For many specialty provider organizations, Medicare hasn’t really been a great market opportunity. The benefits are narrowly defined to those that are medical in nature, and the administrative requirements are daunting. But I left The 2020 OPEN MINDS Strategy & Innovation Institute presentation by Allison Rizer, MHP, MBA, the former vice president of strategy and health policy at UnitedHealthcare, Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid, thinking about the very interesting window to demonstrate value in Medicare Advantage plans in the midst of the pandemic.
The opportunity is with the Medicare/Medicaid dual eligible population—a very diverse population with many interesting service niches. The statistics in Ms. Rizer’s keynote painted a picture of a dual eligible population with a wide range of health care issues. Twenty percent have Alzheimer’s. Fifty percent are disabled, and 50% need supports for activities of daily living. Twelve percent are over 85 and 40% are under 65. But what they share is a high level of co-morbidities and higher resource needs than the general Medicare and Medicaid populations. And, the dual eligible population is growing faster than non-dual eligibles in Medicare.
The new opportunities are due to two factors: The Centers for Medicare & Medicaid Services’ (CMS) goal of more integration and the pandemic. CMS has had a long-standing goal of developing “integrated” approaches to the separate Medicaid and Medicare benefits of this population. Almost nine million of these consumers have a completely uncoordinated experience in the health care system as the integration initiatives—like D-SNPs and PACE—cover a relatively small proportion of the population. CMS has made many efforts to “encourage” these initiatives. In the past year, CMS issued a letter to states encouraging them to extend, expand, and reimagine the Medicaid/Medicare plans. And as of January 2021, Medicare Advantage D-SNP plans will be required to share information with states. State Medicaid plans are moving along that path. “States are becoming savvier about how to ‘lean in’ to Medicare,” said Ms. Rizer, to influence and leverage Medicare dollars. States are adding Medicare components to Medicaid health plan requests for proposals and asking D-SNP plans to accept capitation payment for the Medicaid benefits of their current Medicare members.
The opportunity for specialty provider organizations lies in the Medicare supplemental benefits—and recent changes to those benefits due to the pandemic. All D-SNP plans must cover traditional Medicare benefits and then provide supplemental benefits out of their cost savings (98% of plans do provide supplemental benefits). Historically, supplemental benefits had to be “medical” but in 2019, there was a turning point in Medicare policy and “primarily health related” was redefined to include long-term services and supports—services like personal care and adult day services. And earlier this year, Congress redefined the supplemental benefits further. In the new definition, these benefits are no longer required to be health related as long as they are targeted to complex consumers’ well-being—including social services (food, meals, robotic pets, housing supports, etc.). At the same time, because of COVID, CMS is allowing Medicare plans to make mid-year benefit changes, giving more flexibility than ever before to add supplemental benefits. As a result, these new “non-medical” benefits are being offered in 1,900 counties. It is a sea change for Medicare amid the crisis.
These policy changes and the pandemic have created an unexpected window for new supplemental services. Plans have the ability to add new non-traditional supplemental benefits paid for out of their savings—and savings are up because medical spending is down, as consumers delay care and stay home. At the same time, the pandemic has brought to light the need for social support services for the dual eligible population. This group has high rates of depression and anxiety, and they are more vulnerable to the effects of isolation. As Ms. Rizer pointed out, the new social needs benefits allow for programs that provide companion care for isolation and services to improve emotional and cognitive function.
This is a time for specialty provider organizations to review the services they provide for consumers with coverage through other payers and see if there might be an application in this new Medicare opportunity. The temporary COVID-related flexibility granted to Medicare Advantage SNPs provides a window to demonstrate the return-on-investment of innovative programs that need a new funding source. It’s an opportunity to tell a new value story.
If your business development team needs to know more, I highly recommend Ms. Rizer’s great two-part presentation and open forum—Emerging Models & New Benefits For Individuals Dually Eligible For Medicare & Medicaid and Open Forum On New Benefits Models For Dual Eligible Consumers—as a primer. (I learned a lot!) And, to learn more about the Medicare Advantage plans in any specific geographic area, Elite-level members can download lists of Medicare Advantage plans through our on-demand datasets (go to OPEN MINDS On-Demand Datasets and search for “health plan” with the name of your state). And for more about dual eligible consumers, check out these resources from The OPEN MINDS Circle Library:
- Medicare-Medicaid Dual Eligible 2018 Market Update: Enrollment & Coverage
- The Path Forward In Serving The Dual Eligible Population
- CMS Guidance To State Medicaid Directors Recommends Leveraging Managed Care To Improve Services For Dual Eligibles
- 10 Opportunities To Better Serve Individuals Dually Eligible For Medicaid And Medicare
- Enrollment In Medicare/Medicaid Health Integrated Plans Affected By 3 Main Factors
- CMS Forwarding 3 Opportunities For State Integrated Care For Dually Eligible Individuals
- Illinois Medicare-Medicaid Alignment Initiative Reduced Inpatient Utilization By 15% In First Year
- Where Are The Dual Eligible Demonstration Projects?
- Half States Planning A Dual Eligible Pilot Program Having Second Thoughts
- OPEN MINDS State Profile Series
And for another deep dive, join me on August 26 at The 2020 OPEN MINDS Management Best Practices Institute for the keynote address, “Integrating Behavioral Health In A Fragmented World,” by MaryAnne Lindeblad, State Medical Director, Washington State Health Care Authority.