The New Medicare Advantage Opportunity in Home Care

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Key takeaways

  • A pair of CMS rule expansions in 2018 and 2019 have created new opportunities for home care providers to partner with Medicare Advantage plans
  • Home care providers have the chance to help MA plans reduce hospitalizations and readmissions
  • For MA plans offering in-home support to members, personal care will be the most sought after service
  • To capitalize on this new MA opportunity, home care providers will face five key challenges, including educating MA plans about home care and combing tough-to-find benefits packages
  • Home care providers entering the MA landscape must build new technological capabilities to capture the data that shows home care’s value
  • Home care providers can expect the MA opportunity to kick off in earnest in 2020 and boom in 2021

How the value-based care movement is bringing home care to MA

The Medicare Advantage revolution continues to grow — and starting in 2020, home care providers will reap the rewards.

Following a series of law changes over the past decade, including the Patient Protection and Affordable Care Act of 2010 and the Bipartisan Budget Act of 2018, Medicare’s move toward value-based care and away from fee-for-service models began to take hold. A Change Healthcare study in 2019 concluded that over a five-year period, the number of states and territories implementing value-based reimbursement programs increased seven-fold, with value-based reimbursement models now existing in 46 states plus the District of Columbia and Puerto Rico.

The Centers for Medicare & Medicaid Services (CMS) calls this national shift “part of our larger quality strategy to reform how health care is delivered and paid for.” It has three focuses: improved care for individuals, better health for populations, lower cost.

In either fee-for-service or value-based care, of course, insurers want to keep costs down, and aim to do so by limiting the time members spend in high-cost settings, especially hospitals. Different sources have different estimates of the savings of home care versus these other settings, but all agree: the longer you can keep a person in their home, the more money you can save.

With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that (…) focus on preventing disease and keeping people healthy.

Seema Verma, CMS administrator, in a statement on April 1, 2019 announcing new CMS regulations allowing nonmedical
supplemental benefits in Medicare Advantage

An insurer’s desire to keep costs low is even greater in a value-based model, where payment is predicated on cost and outcomes, not just services delivered. This means moving away from treating people only when they’re sick and instead proactively keeping them well.

The three main purposes for home-based care:

  • Proactive, non-medical care that reduces preventable health failures by targeting the root causes of common medical conditions.
  • Health care services in the home rather than in a hospital, ensuring a person’s isolation from other sick people when they themselves are most vulnerable.
  • Reducing readmissions once a person returns home from the hospital.

With its supplemental benefits not offered by Medicare and its built-in cost controls, Medicare Advantage (MA) is a natural fit with the value-based movement. And over the past 15 years, MA’s popularity has soared, likely for those reasons. Of the 541 MA contracts in June of 2019, only five remained in a fee-for-service plan type as a “Private Fee-For-Service plan.”

Ideally, MA would be a crucial component to keeping people out of the hospital and keeping them healthy. And indeed, a 2017 study sponsored by CMS found that MA beneficiaries in California, Florida and New York outperformed fee-for-service Medicare beneficiaries in 16 clinical quality measures, including preventative care, chronic condition management and, the big one, hospital readmissions.

Yet other studies have not been as kind to MA.

Kaiser Family Foundation (KFF) showed that people who switched from Medicare to MA in 2016 spent about $1,200 less a year on health care than ones who stayed on Medicare, suggesting that MA’s impact on the country’s most at-risk seniors is moderate. This is significant because 90% of the $3.3 trillion spent annually on health care in the U.S. is for people with chronic physical or mental health conditions.

Additionally, a study from Brown University in June 2019 found that MA patients had slightly higher hospital readmission rates (17.2%) than their peers in traditional Medicare (16.9%).

That brings us to home care.

In response to the same trends driving those studies, CMS has taken major steps toward increasing the impact that Medicare Advantage can have on improving outcomes for the chronically ill.

In 2018, CMS announced that it would reinterpret the standards for healthrelated supplemental benefits in MA “to include additional services that increase health and improve quality of life, including coverage of non-skilled, in-home supports.” And in 2019, CMS created a new category of supplemental benefits for the chronically ill, allowing MA plans to consider social determinants of health as a factor for benefits eligibility.

This second rule is monumental. An emphasis on “social determinants of health” (SDoH) means an emphasis on home care, because SDoH is a focus on the non-medical health-related elements of a person’s environment, elements addressed through in-home support services such as personal care, transportation, socialization, nutrition support and home modifications.

