Officials at the Centers for Medicare and Medicaid Services (CMS) are giving insurers more advice about how to put little bits of short-term care insurance into the Medicare Advantage plans they intend to offer in 2020.
CMS officials sketch out the rules for “Special Supplemental Benefits for the Chronically Ill” (SSBCI) in the draft call letter for the Medicare Advantage program bidding process for 2020.
(Related: 4 Top Medicare Advantage Mini LTC Benefits)
CMS officials began letting issuers add some ”not primarily health related” benefits to 2019 Medicare Advantage plan benefit menus in the middle of 2018, after the issuers had already completed much of the work involved with designing and pricing their 2019 plans.
This year, CMS is including the option to offer SSBCI benefits in the plan design and bidding process from the start.
The Medicare Advantage program, which is the best-known Medicare Part C program, gives private insurers a chance to offer an alternative to what CMS calls “Original Medicare,” or a combination of Medicare Part A hospitalization coverage and Medicare Part B outpatient and physician services coverage.
About 22 million people have Medicare Advantage plan coverage, according to the CMS data.
Comments on the draft call letter, and the notice the call letter comes with, are due March.
CMS hopes to release its final 2020 funding and rules notice for the 2020 Medicare Advantage and Medicare Part D drug coverage programs April 1.
The Proposed Numbers
CMS officials say they think the “effective growth rate,” or increase in the underlying cost of care, will be 4.59% in 2020. That’s up from the effective growth rate of 4.35% in the draft call letter released a year ago.
CMS estimates a variety of other adjustments will lead to average per-enrollee revenue to increase 1.59%, down from the average increased of 1.84% projected for 2019 a year ago.
The final parameters are subject to negotiation. Issuers often persuade Medicare program managers to change their initial numbers.
Traditionally, Medicaid — a program that uses a combination of federal and state money to provide care for the poor, and for people who meet state nursing home benefits eligibility rules — has paid for nursing home care for eligible people.
Medicare program managers have developed some programs that provide home care, especially in conjunction with alliances of Medicare plans and state Medicaid programs. But, in theory, Medicare has paid only for medical care, not for support services, such as meal preparation, help with cleaning or help with buying groceries.
CMS began letting issuers provide benefits related to the “social determinants of care” for Medicare Advantage plan enrollees in the call letter for 2019.
In 2019, for example, some Medicare Advantage plan issuers are using that policy to add small amounts of adult day care coverage to their benefits lists.
Congress included a provision in the Bipartisan Budget Act of 2018 that changed Section 1852(a) of the Social Security Act. That provision further expands the kinds of supplemental benefits that Medicare Advantage plans can offer for enrollees with chronic conditions, CMS officials write in the draft call letter.
The kinds of benefits CMS describes appear to resemble small amounts of the kinds of coverage a long-term care insurance, or a short-term care (STC) insurance policy or convalescent care policy, might cover, such as:
- Transportation for non-medical needs.
- Home-delivered meals.
- Food. Produce.
- Other items and services, if the issuer has a reasonable expectation of the items or services improving or maintaining the health or overall function of the enrollee.
To qualify for those mini STC benefits, an enrollee must:
- Have “one or more comorbid medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee”;
- Have “a high risk of hospitalization or other adverse health outcome”s; and
- Require intensive care coordination.
An issuer needs to develop a mechanism for deciding who qualifies for the SSBCIs, tracking the decisionmaking process, and responding to appeals if and when the issuer rejects some patients’ SSBCI claims, officials say.
A plan can target certain SSBCIs to enrollees with specific health needs, but it needs to develop objective criteria for that targeting, officials say.
A plan cannot provide capital or structural improvements to a home, such as the installation of permanent wheelchair ramps, that could increase the home’s value, “to avoid any anti-kickback implications or taxable improvements,” officials say. “Additionally, items and services may not be offered to induce enrollment.”
D-SNP Clone Wars
Some issuers offer Dual-Eligible Special Needs Plans, or D-SNPs.
Those are Medicare Advantage plans designed for Medicare enrollees who also qualified for Medicaid, and who may have serious or chronic health problems, such as diabetes.
CMS officials say some companies appear to be marketing ordinary Medicare Advantage plans that are designed to look like D-SNPs. CMS is calling those plans “D-SNP look-alikes.”
“CMS has received a number of anecdotal reports from multiple sources across multiple states about misleading marketing and training materials for agents and brokers that misrepresent the characteristics of such look-alike plans and describe them as designed specifically for dually eligible beneficiaries,” officials say.
The marketing of the look-alikes may hurt state efforts to integrate Medicare and Medicaid benefits, and the look-alike may lack some important D-SNP features, such as periodic health risk assessments and efforts to develop individualized care plans, officials say.
CMS is seeking comments on the impacts of D-SNP look-alikes.
“Comments will inform future policy development,” officials say. “To the extent that D-SNP look-alike plans impede CMS or state policy priorities in these and other areas, we would consider future rulemaking.”
A copy of the advance notice announcement is here.
Links to more documents related to the bidding process are available here.
— Read CMS Tries to Flush ‘Sick Creep’ Out of Medicare Advantage Rates, on ThinkAdvisor.