Smaller MA Plans Are Leveraging the Home to Get Ahead

The Medicare Advantage (MA) market is controlled mostly by big payers, as the top 10 plans control over 75% of the market. Then there is a 50-foot cliff.

Yet at the bottom of that cliff, there are the smaller MA payers who are often more willing to explore and innovate to stand out.

Examples of bigger MA organizations include UnitedHealthcare (NYSE:UNH), Humana Inc. (NYSE: HUM) and CVS (NYSE: CVS). Smaller MA players aren’t necessarily small in size; they just control less of the MA market.


And a lot of them are banking on proprietary technology and an in-home focus to differentiate themselves among a crowded field. Utilizing supplemental benefits afforded to plans by the U.S. Centers for Medicare & Medicaid Services (CMS), in particular, is a way to do so.

Whether it’s the primarily health-related benefit pathway or the newer Special Supplemental Benefits for the Chronically Ill (SSBCI) route, each allows MA players to be creative, Tyler Cromer, a principal for the Washington, D.C.-based research and advisory firm ATI Advisory, told Home Health Care News.

“I do think that plans think about these benefits as a way to differentiate themselves in a crowded marketplace,” Cromer said. “And providing the right combination of benefits that really meet member needs could result in a competitive advantage in any individual market.”


Over the last few years, both pathways have been offered and expanded for MA plans, which has piqued the interest of home-based care providers.

More aggressive plans have seen this as an opportunity to grow membership and market themselves to MA beneficiaries through home-based offerings. They’ve also viewed it as a way to reduce costs by keeping members out of the hospital.

California-based SCAN Health Plan, for instance, is offering health technology to give members telehealth real-time access to physicians from their homes. They are also offering tech training to give members the ability to use technology they’re given.

Idaho-based Regence — an affiliate of BlueCross BlueShield — is offering virtual companionship through the SSBCI benefit. Similarly, Pennsylvania-based Geisinger is providing allowances of up to $1,000 to beneficiaries for personal care, meals, home modifications and a slew of other offerings.

“We love seeing these options being offered at a local level, that are very person-centered and help to meet the needs of beneficiaries where they are,” Cromer said. “And right now, in particular, that is in the home.”

Plans are handicapped by what benefits they can offer, but being bold enough to jump at the home opportunity as a more regional player can pay off.

“Plans are pretty limited in the amount of dollars they can spend on supplemental benefits,” Elexa Rallos, an analyst at ATI Advisory, told HHCN. “So if they’re introducing a new one, that could potentially mean cutting back on something popular right now. So they really have to be thoughtful about the way they spend the limited resources they have.”

Laggards or leaders?

Some bigger payers are innovating and willing to take risks as well. That is all dependent on the culture of the organization, Cromer said.

“I think we’re absolutely seeing innovation across both small and large carriers, depending on the plans orientation, in trying new benefits and providing new services that help their members,” she said. “There’s a wide variety, from really nothing at all from some of the major carriers down to larger plans that are really leading the charge.”

One of those larger carriers that’s innovating on a significant level is Indianapolis-based Anthem (NYSE: ANTM). Anthem has paired with home-based care providers across the country to provide SSBCIs to its members.

“That’s an example of seeing some real forward-leaning action by a major carrier,” Cromer said. “Anthem offers a menu of benefits that members can choose from, if they meet the eligibility criteria. They’ve really been out in front with their offerings.”

Humana also has unique offerings in select markets that are similar to Geisinger’s, Cromer added.

Clover Health (Nasdaq: CLOV) is not one of the largest MA insurers, but it does have a desire to compete with them. The Franklin, Tennessee-based business, which recently went public through a special purpose acquisition company (SPAC), views itself as a technology company first. 

“We believe that we’ll be able to compete,” Kumar Dharmarajan, the chief scientific officer at Clover Health, told HHCN. “We’re smaller than the legacy players. But as a younger company with a technology-centric vision, we believe we’re actually able to execute on that vision in ways that other payers will find more challenging.”

Because those legacy players have been embedded in conventional wisdom for decades, Dharmajan believes Clover has a leg up moving forward as an MA plan.

“Because of the systems they have and the infrastructure that they’ve been built on, … it’s going to be really hard for them to pivot to the way that we’re doing things,” Dharmajan said.

The company sees its Clover Assistant as a notable advantage. On a high level, the Clover Assistant program enables its provider partners to leverage its data platform and provide more personalized care for their patients.

Reaching those patients in the home has been one of Clover’s primary goals. It believes a home-based focus — paired with technology — will unlock a prosperous path forward for the company.

“Clover believes in the value of providing care in the home, full stop,” Dharmajan said. “We feel that way because we’ve done a lot of it and we’ve seen the value that it can bring to patients. The home lets you access some of your sickest health plan members and patients, who aren’t generally leaving the home in the first place.”

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