Huge money is at stake in controlling these elements. In May 2019, a study from the Johns Hopkins Bloomberg School of Public Health estimated a hypothetical incremental cost savings of $4 billion in Medicare spending if community-living adults 65 or older with disabilities received non-medical care, specifically around household activities, mobility and self-care.

That’s what makes the CMS expansion so significant for home care providers: It lets them receive Medicare reimbursement by tapping into MA. And because MA is heading steadily toward becoming the predominant offering within Medicare, the opportunity for home care providers to benefit from these MA expansions should only continue to grow over the next five years and beyond.

This report will show home care providers where they now stand in the MA landscape, how they can capitalize on their newfound status and what specifically those opportunities will look like.

Medicare Advantage and home care:
the landscape in 2019

What home care providers have to recognize first about the recent MA expansions is where they fit in and why CMS is embracing what they do. To put it simply, the shift toward value-based care over the past decade has increased insurers’ focus on delivering better health outcomes at lower cost — the two hallmarks of Medicare Advantage, and the traits that CMS is betting nonmedical home care services can deliver.

For a decade and a half, Medicare Advantage enrollment has steadily risen. According to KFF, 2019 marked the 15th consecutive year of enrollment growth, from 5.3 million people in 2004 to 22 million in 2019. That accounts for 34% of all Medicare beneficiaries — also an alltime high.

The Congressional Budget Office projects MA growth to continue, reaching a 47% share of Medicare enrollment by 2029. Medicare enrollment is projected to reach over 80 million beneficiaries by 2030, the year that the youngest baby boomers turn 65, making all boomers Medicare eligible and leading to an estimated enrollment of 37.6 million.

Other estimates are more aggressive. Boston-based L.E.K. Consulting sees MA penetration hitting about 50% by 2025 and skyrocketing to 70% some time between 2030 and 2040.

Regardless of whose projections hit, Medicare Advantage may soon exceed 50% of all Medicare beneficiaries, with the importance of controlling the health costs of boomers while providing better health outcomes only expanding.

One big way to achieve these objectives is by helping seniors spend as much time as possible in lower-cost health settings, namely the home. Along with the previously listed home care services, the mere presence of an in-home caregiver is vital for a senior’s health. On a daily basis, a caregiver can identify a senior’s failing health, new aches and pains or cognitive decline. They can note when a certain area of the house is becoming too cluttered or dirty, or when the senior’s health has begun to preclude her from entering certain areas of the house because they represent a fall risk.

This work is especially important for the 75% of Americans over the age of 65 with multiple chronic conditions, who present a massive cost burden to insurers.

“Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease,” CMS Administrator Seema Verma said in a statement on April 1, 2019, with the announcement of the broader expansion. “With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that (…) focus on preventing disease and keeping people healthy.”

That second rule expansion for 2020 is a huge game-changer for home care providers. Medicare Advantage expert Anne Tumlinson, founder of Washington, D.C.-based research and advisory services firm Anne Tumlinson Innovations, told HHCN that she was “pretty shocked” by the announcement.

“The new guidance gives plans nearly as much flexibility as possible within the constraints of the law,” Tumlinson said in April 2019. “I think that CMS has done everything it possibly can, within the constraints of the statute, to make the supplemental benefit flexible and easy for plans to administer.”

How the biggest Medicare Advantage players are embracing home care

The steady growth of Medicare Advantage mixed with the increased emphasis on value-based care has led to a flurry of acquisitions, partnerships and preparations from insurance carriers, home care providers, private equity firms and others that see home care as a major piece in Medicare Advantage over the next decade.

For the four insurers with the largest MA enrollments, this recognition has been central to their wheelings and dealings the past few years. Minnesota-based UnitedHealthcare (UHC) has the largest MA enrollment of any insurer, about 5.7 million seniors, and expects to have $75 billion of its payments to care providers tied to value-based care relationships by 2020.

“Home health care is an important part of the picture,” Jeff Meyerhofer, president of bundled payment solutions for UnitedHealthcare’s Medicare & Retirement division, told HHCN via email in April 2019. “Post-acute care — encompassing home health [and] skilled care — is squarely in the scope of our bundled payment efforts.”

Over the past few years, Louisville, Kentucky-based Humana has executed a series of moves to deliver improved health outcomes for members with help of a multitude of stakeholders, including hospitals, primary care physicians and home care providers.

In 2015, it launched its “Bold Goal” population health strategy, in which it sought to improve population health outcomes for its MA members in seven communities by creating systems aimed to boost five elements: primary care, home health, pharmacy, behavioral health and social determinants of health.

