Why Medicare Advantage Isn’t an ‘Instant Home Run’ for Home Care

With only a few short months to go in 2019, the year is rapidly winding down. As home care leaders take stock of their 2020 priorities, many remain focused on contracting with Medicare Advantage (MA) plans, some of which still lack a basic understanding of what home care services actually look like.

Among those leaders are the CEOs of Interim HealthCare, FirstLight Home Care and Right at Home, three of the largest home-based care franchisers in the world. Interim’s Jennifer Sheets, FirstLight’s Jeff Bevis and Right at Home’s Brian Petranick shared their thoughts on the emerging MA landscape Sept. 18 at the Home Health Care News Summit in Chicago.

One key piece of advice experts had for providers looking to go after relationships with MA plans: The experience is a long and grueling educational process.


“Go into it with realistic expectations,” Bevis said. “It’s going to take quite a while to educate the plans themselves about the value of home care overall. It’s not going to be an instant home run.”

Sheets likewise believes that providers should prepare themselves to educate MA plans on the value of home care, especially in the beginning stages of trying to form partnerships.

Medicare Advantage has become increasingly more important in home care over the past couple of years, as the Centers for Medicare & Medicaid Services (CMS) has expanded the scope of supplemental benefits MA plans can offer.


In 2018, CMS issued a final rule that mandated non-medical in-home care services as a benefit for MA plans in 2019, marking the first time CMS included daily maintenance benefits in Medicare Advantage.

CMS continued its efforts the following year when it issued the rules for 2020. The updated rules allow coverage for benefits that “have a reasonable expectation of improving or maintaining the health or overall function” for individuals with chronic conditions.

In other words, MA plans have lots of runway to take off from.

The steps taken by CMS allowed for more flexibility within the rules and opened the door for more MA plans to include new home care benefits in 2020. An estimated 250 plans will offer access to the new benefits next year, reaching an estimated 1.2 million MA enrollees, according to statistics from the Trump administration.

Additionally, earlier this month, President Donald Trump signed an executive order meant to strengthen and expand Medicare Advantage by bringing it in line with fee-for-service Medicare.

MA may be expanding, but home care providers attempting to negotiate contracts with MA plans have still run into their share of roadblocks.

Due to MA plans’ aforementioned struggles in seeing the value of home care, negotiation talks with providers tend to get muddled, according to Petranick.

“We spend a lot of time talking on the front-end to people who we believe are decision-makers within the organization,” Petranick said. “We will have several meetings, we get them understanding and to a point where we at least have an idea of what we want to do, and then it disappears within their organization. Then it comes back and what they come back with doesn’t match what we discussed in the front-end.”

Omaha, Nebraska-based Right at Home is a home care franchise network with nearly 500 U.S. locations.

“How do you eat an elephant?” Petranick asked Summit attendees. “One bite at a time.”

In 2019, one-third of all Medicare beneficiaries — about 22 million people in total — were enrolled in MA plans, according to Kaiser Family Foundation data. The Congressional Budget Office (CBO) projects that the share of beneficiaries enrolled in MA will rise to about 47% by 2029.

Meanwhile, Cincinnati-based franchise company FirstLight is close to five MA partnerships, according to Bevis. FirstLight provides companion, personal and dementia care services across more than 254 locations in 34 states.

On its end, Interim has agreements with many of the big MA plans in the market, Sheets said, mentioning Humana Inc. (NYSE: HUM), UnitedHealthcare and Aetna Inc.

“Fundamentally, the challenge is as things have started to move to this model and started to look for … fee-for-outcomes, value-based purchasing, home and community care has kind of been an afterthought,” Sheets said. “That’s a lot of the challenge that we see in reimbursement.”

Caring Brands International is the parent company of Interim, founded in 1966. Currently, Interim’s team of caregivers provides almost 25 million hours of home health, hospice and palliative care services to 190,000 people annually.

Although working relationships aren’t as seamless as some providers would like, several insurers have been vocal about their eagerness to work within the home care realm. Anthem Inc. (NYSE: ANTM) is firmly among that group.

Indianapolis-based Anthem was one of the first large insurers to take advantage of expanded MA flexibility in 2019 — when just 3% of plans did. Then, in October, the company announced it was doubling down on that strategy or the 2020 plan year.

“Because it was an entirely new program, the need was initial small upfront,” Martin Esquivel, VP of product management and strategic initiatives for Anthem, previously told HHCN. “But it has grown. We continue to be open to partnering with the types of organizations that make the most sense here. … The home care environment very much aligns with our goals, which are focused on whole-person health.”

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