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Medicare Blog | Medicare News | Medicare Information

Medicare Advantage is nudging aside ‘Old Medicare’

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 02:47 PM

medicare advantage nudging aside medicare


By Michael Adelberg – STAT – April 4, 2019

Nearly a quarter century ago, then Speaker of the House Newt Gingrich said this about the original Medicare program: “We believe it’s going to wither on the vine because we think people are voluntarily going to leave it — voluntarily.”

Gingrich argued that original Medicare — based on a 1960s-style fee-for-service benefit package with a confusing set of deductibles, co-insurance, and copays — was stuck in the past. He saw a day when Medicare-contracted private health plans would prove so attractive that Medicare beneficiaries would have to choose them.

It’s taken a generation, but Gingrich is on the verge of being right about Medicare.

Medicare began experimenting with managed care as an alternative to the original program in the 1970s, and annually contracted health plans — called Medicare+Choice — were made a permanent part of the program in the 1990s. Because of funding reductions, it initially floundered.

That changed in 2003 with the passage of the Medicare Prescription Drug, Improvement, and Modernization Act, which renamed the program Medicare Advantage, raised payment rates, and added risk adjustment to the payment methodology. Leading managed care companies, such as UnitedHealth Group, Humana, Aetna, and Blue Cross Blue Shield companies, began marketing Medicare Advantage products every fall. So did dozens of smaller and health system-owned health plans.

Enrollment in these plans has increased every year since then. Today, more than 22 million beneficiaries choose Medicare Advantage, about 35 percent of all people

with Medicare, up from about 11 million people a decade ago. This has occurred despite a gradual phase down in funding put in place by the Affordable Care Act.

In 2019, Medicare Advantage plans stepped up their coverage to include the delivery of meals, rides to physician appointments and pharmacies, home safety improvements, and a host of other new benefits. As described in a new report on Medicare Advantage plans that one of us (M.A.) co-authored, 153 Medicare Advantage plans are now leveraging new Trump administration guidance and experimenting with 842 “flex benefits” this year. These benefits fall into two broad categories: reducing costs to encourage members to receive preventive care, such as free primary and podiatry care for people with diabetes; and non-medical benefits, such as home-delivered meals following a hospital discharge, home safety interventions, and non-skilled in-home caregiving.

Medicare beneficiaries select Medicare Advantage for a variety of reasons. These include catastrophic cost protection, care management programs, and a range of mainly health-related supplemental benefits such as dental checkups, eyeglasses, hearing aids, over-the-counter drugs, and gym memberships. The trade-off for these extras is limited choice of providers and managed care tools like prior authorization. These limitations put off some Medicare beneficiaries, but have not dampened the high overall satisfaction with Medicare Advantage or its continued growth.

Medicare Advantage’s competitive edge over original Medicare will take another step forward in 2020 when plans are expected to gain additional flexibilities in offering non-medical benefits for people with chronic diseases. The next wave of new benefits can include anything that the Centers for Medicare and Medicaid Services deems “has a reasonable expectation of improving or maintaining the health or overall function” of enrollees with chronic diseases. While CMS has not yet offered its final guidance, this will likely include meals, transportation, pest removal, and activities that combat social isolation and depression, which could include companionship services and pet therapy.

Some of the brightest minds in managed care are working to determine whether relatively inexpensive, newly permissible benefits like these will pay for themselves by reducing the number of expensive medical procedures. Actuaries at Wakely Consulting, for example, have modeled the value of a falls reduction benefit. Using Medicare claims data, they determined that injury-causing falls are associated with spikes in medical costs that average about $10,000 compared to pre-fall costs. So an intervention that reduces falls by even 10 percent would likely pay for itself if it costs less than $1,000 per fall-prone member receiving the service. Hiring a handyman for a couple hundred dollars to install grip bars in a shower or modify cabinetry would be a bargain.