From 2015 to 2018, its MA members in Bold Goal communities reduced their number of Unhealthy Days (their metric) by 2.7%, while their other MA members not in this program saw their Unhealthy Days increase. Overall, Humana MA members in value-based care settings are 7% less likely to end up in the emergency room and 5% less likely to be readmitted to the hospital, according to the company’s internal statistics.

Then there are Humana’s acquisitions and partnerships. In July 2018, Humana and two private equity firms teamed up for a pair of huge acquisitions that drastically altered Humana’s health care capabilities. On July 2, the three parties purchased Kindred Healthcare — the nation’s largest home health and hospice provider — for about $4 billion, and then acquired hospice operator Curo Health Services for about $1.4 billion nine days later on July 11. Humana’s end on the two deals was about $1.1 billion: about $850 million in the Kindred deal and about $250 million in the Curo acquisition.

Our journey into the home is in full gear.

William Fleming, then-segment president of health care services at Humana

These moves, as well as their partnership with Walgreens finalized in 2018, have turned Humana into a coordinated end-to-end health hub, where seniors can turn for nearly all of their health needs. In its 2019 Investor Day report, Humana called home health “the new frontier in value-based medicine,” and called Medicare Advantage “a proven solution for consumers and government.”

“Our journey into the home is in full gear,” William Fleming, then-segment president of health care services at Humana, told analysts in March 2019 after releasing the investor report. “When (a) clinician is in the home, they know about the person well ahead of time. It’s a productivity opportunity for that local clinician who’s working on the front line.”

But of all the insurers offering Medicare Advantage, one has been most proactive marketing the in-home care supplemental benefits, at least according to someone who studies supplemental benefits day in and day out.

“Anthem,” says Doug Robertson, healthcare regulation & compliance manager at Omaha, Nebraska-based Right at Home, a home care franchise network with nearly 500 U.S. locations. “There is no (second place).”

As Right at Home’s internal data guru, Robertson spends much of his work day locating MA plans with new inhome supplemental benefits, which he and Right at Home pass along to their franchisees. It’s a grueling task for reasons that will be made plain later in this report, but a major piece of the challenge is that many payers don’t speak up about what benefits they offer.

The Indianapolis-based Anthem Inc. — which in some states is part of Blue Cross Blue Shield — has been very vocal about its offerings. When CMS announced the first MA expansion, Anthem jumped straight in by announcing a home care-related benefits package in October 2018.

The new package, branded as either “Essential Extras” or “Everyday Extras,” is built mainly around six services: food delivery, transportation, assistive devices, alternative medicine, adult day center visits and personal home helpers. Anthem, along with its affiliates, provides coverage for more than 74 million people, with about 3% of all MA enrollees in a plan offered by an Anthem affiliate.

Robertson took note when Anthem president and CEO Gail Boudreaux said during the company’s 2019 Q1 earnings call that its MA enrollment grew by nearly 14% in the first quarter, and attributed that growth to “our unique supplemental benefits.”

“That was the first plan to say that they saw a numerical benefit from including these benefits in their plan,” Robertson says.

Certainly as payer comfort levels about the benefit packages increase, home care providers can expect to see more proactive marketing from plans. In May 2019, not long after Anthem’s declaration, Humana made a similar pronouncement in its Q1 earnings call, when the company attributed a net income of $566 million in Q1 — up 15.3% compared to Q1 2018 — to strong MA enrollment.

Our entire strategy and business model is all about Medicare Advantage.

Sherwin Sheik, President and CEO, CareLinx

And in June 2019, Connecticut-based Aetna Medicare announced a partnership with national online home care network CareLinx, helping Aetna members in six states (Arizona, California, Connecticut, Nevada, New Jersey, Washington) connect with the Burlingame, California-based CareLinx’s network of more than 300,000 caregivers across the country.

Those four insurers, UnitedHealthcare (26%), Humana (18%), Anthem (part of BCBS, 15%) and Aetna (10%), represent in some fashion nearly 70% of all Medicare Advantage plans.

As CareLinx President and CEO Sherwin Sheik told HHCN following the announcement of its Aetna partnership: “Our entire strategy and business model is all about Medicare Advantage.”

How home care providers are capitalizing on Medicare Advantage

CareLinx’s value proposition for Aetna no doubt stems from CareLinx’s move in December 2018, when it launched a turnkey MA offering to give insurers instant access to a full network of nonmedical, in-home caregivers. The move was one of many made in the wake of the first of the two CMS announcements.

