Flexibility in MA supplemental benefits can move the needle on outcomes
The coronavirus outbreak first suspended — then upended — ordinary life for most Americans. Now, with the explosion of COVID-19 cases across the country, broader health and safety concerns around the epidemic are hitting close to home. The recently enacted coronavirus emergency supplemental legislation, which includes enhanced telehealth coverage for Medicare beneficiaries, will then be welcome news.
But the new legislation foregrounds something else as well: namely, that payors have a number of tools at their disposal, and by thinking outside of the “four walls” of clinical care payors can move the needle on health outcomes.
MA Supplemental Benefits in the age of COVID-19
As COVID-19 continues to spread, leveraging supplemental service benefits may help alleviate some of the long-term implications on community health. With more than 42 percent of adults 65 years or older living under 200 percent of the federal poverty line (on an income of around $23,500 annually), population health leaders are bracing for a surge in communities experiencing hardships.
Before the 2019 plan year, supplemental service benefits funded by rebates had to be items or services not covered by Medicare, primarily health-related, and incurred direct medical cost for the MA plan. But in 2019, the Centers for Medicare & Medicaid Services (CMS) increased flexibility for Medicare Advantage (MA) plans to allow them to cover new benefits that address enrollees’ health-related social needs or long-term care needs.
In other words, non-health related supplemental service benefits for the chronically ill (SSBI) are now far-reaching. They can include transportation, food, social supports (e.g., childcare, companion care, programs to address social isolation), pest control, home modifications, financial literacy, utilities assistance), and more.
MA plans also have broad discretion in developing items and services they may offer as a supplemental service benefit, provided that the item or service has "a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees." But notably, MA plans have broad discretion in determining what may be considered 'a reasonable expectation'.
With new cases of COVID-19 increasing daily and the number of people facing food insecurity, housing insecurity, social isolation, and other social determinants of health (SDoH) factors expected to go up, the flexibility of non-health related supplemental service benefits is a vital tool in combatting some of the long-term consequences of the virus on SDoH.
Operational Challenges Ahead
Despite the flexibility, a study by the Urban Institute and the Robert Wood Johnson Foundation found that none of the MA plans they interviewed rolled out nationwide benefits in 2019, and many enhancements have focused on a limited set of beneficiaries or geographic areas.
MA plans cited that the availability of community-based organizations (CBOs) that can provide a given benefit and bill an insurance company varies by region, and the need to negotiate contracts by county adds great complexity. They also did not think they had sufficient information to select benefits with a high likelihood of a positive return on investment, and some expressed skepticism that addressing health-related social needs would affect health care costs. MA plans also revealed that addressing enrollees’ health-related social needs is complicated. Which has led them to focus on expanding existing benefits, like transportation or home delivered meals, rather than commit substantial resources to exploring new benefits like housing assistance.
Investing in COVID-19-related SDoH
Supplemental service benefits are not the only tools payors are using to alleviate the hardships caused by the COVID-19 pandemic. Payors across the country are looking at ways they can address immediate needs without facing the operational challenges associated with offering supplemental service benefits.
For example, Tufts Health Plan Foundation recently donated $1 million towards addressing SDoH in elderly communities. The funds will cover a variety of services, including food, at-home support, housing, transportation, and medical supplies in communities across Massachusetts, Rhode Island, New Hampshire, and Connecticut.
The Humana Foundation also recently invested $500,000 toward COVID-19 recovery and SDoH. The investment will go toward organizations focused on addressing food access. Ninety percent of the funds will be used to support Feeding America as well as Humana’s Bold Goal communities. Another $125,000 will go towards providing financial assistance such as SNAP application outreach. The remaining $50,000 will go toward expanding an acute care center in Louisville, Kentucky.
Although, payor philanthropy can help mitigate some of the immediate issues arising from COVID-19, it will not solve the long-term SDoH challenges resulting from the pandemic. The disproportionate impact of coronavirus on lower-income populations makes clear that SDoH and health outcomes are inextricably linked and will continue to impact vulnerable communities for years to come.
Now, more than ever, payors and other healthcare organizations must move outside the “four walls” of clinical care and look toward innovative solutions to ensure health equity. And although payors may face seemingly insurmountable challenges on the path toward whole-person care, some resources can help payors navigate the murky waters of operationalizing supplemental service benefits and other SDoH challenges.
Learn more about developing proactive strategies to address SDoH and how to overcome the operational challenges on the path toward whole-person care.