ManagedCareSupplement3

GENERATIONS – Journal of the American Society on Aging

these supplemental benefits—benefits not cov- ered in fee-for-service Medicare, but offered by MA plans—to beneficiaries beyond those enrolled in MA depends on agency implementa- tion and MA plan response. The Bipartisan Policy Center (BPC), under the leadership of former Senate Majority Leaders Tom Daschle (D-SD) and Bill Frist (R-TN), has Striking a balance between beneficiary transparency and flexibility to target benefits will significantly impact the law’s success. been working in recent years to identify barriers to the integration of services and the expansion of successful care models (BPC, 2016, 2017, 2018). In August 2018, the BPC released a report iden- tifying policy decisions that CMS would need to consider as the agency implemented the BBA. The BPC’s leaders stressed the importance of striking an appropriate balance between pro- viding flexibility to plans to select supplemental benefits, and to target those benefits to people with multiple chronic conditions (BPC, 2018). Taking those recommendations a step further, it is important to highlight the differences between the 2019 guidance and the statutory language that will guide CMS in developing regulations to guide benefits and targeting for plan year 2020. Two issues will be important in the law’s imple- mentation. The first is how CMS defines supple- mental benefits and what MA plans decide to cover. Historically, MA plans have used supple- mental benefits to increase enrollment in MA plans by offering benefits popular with older Americans, such as hearing, vision, and dental care, or to reduce beneficiary out-of-pocket costs (BPC, 2018). Increasingly, successful care mod- els have begun to ask questions about nutrition, Differences Between 2019 and 2020 MA Flexibility

housing, and whether patients are living in safe environments, namely, the social determinants of health. Healthcare providers and advocates have expressed enthusiasm over the idea that the new flexibility can be used to address some of these underlying causes of medical conditions. The second important issue is how plans are permitted to target benefits. It is important for Medicare beneficiaries to be aware of the ben- efits for which they may be eligible, so rules should be clear. At the same time, if the services must be offered to broad categories of benefi- ciaries, offering benefits will be very costly to plans, and will discourage plans from offering new benefits (BPC, 2018). Striking the appropri- ate balance between beneficiary transparency and flexibility to target benefits will have a sig- nificant impact on whether the law is successful or not. Supplemental benefits Prior to 2019, supplemental benefits have been defined in a way that limited the plans’ ability to provide lower cost services and supports to reduce more expensive medical costs. Under the law, benefits had to be “primarily health- related,” a term meaning that the item or service is used to “prevent, cure, or diminish an illness or injury.” In the past, plans were prohibited from covering items or services that CMS con- sidered to be used for daily maintenance. Beginning in January 2019, plans will be per- mitted some flexibility to expand supplemental benefits in MA. Because the Medicare statute allows MA plans to offer healthcare benefits, but does not define them, CMS used its authority to expand its previous interpretation of the term. In the April 2018 guidance, the agency redefined the term “primarily health-related,” to mean an item or service that: . . . is used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psy- chological impact of injuries or health conditions, or reduces avoidable emergency and healthcare uti- lization. A supplemental benefit is not primarily

84 | Spring 2019

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