Debate remains as to when the home care impact will be felt on MA. The most prevalent argument is for 2021, when a year’s worth of data will show the impact that the non-medical, in-home care services can have on health outcomes and cost.

“Our number one goal going into 2020 is collection of data,” says Kerin Zuger, vice president of business development at Right at Home.

As of now, Right at Home has one Medicare Advantage contract, with People’s Health in Louisiana, which is part of UnitedHealthcare. To build more, Right at Home needs to produce more data that shows the impact that home care has on a person’s health, specifically its ability to reduce readmissions.

As Zuger notes, “The whole point of this is to reduce the spend (for insurers).”

With that cost-related data still rolling in, Zuger views the MA opportunity in home care in 2020 as a “delicate balance” between what the plans feel comfortable offering now and what they might feel comfortable offering later.

Especially as the industry is growing, having home care providers or independents in alliances or being part of a larger system — that’s going to become even more important. … You’re still going to have your own company. It’ll just be part of a larger brand (…).

Jeff Bevis, CEO, FirstLight Home Care

What is clear is that basic, personal care services are at the top of the list of home care services that MA plans will fund. Home care giants are taking note. In August 2018, Baltimore-based Senior Helpers — with 303 franchise locations nationwide — hired 15-year health technology and aging veteran Michael Hughes as vice president of strategic development to build new MA partnerships. In May 2019, both Addus and Amedisys lauded the impact personal care services under MA can have on their businesses.

Addus CEO Dirk Allison believes that home care opportunities in MA will expand as payers “begin to realize the cost-saving potential of personal care services.” And Amedisys CEO Paul Kusserow told investors that due to MA, the company plans to expand its personal care services into as many as 47 states in the coming years, with a growth target of “national coverage, or close to it.”

Because delivering home care at scale is crucial for a provider’s success with insurers in MA, one key element to success for smaller providers are partnerships with other providers, creating a network. Since launching in 2014, the San Francisco-based home care startup Honor has built such a network. In April 2019, the company expanded into its fourth state, Arizona, with members in California, New Mexico and Texas.

On average, Honor partners see a business growth of 30% within three months of joining, the company says. Whether a home care provider works with a company like Honor or moves into a franchise, the benefits to the provider are clear: greater capabilities to deliver care across an insurer’s membership, making for a stronger partner while reducing internal stress and struggles that would come when trying to deliver scale for the first time.

“Especially as the industry is growing, having home care providers or independents in alliances or being part of a larger system — that’s going to become even more important,” CEO Jeff Bevis of Cincinnati-based franchisor FirstLight Home Care says. “On the negative side, you are losing total independence. But you’re still going to be an entrepreneur. You’re still going to have your own company. It’ll just be part of a larger brand to enable you to access more of the MA Plan opportunities.”

The revenue impact on home care providers

Between the timing of the MA expansion announcements, the lack of historical data showing the value of non-medical services on a senior’s health and the getting-to-know-you relationship that is building between major insurers and home care providers, the non-medical supplemental benefit packages have been slow to reach the market.

But there is another element that is slowing down the rollout from the provider’s perspective that also explains the as-of-now low expectations from providers on revenue opportunities: the reimbursement rates.

“We were looking at these benefits — Anthem, for example — and saying, ‘This doesn’t work for us,’” Robertson says. What he saw was a benefit from Anthem that reimbursed a home care session of up to four hours for $40. If the home care session lasts just an hour, and the home care agency bills $30 an hour, that’s a $10 reimbursement, he says.

But if the session lasts all four hours of the benefit, the agency has charged the client $120 and only received $40 from the insurance company. And because MA prohibits value-based care plans from using “balance billing” — where the client pays out of pocket for however much of the service is not reimbursed — there is no financial incentive for the home care provider to participate if the reimbursements are too low.

“Because the home care benefit in MA is so new, payers are still exploring what a reasonable reimbursement could be,” Zuger says. “We have learned of reimbursements that range from $10 an hour to $22 an hour, so it is going to take a few Medicare plan cycles for payers to determine the right reimbursement based on supply and demand.”

All of this explains why most providers are taking a wait-and-see approach on the revenue impact. Yet one home care provider is not just optimistic about MA revenue, but downright bullish.

“We think that we should see probably a 15 to 18% revenue increase from MA in 2020 (system-wide),” Bevis says.