How does original Medicare stack up in comparison to Medicare Advantage? The Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA) introduced value-based reimbursement reforms into original Medicare. These may make the program a more efficient payer, but they do not necessarily improve benefits for Medicare beneficiaries. Medicare Supplement Insurance (Medigap) continues to be purchased by roughly 13 million Medicare beneficiaries. It plugs gaps and simplifies original Medicare’s idiosyncratic coverage, but it is too expensive for lower-income beneficiaries. In addition, state and federal laws prevent Medigap from keeping up with Medicare Advantage.

A 2017 report by the National Association of Insurance Commissioners demonstrates that only a handful of states permit Medigap carriers to offer any “innovative” benefits. And the modest flexibilities permitted — such as eye exams — pale in comparison to the richness and diversity of Medicare Advantage benefits.

In subtle and unsubtle ways, the Trump administration has seeded the ground for massive gains in Medicare Advantage enrollment. These include loosened restrictions on marketing Medicare Advantage plans, new consumer tools that accentuate the advantages of these plans, greater use of telehealth than permitted in original Medicare, the elimination of “meaningful difference” tests that limit the number of Medicare Advantage plans in a given market, and extra time for plan sponsors to secure a provider network. Meanwhile, the administration has finalized a regulation that may substantially lessen the number of accountable care organizations participating in original Medicare — the original Medicare reform with the greatest potential to align providers in reimbursement systems outside of Medicare Advantage.

Congress has also quietly added tools to Medicare Advantage that aren’t available in original Medicare. A little-noticed MACRA provision will remove two of the most popular Medigap plans from the market in 2020, further weakening its value proposition versus Medicare Advantage. This is not an accident: Many conservatives have long disliked original Medicare’s centralized pay schedules and the perverse incentives of fee-for-service medical care. And many liberals are willing to strengthen Medicare Advantage if that’s the only way to offer more generous health care coverage to seniors.

Intentionally or not, Congress and various administrations have created two Medicare programs: the original fee-for-service program with rules and coverage that the private market largely abandoned decades ago, and a managed care program that has just benefited from another set of favorable legislative and regulatory tweaks. Maybe it is unfair that policy makers are favoring Medicare Advantage. But if this is the only way to deliver modern and more generous health benefits to Medicare beneficiaries, then a thumb on the scale is better than denying beneficiaries access to 21st-century benefits.

It’s no wonder that Medicare beneficiaries are voluntarily leaving original Medicare — voluntarily.

Source: https://www.statnews.com/2019/04/03/medicare-advantage-nudging-aside-old-medicare/

Image: www.Canva.com

Additional Updates:

Tags: Medicare Advantage, Medicare

Retiring in 2019? Health Care = $285,000

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 02:27 PM

Retiring is expensive

 The estimate is for an enrolled-in-Medicare couple’s retirement

By Rebecca Moore – PlanAdviser – April 3, 2019

In case you’re wondering how much of your retirement savings might go toward health care, Fidelity has a new number – and it’s going up. A 65-year old couple retiring in 2019 can expect to spend $285,000 in health care and medical expenses throughout retirement, compared with $280,000 in 2018, according to Fidelity’s annual Retiree Health Care Cost Estimate.

For single retirees, the health care cost estimate is $150,000 for women and $135,000 for men. The estimate assumes both members of the couple are eligible for Medicare. While Fidelity’s estimate is for a couple retiring in 2019, the firm says it’s a call-to-action to younger generations to prepare – such as buying the right insurance products – for a lengthy retirement.

Source: https://www.planadviser.com/couple-retiring-year-will-spend-285000-health-costs/

Image: www.Canva.com

Additional Updates:

Tags: Retirement Planning

The Need for Dental Insurance

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 02:00 PM

the need for dental insurance.jpg

Mutual of Omaha offers two dental plans
* Mutual Dental Preferred and Mutual Dental Protection insurance policies with an optional vision care rider** underwritten by Mutual of Omaha Insurance Company. The dental product is available in all states except: New Mexico, New York, Virginia and Washington.

