CMS Updates Medicare Advantage Payment Policies, What It Means for SDoH


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New supplemental benefit coverage may help address SDoH amongst seniors

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) finalized new Medicare Advantage payment policies for 2020 that will increase competition among health plans, so patients receive higher quality care at lower costs. The changes announced by CMS will increase plan choices and benefits, allowing seniors the option to choose Medicare Advantage plans that offer supplemental benefits customized to their specific needs. Additionally, the new policies will also give chronically ill patients with Medicare Advantage plans access to a range of supplemental benefits that aren’t exactly health-related, but may improve or maintain their overall health.

The new updates to Medicare Advantage payment policies mark an important step toward addressing the social determinants of health (SDoH), particularly amongst beneficiaries who have high needs that require both medical and social services.

The Impact of SDoH on Seniors

According to a 2015 survey by The Commonwealth Fund, 37 percent of enrollees in Medicare Advantage plans have high needs. The survey also found that those with high needs are more likely to report having limited financial resources, low levels of education, social isolation and poor health.

Additional research by the Kaiser Family Foundation found that one in four Medicare beneficiaries has less than $15,000 in total savings, and almost one in 12 has no savings or is in debt. On a more granular level, wide disparities among racial and ethnic groups within Medicare populations remain stark: median per capita savings among white Medicare beneficiaries is more than six times greater than among either black or Hispanic beneficiaries. And even with Medicare coverage, beneficiaries still struggle with out-of-pocket medical costs. Of beneficiaries with incomes below the federal poverty level, 38.7 percent spend more than one-fifth of their annual incomes on premiums and out-of-pocket medical expenses.

By offering supplemental benefits, CMS may be able to make significant strides toward reducing the financial burden of medical expenses and improving the quality of care for beneficiaries. The new supplemental benefits may include meal delivery, transportation for non-medical needs like grocery shopping and home environment services. For a beneficiary with asthma, a Medicare Advantage plan could now cover home air cleaners or carpet shampooing to reduce irritants that can trigger asthma attacks. A Medicare Advantage plan could also cover healthy foods or produce for beneficiaries with heart disease or transportation to doctor’s appointments, diabetes education program or a nutritionist for beneficiaries with diabetes.

How Other Payers Are Addressing SDoH Among Seniors

As studies continue to show the real impact of economic and social conditions on overall senior health, private and public payers are developing innovative programs to improve health outcomes and reduce health expenditures for senior populations.

Programs that aim to connect seniors to social services can help bridge the gap between clinical and nonclinical care. For example, in 2014, the Health Plan of San Matteo (HPSM) launched the Community Care Settings Program (CCSP), a program that seeks to help aging and disabled individuals transition from long-term care facilities back into their own homes. As part of the program, case managers meet with the member and everyone involved in their care, and then they’re connected to community resources, stable housing and healthcare resources to support their ability to live in their homes. Within the first three years of the program, more than 70 HPSM members have successfully moved from nursing homes into an apartment or an assisted living communities. Another 90 members have received services and support from CCSP that have allowed them to remain in their current residential setting and continue to thrive within their communities.

Key SDoH Takeaways from Medicare Advantage Updates

Supplemental benefit updates to Medicare Advantage plans mark a pivotal moment in the journey toward health equity. Through nonclinical support, vulnerable populations can make improvements in their overall health outcomes. In addition to Medicare Advantage plan updates, other payers are creating innovative programs that aim to address the SDoH that many seniors face.

However, addressing SDoH is not without its challenges. For payers, traditional approaches to care delivery are often reactive. How can payers develop proactive strategies to address SDoH before member health outcomes worsen, and health expenditures continue to rise? Our latest white paper examines the effect of unaddressed social needs on payers, the challenges associated with implementing interventions, and how payers can develop proactive strategies to overcome those challenges. To learn more, download the white paper.

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Topics: social determinants of health Medicare

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