Because the home care benefit in MA is so new, payers are still exploring what a reasonable reimbursement could be.

Kerin Zuger, vice president of business development at Right at Home

For the most part, though, the revenue opportunities are down the line, and the providers entering the space now are doing so out of a mix of organizational mission and proactive steps for a more lucrative future.

“You have to play,” says Jennifer Ramona, vice president of strategy and health care innovation at the Denver-based franchisor Homewatch CareGivers, “or you’re going to lose clients.”

When CMS announced its first MA expansion, there was no clear indication as to how many payers would participate nor what the available benefits would be.

Not surprisingly, participation was low. An AARP study of CMS data in October 2018 found that only 13% of MA plans offered family caregiver support, while only 3% of plans covered in-home support services, the bread and butter of home care.

The expansion in 2019 was monumental, with the level of flexibility and creativity that plans can take basically 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.” One of the examples the letter uses on what services can be included? Pest control.

But all of that experimentation and flexibility brings new challenges for home care providers, including a big one: interacting with major insurers. The MA expansions represent a massive shift in the day-to-day operations of many if not most home care providers, which are accustomed to private pay clients and must now interface with national organizations and new technological demands.

The other huge logistical challenges will come simply from attempting to find the right plans that align with their service areas, service offerings and client needs. One of the challenges is simple: teaching plans the difference between home care and home health.

“(They view home care) as a red-headed step child, as a variant of the home health world,” Bevis says. “Historically, they have placed us far down the food chain — that’s maybe the way to put it. Not really acknowledging the value that we can provide them as a payer, and certainly as a service to their policy holder.”

That information gap is just one of the five biggest challenges home care providers will face as they enter MA. Here’s a look at all five, and how providers are combating them.

The five major challenges for home care providers entering MA

  1. Starting the conversation with MA plans
  2. Finding the plans that align with your services
  3. Educating MA plans on the difference between home care and home health
  4. Implementing the necessary technology
  5. Building the 24-hour infrastructure that payers desire
Challenge 1
Starting the conversation with MA plans

The first challenge home care providers will face in MA is the basic question of how to begin discussions with payers. Homewatch CareGivers’s answer: take both a top-down and bottom-up approach with insurers.

To make these connections, the company built a threepronged approach to help it serve as facilitator between its franchisees and MA plans. First, it uses its national contacts to learn each payer’s big-picture strategies and gain national contracts. Then it talks to local plans that have supplemental benefits related to home care. Lastly, it talks to local plans whose members are also Homewatch clients.

(Payers) place (home care) far down the food chain — not really acknowledging the value that we can provide them as a payer, and certainly as a service to their policy holder.

Jeff Bevis, CEO, FirstLight Home Care

While the specific plan decisions must be made at the local level, the national offices can often give the 30,000-foot view necessary to start paring down the options. Homewatch CareGivers’s executive team has used 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 the mountain of existing contracts to locate the slivers of information relevant to a home care provider’s clients. Homewatch CareGivers views handling this process as part of its value proposition to its franchisees, for whom the task of determining which local plans offer which home care-related supplemental benefits 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.

Challenge 2
Finding the plans that align with your services:
A five-step process

Home care providers searching for the MA contracts that are right for them will quickly come to a confusing road. MA plans don’t just vary by the state, but by the 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, where providers can otherwise use the “Find My Plan” search tool to locate other types of benefits.

“These new supplemental benefits are like budget dust in these MA plans,” Robertson says. “It’s a very small financial component of an overall plan that could cost millions of dollars to the insurance company.”

Fortunately, there is enough information available publicly to find the right plans, if you know how to look. Based on our interviews as well as our own determination of best practices, here are five steps to follow:

  1. Start with the Milliman Report

In October 2018, Better Medicare Alliance financed a Medicare Advantage benefits study by data firm Milliman. The Milliman Report is available for free online and provides a streamlined view of the available MA plans that offer nonmedical supplemental benefits in 2019. The report shows the states where they are available and each plan’s category of benefits.

Providers can then search for more detailed information about these plans — including through CMS — and begin the process of connecting with them.

“I think like many (providers), we’ve been watching for different research papers, like the Milliman Report, that helps drill down and identify which plans have opted into certain services,” says Christy Johnston, vice president of governmental & managed care services for New York-based Premier Home Health Care Services, Inc. “But a directory that has all the quick answers is not something I have found yet.”