While this product is positioned for individuals who are Medicare eligible the issue age is 19 – 99 for these policies. For more information and to see rates view the Dental Insurance Product and Rate Guide.

Medicare supplement and Dental Insurance – Better Together
You have a built-in target market. If you are selling Medicare supplement, there are a number of reasons you should be offering your Medicare clients a dental policy.

First, good dental care is important to overall health. But do you know Medicare doesn’t cover dental services? That means dental bills have the potential to take a bite out of people’s savings.

Second, there is a need among individuals age 65 and older for dental insurance.

  • 87% of this group still have their natural teeth
  • Due to cost, 1 in 5 of them has untreated tooth decay and fewer than half see a dentist even once a year
  • Only 12% have dental insurance

Third, it is an easy sale. If you are taking a Med supp e-App the dental plans are quoted up front and with a few simple questions at the end of the app you can complete a dental sale. Also, all Med supp paper apps have the dental application included in the application book.  And with our mobile quote app you can provide your clients a quote on the spot.

Not appointed with Mutual of Omaha. Request details on both their competitive Medicare Supplement and Dental Plans.

Image: www.Canva.com

Additional Updates:

Tags: Medicare Supplement, Mutual of Omaha Medicare Supplement, dental plans, MACRA

How To Make An Upline Change

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:53 PM

How to Make an UpLine Change 

How to make an upline change


In order for a business to be successful all parties involved have to benefit or the relationship will eventually break down.

As an insurance agent, it’s likely only a matter of time until you find yourself in a situation where you feel that your upline partnership isn’t working for you.

When that happens, it may be time to cut ties with your current upline and move on. This can be a simple or complicated process, depending on your upline FMO and the carrier involved.

It is important first to understand that, if the carrier in question will honor a signed release from your upline, it needs to be from the highest level in your hierarchy. Carriers will not accept a signed release from a mid-tier FMO.

For example, as an FMO we have a direct relationship with the carriers we broker for. For the most part, carriers will honor our release requests, no questions asked.

We have a general open release policy and would normally process a release without delay. Having said that, we also give our mid-level down lines flexibility to implement their own release guidelines and allow them to release down lines as they see fit, as long as carrier guidelines are respected.

For the most part there are 2 ways to transfer your contract to a new upline. A “Signed Release” or a “Self-Release”.

Let’s take a look at these options:


Signed Release:

An agent may request to be released from their upline for immediate transfer to a new FMO. It is important to stress that this request must be signed by the top level upline and NOT by a mid-tier. If the top line FMO signs the release, the agent is then free to transfer to a different broker immediately.


Self Release:

If an upline doesn’t want to give an agent an immediate release, then an agent can exercise the Self-Release process. It may vary by carrier, but as a general rule there are a couple of ways to do it:

  • An agent stops writing business for a period of time, usually 6 months, and they will be able to transfer at the end of the time period due to non-production.
    • Most Med Supp carriers follow this Self-Release process
  • An agent may submit a notice to the carrier detailing their intent to transfer to a new broker. The agent should be able to continue to write business (depending on the carrier) for a time frame specified by the carrier. When that time frame is up, the agent will be allowed to transfer their contract to the broker named in the original intent letter.
    • Most Med Advantage carriers follow this Self-Release process


Below is a sampling of a few carriers and their release process:

Aetna Med Advantage/Part D - Notice and new contracting must be sent to Aetna to start the clock. You can continue to write business during their 3 month Self-Release period.

Mutual of Omaha - Non-Production for 6 months will allow an agent to transfer their contract.

Aetna Med Supp - Email notice must be sent to Aetna Supplemental to start the clock. You can continue to write business during their 6 month Self-Release period. However, different guidelines apply if you have producing downlines.

Humana - Notice and new contracting must be sent to Humana to start the clock. You can continue to write business during their 3 month Self-Release period.

United Healthcare – Email notice must be sent to UHC to start the clock. You can continue to write business during their 6 month Self-Release period.


