Changes Afoot for Medicare Advantage Plans?

by Anne Shropshire | May 14, 2018

At a recent Medicare conference, the Centers for Medicare and Medicaid Services (CMS) indicated that Medicare Advantage plans will be able to cover certain services commonly associated with long-term care, beginning in 2019. This will be possible because CMS has expanded the definitional scope of “supplemental benefits” that Medicare Advantage plans can offer. 

Supplemental Benefits

Supplemental benefits are additional benefits that Medicare Advantage plans can offer to their enrollees that are not covered by Original Medicare. Previously, CMS did not allow any item or service to qualify as a supplemental benefit if its primary purpose was for “daily maintenance.” The agency has now reinterpreted the requirements for supplemental benefits to include a “primarily health related” definition, as follows:

An item or service that is used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.

Accordingly, this reinterpretation of supplemental benefits will allow Medicare Advantage plans to offer coverage or benefits for the following:

  • Adult day care services – services provided outside the home, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 
  • In-home support services – services performed by a personal care attendant to assist disabled or medically needy individuals with ADLs and IADLs.  Services must be performed by individuals licensed to provide personal care services, or in a manner that is otherwise consistent with state requirements.
  • Home-based palliative care – services not covered by Medicare in the home for palliative care (“comfort care”) to diminish symptoms of a terminally ill enrollee with a life expectancy of more than six months.
  • Transportation for (non-emergency) medical services – transportation to obtain Part A, Part B, Part D and supplemental benefit items and services.  The transportation must be used to accommodate the enrollee’s health care needs; it cannot be used for non-medical services, such as groceries or errands.
  • Home safety devices and modifications – safety devices to prevent injuries in the home and/or bathroom.  The modifications must be non-structural and non-Medicare covered.  This benefit can include a home and/or bathroom safety inspection to identify any need for safety devices or modifications.

These supplemental benefits must be recommended by a physician or licensed medical professional.

Benefits Uniformity Flexibility

In addition to a revised interpretation of supplemental benefits, CMS is also planning to allow greater flexibility in its “benefits uniformity” requirement. Currently, Medicare Advantage plans must offer the same benefits and cost sharing to all plan enrollees. Effective 2019, a Medicare Advantage plan will be able to deviate from this strict standard in the following ways:

  • It can reduce or eliminate cost-sharing for certain covered benefits or services.
  • It can make coverage for certain supplemental benefits available only to targeted populations.
  • It may offer targeted benefits to enrollees who participate in a plan-sponsored wellness or care management program.
  • It may offer targeted benefits to enrollees when they visit providers identified by the plan as being high value.

Anne Shropshire, CLU, is Director of Content for WebCE. She has been in the insurance training and CE business for over 20 years, and has authored many courses on a wide range of topics, including life insurance, health insurance, annuities and ethics.

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Source:  From the “Medicare Advantage Benefit Flexibility” session delivered at CMS’ Medicare Advantage & Prescription Drug Plan Spring Conference and Webcast, May 9, 2018.