  1. Go to and find the spreadsheets of raw data

The Milliman Report does not give all existing detail on MA plans, crucially omitting each plan’s service area zip code. For this, you must undertake the grueling task of drilling deep into

  1. Comb through insurance press releases

Along with Milliman and the CMS data, another key source is press releases from the insurers, Robertson says. When the plans themselves write press releases, Robertson knows that, one, a given plan or benefit exists, and two, that the payer is proactive and hence wants to work with home care providers.

“Otherwise, there is no way to know these benefits exist outside of the private marketing of the insurance company, because the government has not yet started to track them,” Robertson says.

  1. Contact the insurance carriers

There is a monkey wrench in this process from a surprise party: the plans themselves. Many are not marketing their supplemental benefits.

“This is what I think: insurance carriers still don’t have any historical data on how these new benefits will impact the plans,” says Right at Home’s Zuger. “So carriers are hesitant to open the floodgates (by promoting their plans) because they don’t know how many people want (a given) benefit yet. If you market a benefit, you need to deliver on it.”

24 Hour Home Care’s experience with MA shows the combination of challenges presented by the regionalspecific offerings and the potential lack of marketing. As of 2019, they are working with two payers, SCAN Health Plan and CareMore, based largely on the aligned geography, as the home care provider operates in California (Southern California along the coast, Silicon Valley and the greater Oakland area), along with Maricopa County in Arizona and Dallas.

“Right now, one of the reasons we’re not contracted with other plans is that we’re not aware of other plans in the three states that are offering benefits in our service areas,” Gavin Ward, regional director of strategy and partnership at 24 Hour Home Care, says. “And if they are, they’ve done a good job keeping it a secret.”

  1. Read the 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+ page PDFs, and they provide the specific detail on the benefits a plan offers.

Challenge 3
Educating MA plans on the difference between home care and home health

This might sound silly, but according to a number of home care providers interviewed for this report, 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,” Zuger says.

To combat this, Zuger and co. created a four-page brochure that laid out home care’s value proposition within the Medicare Advantage framework. Right at Home then sent the brochure to all of the biggest MA plans in the country to introduce themselves and their services.

Titled “Why Medicare Advantage Needs Home Care,” the document serves as a Home Care 101. The top-line information stresses the tie between home care and social determinants of health, before going into the numbers that paint the picture of 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 where non-medical home care delivers vital health-related outcomes, including hospital readmissions.

I didn’t realize how big of a learning curve there actually was for these payers.

Kerin Zuger, vice president of business

Yet perhaps more impactful than highlevel insights or the data that supports them is the brochure’s simple list of tasks that home care providers deliver to prevent seniors from falling:

  • Household chores
  • Medication reminders
  • ADLs
  • Helping seniors stay active
  • Identifying fall risks
  • Reporting signs of declining health

That list is so simple that home care providers might not even think to mention those tasks to payers as they begin their conversations. But going that basic, Zuger found, is one of the first keys to success as providers build new relationships with plans.

Challenge 4
Implementing the technology piece to capture data

Even if all of the communication was streamlined and the information barriers were gone, the data challenge would remain, being in the early stages of this new MA landscape.

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

In New York, Premier Home Health Care Services is building its data capabilities to lay the groundwork for expanded MA opportunities over the coming years. The company has an MA contract with health insurer HealthFirst, and is focused on collecting data that shows how in-home aid services reduce hospitalizations.

The company recently launched its “Real Time Data” dashboard, along with a training program called “Observe, Ask, Report,” converting the data it collects into actionable changes in care, all with the goal of helping its staff understand how their services as in-home caregivers have quantifiable benefits to insurers.

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.

Kerin Zuger, Vice President of Business Development, Right at Home

“I think as an organization, we know that the need for home care services will only continue to grow, and the recognition of the value that inhome 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,” Johnston says. “So we watch and we try to identify data that helps us drill down and understand what is happening in different areas of the country that that we’re involved in (…).”

Providers that want to capture the data that will help them connect with MA plans need to build their technological capabilities, including electronic health record systems and electronic visit verification systems. Companies providing these services include AlayaCare, AxisCare and Skedulo, which in March 2019 raised $28 million in venture capital.

Another leader in this space is ClearCare from San Francisco, 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, CEO Geoffrey Nudd sees four crucial tech requirements: interoperability, quality, security and scale.

Geoffrey Nudd’s four crucial tech requirements for home care providers in MA:

Interoperability. Home care providers must be able to connect electronically to MA plans and health care providers to receive care plans and exchange patient data as part of integrated care protocols. “The handoffs between acute settings and clinical care, including home health care, are really critical with this population,” he notes.

