the team at the Omaha, Nebraska-based franchise network — which has nearly 500 U.S. locations — created a four-page brochure highlighting home care’s value proposition within the MA framework. Right at Home then sent the brochure to the country’s biggest MA plans to introduce themselves and their services.

Titled “Why Medicare Advantage Needs Home Care,” the document serves as Home Care 101. The top-line information stresses the connection between home care and social determinants of health, in addition to outlining the coming decades of home care need.

Sourcing the 2016 report “Caring For America’s Seniors: The Value of Home Care,” written jointly by Home Care Association of America and Global Coalition on Aging, Right at Home’s brochure focuses on four areas that illuminate the growing impact that non-medical home care can have on health-related outcomes: 

— The growing need for affordable in-home care

— The impact home care has on preventing falls

— The impact home care-related early intervention has on delaying institutionalization

— The correlation between home care services and reduced hospital readmissions

The brochure even goes one level further than high-level insights and data, providing a straightforward list of six tasks that home care providers deliver to prevent seniors from falling, such as household chores and medication reminders.

The list is so simple that home care providers might not even think to mention some of those tasks to payers. But going that basic, Zuger found, is crucial to success as providers build relationships with plans.

3. Bulk up your technological infrastructure

Even if all of the information barriers were gone, the data challenge would remain.

“We can talk until we’re blue in the face on what the value is of including personal and companion services or respite care services in a plan, but until you have the data to prove it, it’s difficult for payers to really digest,” Zuger said.

Until payers can do that, “it’s hard for them to determine what specific services and hours they should include in the plan,” she added.

One strategy is for providers to teach their staff the connection between data procured and outcomes delivered. New York-based Premier Home Health Care, which has an MA contract with health insurer HealthFirst, is focused on aligning its data collection, especially around how home care helps reduce hospitalizations, with its staff training program.

This strategy helps staff understand the quantifiable benefits home care has to insurers, allowing them to create actionable changes in care based on analytics.

“As an organization, we know that … the recognition of the value that in-home support plays in keeping people out of the hospital and improving their quality of life while living with chronic illnesses will only continue to grow,” said Christy Johnston, vice president of governmental & managed care services for Premier.

“So we will watch to identify data that helps us drill down and understand what is happening in different areas of the country that we’re involved in (…).”

To capture this data, providers need to build their technological capabilities, including electronic health record systems and electronic visit verification systems. Among the leaders in this space is ClearCare, which serves more than 4,000 home care providers, including eight of the largest 10 home care enterprises. For home care providers entering the MA space, ClearCare CEO Geoffrey Nudd sees four crucial tech requirements:

  • Interoperability Providers must be able to connect electronically to MA plans to receive care plans and exchange patient data as part of integrated care protocols. “The handoffs between acute settings and clinical care, including home healthcare, are really critical with this population,” Nudd told HHCN.
  • Quality. Plans want to know that their home care partners are well-managed, with strong oversight of the care, screened caregivers and positive member experience. “A value-based construct oriented to improving outcomes and reducing cost … requires precisely targeted, integrated, and clinically informed protocols even if the care is ultimately non-medical (and is) simply help with ADLs and iADLs,” Nudd said.
  • Security. All of MA plans expect home care agencies to use operating software that is HiTRUST certified, Nudd said.
  • Scale. MA Plans cannot build thousands of connections to thousands of different home care agencies, let alone individual caregivers, Nudd noted. “For technology companies like ClearCare, the onus is on us to provide turnkey points of connectivity, and FHIR compatible APIs, for MA plans to reach our home care partners,” he said.

4. Deliver 24-hour services

Though it will take at least a year for providers to begin to capture the cost and health outcomes data that payers want to see, there is one big piece of infrastructure providers can implement now to bolster their value: the ability to assist seniors and their loved ones 24 hours a day.

“When you drive by our office, our lights are on at two in the morning,” Gavin Ward, regional director of strategy and partnership at Los Angeles-based 24 Hour Home Care, told HHCN. “If you can’t give someone 24 hours a day, I don’t think those companies should partner with MA.”

In MA, 24/7 readiness means the capability to field calls and answer questions from clients and caregivers at all times. Additionally, a provider must have the technology that lets caregivers swap or reschedule shifts autonomously and lets providers quickly facilitate those reschedulings, thus reducing shift cancellations.

“What we’re looking for, depending on the nature of the need, is someone who has the ability to meet the home care needs of our members in a timely manner,” Kirk Allen, president of Humana’s home health segment Humana At Home, told HHCN.

While CMS requires that home health providers reach a senior’s home within 48 hours of their return from the hospital — what’s known as “timely initiation of care” — Humana looks for providers that can get there sooner, ideally within 24 hours, “so that the patient doesn’t seek unplanned care in the wrong setting,” Allen said. If a provider delivers both home health and home care, its proven ability to promptly initiate care in home health may bode well for its ability to do so in home care.

5. Learn your way around CMS.gov and other sources

Home care providers searching for the MA contracts that are right for them will quickly come to a confusing road. As stated, MA plans don’t just vary by the state, but by zip code. A home care provider serving California, for instance, would find 36 contracts in June 2019 across 22 zip codes.

And because some of these benefits are so new and so small, they’re not always available at Medicare.gov, where providers can otherwise use the “Find My Plan” search tool to locate other types of benefits.

Fortunately, there is enough information available publicly to find the right plans, if you know where to look. A home care provider that aims to locate the right plans for their clients needs to learn its way around several sources, most notably:

— CMS.gov

— Multiple spreadsheets from CMS with hundreds, thousands or even tens of thousands of data rows

— Publicly available analyses of this data, such as the Milliman Report

“The New Medicare Advantage Opportunity in Home Care” includes a five-step process that lays out best practices on how to find MA plans with specific supplemental benefits in specific service areas, as well as an additional pro-tip source for finding plans.

6. Learn how to read insurance plans

While the Milliman Report gives a great overview of plans, and the individual datasets on CMS let providers dig deeper, all of the research eventually leads to the individual plan websites and the documents that list specific benefits, known as the Explanation of Benefits (EOB) or Evidence of Coverage (EOC). These are often 200-plus page PDFs, and they provide the specific detail on the benefits a plan offers.

The key takeaway here is to use all of this material in concert. An outside analysis of CMS data without the raw CMS data would mean a lot of additional digging, but the raw CMS data without these analyses would mean too much digging.

“These new supplemental benefits are like budget dust in these MA plans,” Doug Robertson, health care regulation and compliance manager at Right at Home, told HHCN. “It’s a very small financial component of an overall plan that could cost millions of dollars to the insurance company.”

This article draws from the new report, “The New Medicare Advantage Opportunity in Home Care.” Click here to access the complete report, which includes a guide to the five key challenges home care providers will face in MA as well as a comprehensive five-step process for finding MA plans that offer specific supplemental benefits related to home care, including instructions for combing CMS.gov.

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