Take Advantage of New Health-Related Supplemental Benefits

Stable, safe housing and access to nutritious food are undoubtedly necessary elements required for optimal health. And few would argue that a patient must have access to transportation to obtain preventive services and manage chronic conditions. Now is the time many plans begin evaluating which social support and non-medical services to include in 2020 Medicare Advantage (MA) offerings, which can now include such things as adult day care services, home-based palliative care, respite and other supports for caregivers, in-home support services, home and bathroom safety devices and modifications, transportation, over-the-counter drug benefits, etc.

With the Centers for Medicare & Medicaid Services (CMS) expanded definition of health-related supplemental benefits, combined with the personalized benefit offerings afforded in 2020 through the CHRONIC Care Act, designing benefits has never been more complex or critical to an MA plan’s success. Even though CMS has given us the flexibility we’ve long desired, where do we go from here?

  • Identify your members’ needs. Selecting appropriate health-related supplemental or condition-specific benefits will require hyper-local evaluation. For obvious reasons, product design decisions initially focus around market competitiveness. But identifying which health-related supplemental benefits and condition-specific benefits will be beneficial for your plan requires careful analysis of your data. We recommend identifying which members your expanded benefits need to target then evaluating their clinical conditions, care patterns, and likely social determinants of health in order to ensure your investment in additional benefits achieves your desired return on investment.
  • Involve your providers. Expanded benefits can help MA plans and their at-risk providers truly improve health, improve outcomes, and improve their empathetic care for members. If designed well, and with sound strategy, they can also improve medical spend. Ask your providers what their patients need and who they lean into in the community to support these needs. And share the chronic condition data you collect through in-home assessments, health risk assessment responses, and other patient insights with providers so they don’t have to waste precious time in the exam room duplicating services you’ve already completed. Finally, for your fee-for-service providers, recognize the financial impact healthier patients who require fewer services have on their practices and adjust contracts and payment terms accordingly.
  • Know your partners. Part of the current challenge many MA plans face in selecting new health-related supplemental benefits and/or condition-specific benefits is the inability to identify vendors and service providers who can service the plan’s entire MA service area. While searching for vendor partners to support non-traditional benefit offerings, develop clarity between the direct interventions you plan to support, those you’ll leverage your providers to deliver, and those you may need to lean into community partnerships to support in new ways. Explore solutions that supplement resources already available in the community (potentially augmenting their resource gaps) rather than replacing and/or displacing these important support systems.
  • And remember – expanded benefits must complement sound core benefits. Operating successfully in MA requires plans to first offer provider networks, formularies, and services that meet members’ clinical needs. Many plans will be tempted to try to compensate for weaknesses in these core areas through health-related supplemental benefits and condition-specific benefits because it’s such a “flashy” marketing opportunity; however, simultaneously resolving known gaps and weaknesses among the network and formulary while investing in enhanced benefits will provide the greatest near-term opportunity. And don’t forget – these services will be subject to standard appeals and grievances regulations just as all other services are, so staff will need to thoroughly understand how members will access these new, exciting benefits.

CMS continues its focus on consumers and market competition through these enhanced benefit offerings, which will be exacerbated by the increased weighting of Patient Access and Experience Star Ratings measures beginning in 2019. Are you ready? If not, we can help. For questions or inquiries, please contact me at msmith@gormanhealthgroup.com.




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Melissa Smith
Melissa Smith

Melissa Smith is Senior Vice President of Stars & Strategy at Gorman Health Group, LLC (GHG). Melissa’s team helps clients improve performance within quality ratings systems such as Star Ratings, improve health outcomes and the member experience, evaluate market dynamics and opportunities, optimize distribution channels, and supports our clients’ strategic planning needs.

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