Quality. Plans want to know that their home care partners are wellmanaged, with strong oversight of the care, screened caregivers and positive member experience. “A valuebased 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 says.

Security. All MA plans expect the home care agencies to use operating software that is HiTRUST certified. “This is table stakes,” Nudd says.

Scale. MA Plans cannot build thousands of connections to thousands of individual home care agencies, let alone individual caregivers, Nudd says. “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 says.

“Our partnership with ClearCare ensures all of our franchise locations can process service delivery and billing with a payer in a uniform manner,” Zuger says. “As home care benefits become more prevalent in Medicare Advantage plans, payers will need to recruit more providers and make their technology needs known.

Challenge 5
Building the 24-hour infrastructure that payers desire

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

“When you drive by our office, our lights are on at 2 in the morning,” says Ward of 24 Hour Home Care. “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 takes two key forms. The first is availability to clients and caregivers: the capability to field calls and answer questions at all time. There is a tech piece tied to this too: the ability for caregivers to swap or reschedule shifts autonomously, or for providers to quickly facilitate those reschedulings, thus reducing shift cancellations.

“A member of an MA plan who cannot reach a (live person), they are going to be dissatisfied with their care benefit,” Ward says. That dissatisfaction can impact a provider’s star rating, which can impact a plan’s decision to partner with that provider.

“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,” says Kirk Allen, president of Humana’s home health segment Humana at Home.

When you drive by our office, our lights are on at 2 in the morning. If you can’t give someone 24 hours a day, I don’t think those companies should partner with MA.

Gavin Ward, Regional Director of Strategy and Partnership, 24 Hour Home Care

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 says.

Making connections: what these MA partnerships look like

Over the next few years, the evolution of the home care opportunity in Medicare Advantage will be driven by data. The non-medical supplemental benefits that end up in the most plans will be the ones that payers can trace directly to cost-related health outcomes. And the home care providers that already have some level of experience working with MA populations and can show improved patient outcomes will have a head start.

For instance, in 2018, 24 Hour Home Care turned a pilot with Los Angeles’s Cedars-Sinai Medical Center and Honor Home Care into a deeper partnership. In the pilot, the two home care providers brought in-home support to the hospital’s high-risk discharged patient population, with the program specifically targeting the hospital’s United Healthcare population of 2,800 MA patients.

As a result of that experience, 24 Hour Home Care in the fall of 2018 landed its first MA contracts, with SCAN Health Plan out of Long Beach, California, and CareMore, which serves more than 150,000 patients across nine states and Washington, D.C.

The work 24 Hour Home Care did with Cedars-Sinai, and other work with HealthSouth BPCI, helped identify outcomes, develop processes and instruct how to deliver both with size and scale, all aspects that they needed to be a good partner for insurers.

“The fact that we had existing partnerships with good outcomes … was helpful for people like SCAN,” says 24 Hour Home Care’s Ward. “We’re not a mom-and-pop who can help an insurer with (only) 1% of their population or 5%.”

Instead, 24 Hour Home Care serves 75% of SCAN’s population.

“I think those are all reasons why SCAN decided to move forward with us,” Ward says.

The most popular non-medical in-home services

An HHCN survey in May 2019 queried 105 home care providers about the top non-medical in-home services that they expected MA plans to be most interested in covering in the 2020 plan year. Respondents were asked to choose up to three, and personal care — such as bathing, grooming, toileting and the like — was far and away the top response.

Here is a look at what providers are doing with some of these benefits.


FirstLight is a purely non-medical home care provider, and in 2020 they will have MA contracts with multiple payers in at least six states: Arizona, California, Florida, New York, Ohio and Texas. They are with five payers now, and they’ve seen the focus on personal care.

“We have been hearing from payers that personal care services are by far the vast majority of the actual requests of services expected (in 2020),” FirstLight’s Bevis says.

Along with the value of assisting a person in their home with specific tasks, the simple presence of a caregiver in someone’s home is valuable to payers. They can monitor a person’s evolving health needs and serve as an educator about which home care benefits might already be available on a person’s plan.


The benefit of having a person in the home was codified technologically in April 2019, when CMS announced a finalized set of policies designed to expand the use of telehealth benefits under MA.

“(Telehealth) is one area that we have been trying to sprint toward,” Bevis says. “We think that’s going to be a gamechanger.”

The importance of technology to connect seniors in the home with their doctors and insurers outside of it is paramount to the success of these in-home benefits. And because telehealth platforms are not necessarily already in the home, this is another area where simply having a caregiver is a boon to health outcomes.


