Health+Benefits Vital Signs the December 2019 issue

Medicare Advantage Takes Holistic Approach

Q&A with Mark Kriscunas, leader of business operations and finance, and Peter Phillips head of account management and client services, at Cavulus, a Medicare Advantage technology provider.
By Tammy Worth Posted on November 26, 2019
How did this change in Medicare Advantage benefits come about?
Kriscunas: Prior to this benefit year, CMS [the Centers for Medicare & Medicaid Services] hadn’t allowed anything supplemental in terms of benefits of daily maintenance or those types of offerings. This year, they said they would. Now, insurers can compensate for things related to physical impairment or diminishment injuries. It will help keep people in their homes and help reduce ER visits by taking care of them before they get to a hospital.

In the past, Medicare Advantage plans could offer things like vision and dental. And I think finally CMS is thinking of the plans from a cost containment approach, which would be why they added these additional benefits. Including transportation and daily maintenance items could help people stay out of the hospital and take a more aggressive approach to cost containment. It’s good for the Medicare Advantage plans, that’s for certain.

Phillips: It’s as though the industry is following the general culture of taking preventive measures, staying healthy and focusing on social determinants of health instead of treating physical outcomes and reacting to illness. All of the plans are talking about how to take a holistic approach to care and paying attention to the appropriate preventive measures to keeping members healthy.

The purpose is to look at the whole person and offer what is known as upstream care instead of reacting to downstream health problems, correct?
Kriscunas: The whole idea of CMS allowing these supplemental benefits is to compensate for physical impairments. What they are trying to do is diminish the impact of health conditions, avoid admissions to the emergency room and hospital, and having relatively minor issues become major ones over time.

The cost impact of keeping people out of the ER—or, most importantly, an inpatient type of situation—is very great. And these additional benefits can help curb that or manage it in a way that is very accessible to members. This experience with their health plan should help realize savings. That’s the aim of doing this, and they [CMS] are on the right track.

Find out what supplemental benefits look like for Anthem, Humana, and UHC.

Even though there may be greater costs up front, you think the additional benefits will reduce costs overall?
Kriscunas: There are always going to be things that you can manage and others you can’t. If someone has a chronic condition like diabetes, it is manageable, and health plans have gotten good at disease management and the activities used to manage different conditions. Diabetes isn’t going to go away.

Then there are other conditions that are more episodic, like not having a bar in the bathroom, so someone falls and breaks their hip. We can’t manage that. I could fall off of my chair and break my arm right now. But to the extent we can get a bar in a bathroom or provide someone transportation for a preventive visit, maybe we can better manage those types of costs.

We will probably be able to tell as we analyze claims data to see the risk adjustment score from one year to the next if these benefits are working. It can be proven out; we may only need one cycle, but there are easy analytical ways to prove it out.

Do you think this change will increase uptake in Medicare Advantage plans?
Kriscunas: We think it’s too early to tell for sure, but we do expect enrollment to increase. Market penetration over time has been significant, and this will only advance that. When we look at additional benefits being added, it touches both sides of the spectrum.

Older members on fixed incomes will appreciate benefits like transportation, in-home care and meal delivery. On the younger side, folks aging in and boomers turning 65 will have high expectations of their member experience. It meets this group by offering more touches to the member and things like alternative medicine, which are attractive to younger folks. There is market penetration from both sides, and an increase in the covered population is what we are hoping for.

Phillips: Among baby boomers, there is almost an expectation to be more in touch with their provider and the expectation of this quality of care up to the point where more extensive care is needed. The entirety of Medicare Advantage is heading in that direction, with some more aggressively, and soon it will be the expectation all around.

From a competitive standpoint in the marketplace, insurers will be able to win over membership by offering these supplemental benefits. Taking a more holistic approach helps gain members and, in turn, become a more dominant player in the Medicare Advantage space.


Insurers can now provide care outside of the immediate medical needs of members.

In April 2018, Congress passed regulations allowing the expansion of Medicare Advantage supplemental benefits. Beginning this year, insurers can provide coverage for care outside of the immediate medical needs of members. They can now offer benefits for disease prevention and mitigation of avoidable healthcare utilization. The Centers for Medicare & Medicaid Services opened the door for insurers to provide coverage that bridges the gap between Medicare and long-term care.

Support now covered by plans includes transportation, home meal delivery, safety devices, daily maintenance, adult daycare and alternative health services. For instance, a patient who recently had hip replacement surgery would have grab bars in his home. A patient with heart disease or diabetes may be eligible for health meal deliveries or appointments with a nutritionist. And for older individuals unable to drive, transportation can be provided to and from doctors’ offices or to a pharmacy for medication.

New in 2020, Medicare Advantage plans may offer the Special Supplemental Benefits for the Chronically Ill. These are meant for Medicare Advantage members with one or more chronic conditions or who have complex medical challenges diminishing their overall health or function. The benefits offered through this program include:

  • Delivered meals
  • Food and produce
  • Non-medical transportation
  • Pest control
  • Indoor air-quality equipment and services
  • Social needs benefits
  • Complimentary medicine services
  • “Self-directed” services like attorneys for medical decision-making
  • General home modification
  • Living supports, including utility subsidies

Supplemental benefits aren’t yet ubiquitous (they are currently provided by only some insurers in certain markets). One-third of the 22 million Medicare beneficiaries in the nation are enrolled in a Medicare Advantage plan. A majority of those individuals are covered by three insurers: UnitedHealthcare, Humana, and Blue Cross Blue Shield, which, together, account for more than half of the total market. Twenty percent of Medicare Advantage members are part of an employer- or union-sponsored plan.

Tammy Worth Healthcare Editor Read More

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