ManagedCareSupplement3

A Primer on Managed Care: Multiple Chronic Conditions

year 2020 was expected to be included in regula- tions released in November 2018, but CMS pro- vided no additional guidance to plans on which types of services the agency would approve. In setting parameters for coverage of supple- mental benefits, Congress defined supplemental benefits broadly as “items or services that have a reasonable expectation of improving or main- taining health or overall function.” The language expressly prohibits the Secretary of Health and Human Services from requiring that the benefit be health-related (BBA, 2018). This language has the potential to greatly improve person-centered care by allowing plans and providers to talk to patients and their families about their goals and to develop a care plan based upon their needs, rather than what is covered under the Medicare program. If CMS takes the same approach for 2020, plans will submit benefits for approval, and while the agency has considerable flexibility in approving benefits, they will work to consider evidence provided by plans that can improve or maintain health or functional status for com- plex patients. Because at least a subset of benefits will overlap with Medicaid-covered benefits for those covered by both Medicare and Medicaid, plans that have provided Medicaid long-term services and supports (LTSS) may have valuable experience, as well as plan-level data that could prove to be useful. Targeting of services The 2019 guidance permits plans to develop disease-specific benefits for those with chronic conditions (or other serious illnesses) if they are made broadly available to all enrollees with the given diagnosis. Under the guidance, allowable supplemental benefits must be medically related to the targeted enrollee’s health status or disease state (CMS, 2018a). This approach limits the abil- ity of plans to arbitrarily decide who receives an item or service and who does not. In establishing guidelines for 2020, CMS also will need to make sure that similarly situated enrollees are treated in the same manner. However, one factor that

health related under the previous or new definition if it is an item or service that is solely or primar- ily used for cosmetic, comfort, general use, or social determinant purposes.” As an example, the agency cited fall prevention devices as an allowable sup- plemental benefit. Expanding the definition to include daily maintenance for a “defined period and in certain situations” (CMS, 2018b). A recent report by the Long-Term Qual- ity Alliance (LTQA) provided insight into MA plans’ experience around the expansion of sup- plemental benefits in 2019. Survey participants reported that many benefits that were suggested by plans were not approved by CMS; these ben- efits included home-delivered meals and non- emergency medical transportation, primarily ‘Allowable supplemental benefits must be medically related to the targeted enrollee’s health status or disease state.’ because they were not considered health-related (LTQA, 2018). According to an analysis of CMS data, about 40 percent of plans will begin offer- ing new supplemental benefits in 2019. The most common new supplemental benefit is the expan- sion of Medicare’s smoking cessation benefit to include nicotine replacement therapy. A subset of plans will offer caregiver support services, in- home support and personal care services, social worker phone lines, and adult day services bene- fit (Creighton and Young, 2018). Many of the plans that have been delaying their decisions about whether or not to expand supplemental benefits until 2020 would like additional clarification from CMS in several areas, including which types of services can be covered. Others have expressed a need for more time to consider member needs, more data on the cost-effectiveness of benefits, and information on consumer response to the added benefits in 2019 (LTQA, 2018). The additional guidance for plan

supplement 3 | 85

Made with FlippingBook Learn more on our blog