Why Home Care Can Still Define Medicare Advantage in 2020

In November, the Better Medicare Alliance and actuarial consulting firm Milliman dropped their latest report detailing how Medicare Advantage (MA) plans were acting on the expanded supplemental benefits rules federal policymakers established over the past couple of years.

Home care executives devoured the report, but came away feeling somewhat discouraged by an apparent lack of home-focused benefits for 2020. According to the Better Medicare Alliance and Milliman, just 148 MA plans said they’ll cover in-home support services this year, a far cry from the blockbuster some home care providers anticipated.

The reality, though, is that November’s report only tells part of home care’s MA story for 2020.

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“For the purposes of us knowing what’s being offered, where and how much … all of those questions, we need to make an important realization that the Centers for Medicare & Medicaid Services (CMS) has only released data on one pathway,” Anne Tumlinson, founder and CEO of Anne Tumlinson Innovations (ATI), told Home Health Care News. “There are two pathways for new supplemental benefits.”

The first of those supplemental benefits “pathways” was created in April 2018, when CMS announced it was expanding its definition of “primarily health-related.” So far, it’s this relatively narrow pathway that is most transparent and that home care providers know most about.

The second supplemental benefits pathway has its origins in 2018 as well, specifically in the Bipartisan Budget Act of 2018 and related Chronic Care Act. Following Congressional action, CMS was ultimately able to craft the SSBCI MA option, or “Special Supplemental Benefits for the Chronically Ill.”

The primary distinction between the two pathways — the expansion of primarily-health related supplemental benefits and SSBCI — is that SSBCI is not required to be primarily health-related, while typical supplemental benefits are, according to Tumlinson.

Other requirements are also less demanding for SSBCI.

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“That second pathway allows for a service set that is much more socially oriented,” Tumlinson said. “There might be other home care services and supports being offered under that pathway that look a little different or have other nuances to them. Like housing, for example. Housing is on that list [of potential supplemental benefits] for SSBCI.”

Tricky for franchises

ATI expects CMS to release the data on SSBCI supplemental benefits “any day now,” Tumlinson said.

In the meantime, the Washington, D.C.-based research and advisory services firm is busy gleaning insights from what’s already out there about in-home care and the primarily health-related MA pathway. ATI is likewise ramping up its collaboration with home care provider clients, helping them do organizational assessments and figure out how to strategically engage with health plans.

When it comes to the latter task, ATI has particularly done a lot of work with franchise organizations and their local-level franchisees.

“When you’re a franchise organization, [MA] can be tricky,” Tumlinson said. “There are a whole bunch of issues that come up.”

Similar to the November report from the Better Medicare Alliance and Milliman, ATI determined that 223 plans will offer in-home support services benefits in 2020, including Dual Eligible Special Needs Plans (D-SNPs). Those plans serve nearly 950,000 Medicare beneficiaries combined across 30 states and Puerto Rico.

“I would definitely not say that it’s not very much,” Tumlinson said, commenting on the general “too little, too slow” attitude some in-home care providers maintain. “In terms of geographic coverage and carriers, there’s a lot going on — with in-home services supports alone.”

Additionally, the list of carriers to get in on the in-home support services action is vast, research from ATI shows.

Aetna, Anthem, Humana and UnitedHealthcare have all developed home-focused benefits in at least one of their markets, as have WellCare, Amerigroup and “a lot of the Blues.”

“It doesn’t mean they’re offering them everywhere, obviously,” Tumlinson said. “But these carriers are offering them in at least some of their markets.”

Unsurprisingly, in-home support services supplemental benefits are typically found where MA penetration is already pretty high. It’s also worth noting that at least 85 plans in 16 states are offering adult day health services benefits in 2020, she said.

Post-discharge benefits

There are already some examples of SSBCI-type benefits that have emerged.

For example, multiple plans toward the end of 2019 touted their relationship with Papa, a Miami-based startup that connects older adults to college students with the goal of decreasing social isolation.

Specific examples of the narrower, primarily health-related pathway are also plentiful.

Upon discharge from a hospital or nursing facility in 2020, for instance, Anthem MediBlue Value Plus members in Los Angeles County have access to up to eight 4-hour shifts of assistance in performing activities of daily living (ADLs). That could mean support with light housework or even with grocery shopping. 

“There seems to be … a lot of post-discharge benefits,” Tumlinson said. “Something approximating in-home support services can, theoretically, be offered as part of a readmission-prevention benefit. When we say there are 223 plans offering in-home support services, we’re not counting, necessarily, plans that have filed for this readmission-prevention benefit, which may include an in-home safety assessment, post-discharge meals or post-discharge, in-home medication reconciliation.”

There are 98 plans offering readmission-prevention benefits in 2020, according to ATI.

While there are a couple hundred plans covering-in home care this year, there are 2,000 or so covering transportation or meals under the primarily health-related pathway.

“But if you’re offering a transportation benefit under the first pathway — primarily health-related — the transportation has to be … to a medical appointment,” Tumlinson said. “If you offer a meal, the meal has to be following a hospital or SNF discharge, only for that period of time.”

ATI expects to share insights on SSBCI shortly after CMS releases data on that pathway later this month.

“We’re waiting with bated breath,” Tumlinson said.

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