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Medicare Advantage (MA) only became a real opportunity for home care providers five years ago. That is when the Centers for Medicare & Medicaid Services (CMS) introduced primarily health-related benefits, allowing for agencies to step in and provide personal care for beneficiaries on a limited basis.
Since then, MA plans have continued to expand these benefits, both through the primarily health-related pathway and the slightly newer Special Supplemental Benefits for the Chronically Ill (SSBCI).
Home care leaders have not come to a consensus on the right way to approach MA business. Some have indicated they are staying away, some are all in, and others are taking a wait-and-see approach while dipping their toes into the water.
“In-home support services are a really popular offering,” ATI Advisory Principal Tyler Cromer told me last month. “Nearly a quarter of all the plans are offering in-home support services this year.”
An even larger percentage of plans are offering some sort of in-home care ancillary benefit. About 40% of plans are offering primarily health-related benefits or SSBCIs.
But with five years of anecdotal and numerical data now available, the whole picture is becoming clearer. Home care agencies are not just saying they’re invested in MA; they’re saying how they specifically can make it work.
The growth of home care in MA, and the means in which providers are engaging with plans, is the topic of today’s exclusive, members-only HHCN+ Update.
Home care growth in MA
There are three reasons, as far as I can tell, that certain home care providers are unwilling to take a chance at MA business.
The first is the pay, which is far less than private pay and less consistent than VA or Medicaid. The second is hours, which are both lower in MA and less seamless from a scheduling perspective. The third is rooted in the idea that business is currently good for providers, so don’t try to fix something that’s not broken.
But both providers and the plans are starting to find ways to change – or work around – those issues.
The Chicago-based BrightStar Care is one of the most staunch supporters of leaning into MA. It has been since the start, with CEO Shelly Sun citing demographics as the reason behind its stance. MA, after all, is growing rapidly.
Sun has previously said that the company is already converting a small percentage of MA beneficiaries into private-pay clients later down the road. She’s also combining two challenges – MA’s constraints and internal scheduling woes – and attempting to find a solution.
“We make sure [to have] really strong engagement with our workforce,” Sun said. “We’re trying to understand what they’re looking for, and making sure that we have different paths. For instance, they may want more hours, or there’s the portion of the workforce that only wants to work two to four hours, and that’s a good matchup for MA.”
On the plans’ part, many have taken stock of beneficiaries’ engagement with certain benefits, such as in-home support services (IHSS).
“We continue to see a movement toward providing beneficiaries flexibility in how they use these benefits,” Cromer said. “It is a more person-centered approach. And what I mean by that is, we see plans offering – particularly within SSBCI options – anywhere from $1,000 to $2,000 per year to spend on any assortment of available supplemental benefits.”
ATI Advisory is a Washington, D.C.-based research and advisory firm that studies supplemental benefit developments closely.
Though the money is not enough to write home about just yet, the plans’ willingness to evolve these benefits is. The person-centered design approach, which ATI experts believe will continue, could benefit both beneficiaries and home care providers.
“We’re still just seeing quite a bit of activity in this space,” Cromer said.
While the picture is becoming clearer, it is far from perfectly clear. It’s evident that plans are offering more supplemental benefits, and those benefits are being taken advantage of more, but CMS is still collecting minimal utilization data.
“MA plans are required to submit detailed, service-level utilization data to CMS, the agency that oversees MA,” the U.S. Government Accountability Office wrote in a report. “These data – known as encounter data – must include supplemental benefits to the extent required by CMS. However, GAO found that information submitted by plans on enrollees’ use of supplemental benefits is limited.”
GAO listed two reasons for that: a disconnect between CMS and plans on what utilization data must be submitted, and a lack of procedure for collecting supplemental benefit data in the first place.
We do know that 1,091 plans are offering IHSS through the primarily health-related benefits in 2023, compared to 729 last year. Under the SSBCI pathway, 284 plans are offering IHSS, up from 216 in 2022. IHSS is unique in that it can be offered through both pathways.
The number and percentage of plans offering SSBCI continued to increase in 2023, though not at as great of a rate in years prior. That’s in line with expectations, according to Cromer, and also partially due to mathematical realities.
But another reason could be the growth of the value-based insurance design (VBID) model, which is in its third year.
VBID allows plans to target supplemental benefits toward those with low-income status. Low-income beneficiaries can receive certain benefits under VBID that they wouldn’t qualify for otherwise.
“We’re seeing that a lot of the dually eligible D-SNP plans are entering the VBID model and offering benefits that way,” Cromer said. “So I actually think, when we add in that VBID growth, we’ll see more growth in non-medical supplemental benefits.”
At the same time, there are precarious times ahead for MA plans. A CMS final rule suggested overpayment clawbacks were on the horizon, and plans are bracing for a negative payment adjustment in CY 2024.
They’ll have less money to work with. That could mean less investment in supplemental benefits. It could also mean a further investment in home-based care services to keep post-acute spend at bay.
Another way to MA
Given the breadth of the MA landscape, there are other ways to reach these beneficiaries without strictly going through two- or four-hour supplemental benefit cases.
Griswold Home Care CEO Michael Slupecki recently told Home Health Care News that he believes home care-home health relationships are another way in.
“Skilled home health doesn’t have the margin to pay us, but they could certainly introduce us to families that have the ability to pay,” Slupecki said. “Skilled home health is really there three to four hours a week. They’re in, they’re out, and it’s all about getting somebody well after a procedure or something similar. We can help by being there as eyes on a person on a daily basis.”
Home health providers leaning into risk- and value-based contracts with MA plans may see personal care partnerships – at no-cost to them – as an obvious value-add.
All the while, those home care providers could make inroads with future private-pay clients, just as BrightStar Care is through supplemental benefits.
“Anybody that’s getting reimbursed from managed Medicare has got skin in the game on rehospitalizations and unnecessary hospital visits,” Slupecki said. “That’s what we think is an immediate partnership opportunity at no cost to them. At the same time, we can demonstrate value and they’re, frankly, going to make more money by not being penalized for these preventable rehospitalizations.”