Telehealth is a vital piece of a senior’s SDoH: it reduces unnecessary travel.

But the flip side is true too: the MA expansion can now facilitate necessary travel that seniors previously weren’t getting, such as to doctor appointments or the grocery store. According to a report by health care technology firm SCI Solutions, lack of transportation contributes to as many as 30% of all patients missing doctor appointments, with this absenteeism draining as much as $150 billion in revenue annually from the health care industry.

Ride-share companies are taking advantage. In March 2018, Uber launched the senior-centric ride share service “Uber Health,” while Lyft announced in May 2019 a new focus on partnering with MA plans to help seniors reach their destinations, stating a goal to work with “the majority of the largest MA plans” by 2020.

(Telehealth) is one area that we have been trying to sprint toward. We think that’s going to be a gamechanger.

Jeff Bevis, CEO of FirstLight Home Care

Right at Home has a focus on transportation as part of its service offering, along with wellness and safety. A franchise signs up with either Uber or Lyft, and when a client or employee needs a ride, they call the Right at Home office and the office books the ride.

But with a number of seniors feeling uncomfortable or unequipped to use a mainstream ride-sharing company for their transportation needs, other offerings have sprung up that are specific to senior needs. A huge list of transportation providers by service area is available at

2020, 2021, 2022 and beyond

Debate remains as to when the CMS expansions to MA will become a true game-changer for home care providers.

It could be 2020, the year in which MA plans can be as creative as they want in offering benefit packages with nonmedical, in-home services. It could be 2021, the first year in which data showing outcomes and impact of home care is available, as well as a full year for plans to adjust their reimbursements to the liking of home care providers.

It could be 2022 or beyond, assuming that just one year is not enough to get everyone — providers and payers — into the pool.

“We do not believe (MA and home care) is a 2020 event,” Addus’s Allison said at a conference in June 2019. “We believe it’s more of a 2021 event, largely because I think that the plans have to file this month for their 2020 plans, and (CMS) clarified the rule about six weeks ago. I don’t think that MA plans have the time to really put the thought in for 2020.”

That is a view held by many providers and payers alike. Yet the 2019 HHCN survey showed that home care providers are already jumping into MA. Of 105 home care provider respondents, 59% said that they were already contracted with an MA plan in the plan year of 2019. That figure jumps to 90% for 2020.

“We want to be engaged with the MA plans early in order to help inform the expectations of a home care partner to be able to demonstrate value to the plan and their enrollees, and in return for home care providers to be able to expect fair requirements and reimbursements from the plans,” Ramona told HHCN in April. “We are not waiting for 2021.”

Whether a provider follows Homewatch CareGivers’s lead or Addus’s, the bottom line is this: The change is here and will continue to grow.

“I think there is going to be a really steep and fast learning curve for the Medicare Advantage plans themselves between now and 2022,” Tumlinson says. “They’re trying to understand a variety of different things around not just home care benefits but all of the things they can offer under the supplemental benefit flexibility.”

But with MA enrollment increasing and CMS seemingly going all in on its emphasis on SDoH and the value of home care within MA, the opportunities for home care providers should only increase. And this is all without considering the possibility of yet another expansion from CMS some point down the road that would further stimulate home care involvement in MA.

“So 2019 is a very skinny, little, experimental year that is just reflective of some regulatory changes CMS made,” Tumlinson says. “2020 is really year 1 — the year where CMS is now implementing a new law, and that law specifically says that health plans can offer these special supplemental benefits to the chronically ill, and they don’t have to be primarily health related. These are subtle differences and nuances from one year to the next, but they’re really important.”

I think there is going to be a really steep and fast learning curve for the Medicare Advantage plans themselves between now and 2022.

Anne Tumlinson, Founder, Anne Tumlinson Innovations

Both Ramona and Ward view the MA opportunity of 2020 as a greater chance to “make history” than to make money. The degree to which the profits will roll in, as well as the timeline for any great payday, remains uncertain.

No matter the timeline, though, the clock is ticking.

“From a growth and attracting new members standpoint, having something like this that is unique and better than what our competitors offer certainly is helpful,” Chris Boles, regional vice president of Medicare at Anthem, told HHCN in October 2018. “But it goes beyond that and gets into our commitment to developing products that really do help address the health and wellness of our members. “If we don’t do that, there’s no reason for members to sign up with us and no reason for them to stay.”