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Medicare Advantage Will Soon Have Even Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year. The Centers for Medicare & Medicaid Services expanded how it defines the "primarily health-related" benefits that insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare offers. "Medicare Advantage beneficiaries will have more supplemental benefits, making it easier for them to lead healthier, more independent lives," said CMS Administrator Seema Verma. Of the 61 million people enrolled in Medicare last year, 20 million have opted for Medicare Advantage, a privately run alternative to the traditional government program. Advantage plans limit members to a network of providers. Similar restrictions may apply to the new benefits. Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. But the new rules, which the industry sought, will expand that significantly to items and services that may not be directly considered medical treatment. CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care. Although insurers are still in the early stages of designing their 2019 policies, some companies have ideas about what they might include. In addition to transportation to doctors' offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries' homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating and other personal care needs.
"This will allow us to build off the existing benefits that we already have in place that are focused more on prevention of avoidable injuries or exacerbation of existing health conditions," said Alicia Kelley, director of Medicare sales for Capital District Physicians' Health Plan, a nonprofit serving 43,000 members in 24 upstate New York counties. Even though a physician's order or prescription is not necessary, the new benefits must be "medically appropriate" and recommended by a licensed health care provider, according to the new rules. Many beneficiaries have been attracted to Medicare Advantage because of its extra benefits and the limit on out-of-pocket expenses. However, CMS also cautioned that new supplemental benefits should not be items provided as an inducement to enroll. UnitedHealthcare, the largest health insurer in the US, also welcomes the opportunity to expand benefits, said Matt Burns, a company spokesman. "Medicare benefits should not be one-size-fits-all, and continued rate stability and greater benefit design flexibility enable health plans to provide a more personalized health care experience," he said. But patient advocates including David Lipschutz. Senior policy attorney at the Center for Medicare Advocacy, are concerned about those who may be left behind. "It's great for the people in Medicare Advantage plans, but what about the majority of the people who are in traditional Medicare?" he asked. "As we tip the scales more in favor of Medicare Advantage, it's to the detriment of people in traditional Medicare." The details of the 2019 Medicare Advantage benefit packages must first be approved by CMS and will be released in the fall, when the annual open enrollment begins. It's very likely that all new benefits will not be available to all beneficiaries since there is "tremendous variation across the country" in what plans offer, said Gretchen Jacobson, associate director of the Kaiser Family Foundation's Program on Medicare Policy. |
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The CMS is also moving forward with plans to increase the use of encounter data to determine risk scores for plans. As a result of the finalized rule, 75% of Medicare Advantage risk scores will be based on traditional fee-for-service data, and 25% based on encounter data. That differs from 2018, when the agency used a risk score blend of 85% fee-for-service data and 15% encounter data.
Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn't accurate.
"Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend," the agency said in a release Monday.
The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they'll be locked into one pharmacy or prescriber for Medicare Part D benefits.
This lock-in will limit an at-risk beneficiary's access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.
Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.
Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn't accurate.
"Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend," the agency said in a release Monday.
The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they'll be locked into one pharmacy or prescriber for Medicare Part D benefits.
This lock-in will limit an at-risk beneficiary's access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.
Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.
