Seema Verma Seema Verma (Photo: CMS)

Starting in 2019, Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications, a top Trump administration official said Wednesday.

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services (CMS), talked about the Medicare Advantage program’s new benefits flexibility at a Medicare conference at CMS headquarters, in Baltimore.

(Related: Maybe Traditional Medicare Should Cover Chronic Care: Hearing Witnesses)

CMS announced the rule reinterpretations in April, in a memo sent to potential 2019 Medicare Advantage plan issuers. It is not yet clear whether any issuers will add significant chronic care supplemental benefits for 2019, although executives from Humana Inc. hinted during their first-quarter earnings call that they might be able to work with partners to do so.

Verma told insurance company executives at the conference that CMS hopes its new “reinterpretation” of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.

She said she has seen the effects of that creativity in her own life.

“Both my parents are enrolled in a Medicare Advantage plan, and they can’t stop talking about them,” Verma said, according to a written version of her remarks distributed by CMS.

A copy of the speech is available here.

The Old Rules

The Medicare Advantage program lets private insurers use a combination of government money and patient premiums to provide an alternative to traditional Medicare coverage.

In the past, managers of Medicare Advantage have tried to simplify the plan shopping process, and discouraged plans from offering benefits that might drive up health care costs, by putting tight restrictions on the kinds of benefits a plan issuer can offer.

Those restrictions kept plan issuers from adding benefits such as adult day care benefits, except when  the plans were participating in CMS pilot programs or other special programs.

The New Rules

Verma said CMS now wants to let plans offer benefits that can compensate for physical impairments, reduce the impact of injuries, or reduce avoidable use of emergency rooms.

Verma did not use the term “long-term care,” or “short-term care,” but the benefits she described appear to be similar to the kinds of benefits many private long-term care insurance policies through home health care and community care provisions.

Plans can also add supplemental benefits tailored to meet the needs of people with specific conditions, Verma said.

Staff Presentation Details

Also at the conference, two other CMS employees, Heather Kilbourne and Brandy Alston, presented a slidedeck that gives benefits flexibility details.

A “zipped” packet of conference presentations is available here.

The CMS staff members noted that CMS is offering benefits flexibility through what legally are two separate interpretations: a supplemental benefits interpretation and a benefits uniformity flexibility interpretation.

The new interpretations are separate from the chronic care benefits versions in the Bipartisan Budget Act of 2018. The BBA-2018 provisions will further expand the range of Medicare supplemental benefits chronically ill enrollees can get starting in 2020, the staffers said.

Supplemental Benefits

Plans adding benefits based on the supplemental benefits interpretation must make sure the benefits are ”primarily health related,” and not primarily for a patient’s comfort.

The services covered must be recommended by a physician or other licensed medical professional as part of a care plan.

The new benefits must not include items or services used to induce enrollment.

A plan can choose to help individuals both with basic “activities of daily living,” such as walking, and with the “instrumental activities of daily living,” such as taking medications correctly.

Uniformity Flexibility

The new “uniformity” flexibility interpretation will let a plan tailor benefits, such as deductibles or wellness options, to fit people with certain medical conditions, such as diabetes.

That interpretation will not let a plan tailor benefits based on an enrollee’s income or poverty level, or any other characteristic other than health status,  the officials said.

Plans must use “objective and measurable” criteria to identify eligible enrollees.

— Read Medicare Advantage Plans Can Pay for Many LTC Services in 2019: Feds on ThinkAdvisor.

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