Transfer Freezes

Some Med Advantage carriers implement transfer freezes in the 4th Quarter of each year, which prevents an agent from transferring their contract no matter what the release scenario may be. UnitedHealthcare, Aetna, and Humana are a few of the major carriers who implement a transfer freeze period. 

With that being said, it’s important to carefully consider the timing if you’re looking to initiate a self-release.

For example: If an agent were to start a self-release and that self-release time frame expired in the middle of a transfer freeze (9/1/19 to 12/31/19), they would be forced to stay under their current upline until the end of the freeze period. In other words, they are stuck until after AEP and usually until January 1st of the next year.

Obviously, if the agent could have timed the self-release so that the self-release time frame expired before the freeze period, that may have been the more favorable situation.

Again, not all carriers have the same process, so ensure you understand the carrier’s requirements before starting the process.

The important thing to remember is that, if your business relationship isn’t working, you have options. It is also a good idea to understand the release policy of your upline, before you work with them, so you are not surprised when the situation arises.

Your success is up to you, but a bad business relationship can definitely make that success more difficult.

If you have any questions, our experienced marketers are here to help.


Additional Updates:
What are the Benefits of Using an FMO?
14 Ways to Generate Medicare Leads

An Agents Guide to Dual Eligible Special Needs Plans
Social Media Marketing for Insurance Agents

Tags: Insurance Agents, upline change

Mutual of Omaha: Your Guide to MACRA

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:46 PM

What is MACRA?

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changes some of the Medicare supplement plans people new to Medicare can purchase. The rule says that as of January 1, 2020, newly-eligible Medicare beneficiaries won’t be able to purchase Medicare supplement plans that cover the Part B deductible. These are Medicare supplement Plans C, F, High-Deductible F and Minnesota and Wisconsin Part B deductible coverage. For MACRA purposes, “newly-eligible” people are those who become eligible for Medicare on or after January 1, 2020.

Download the Flyer here


Additional Updates:

Tags: Medicare Supplement, Mutual of Omaha Medicare Supplement, MACRA

Re-calibrating Medicare Advantage Risk Adjustment

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:29 PM

The Implications Of Re-calibrating Medicare Advantage Risk Adjustment Using Encounter Data

Med-Adv-Re-calibratingMA plans play an increasingly important role in the Medicare program, with enrollment growing from about a quarter of all Medicare beneficiaries (or 11 million) in 2010 to 34 percent of beneficiaries (approximately 20 million) in 2018. And, according to the Congressional Budget Office, enrollment in MA is projected to exceed 40 percent (32 million) of the total Medicare population by 2028.

MA’s popularity indicates that it works well, and one of the reasons the system functions as well as it does is that plan payments are adjusted for the health risks of enrollees.

Until now, the Centers for Medicare and Medicaid Services (CMS) has estimated its MA risk-adjustment models using data from traditional Medicare, but the agency has signaled in the past its interest in using encounter data from MA to estimate (or recalibrate) the model. CMS reiterated this interest in its fiscal year 2020 performance budget.

Under such recalibration, CMS would recalculate the coefficients for the demographic characteristics and health conditions based on MA encounter data, instead of on traditional fee-for-service Medicare claims.

Read the full article: https://www.healthaffairs.org/do/10.1377/hblog20190412.299173/full/

Additional Updates:
An Agents Guide to DSNP Plans
Medicare Marketing Guidelines - Changes for 2019
14 Ways to Generate Medicare Leads
Medicare Advantage and PDP Online Enrollment Solution

Tags: Medicare Advantage

New Georgia Medicare Supplement Release from Mutual of Omaha

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:26 PM

We have some exciting news to share!

Mutual of Omaha is releasing a new Medicare Supplement in Georgia. Request details today and be ready when the product roles out for new sales.

Call us at 800-998-7715 and one of our marketing representatives would be happy to share this valuable information with you.

There are Medicare changes coming effective January 1, 2020 as a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Act eliminates Medigap plans that cover the Medicare Part B deductible (Plans C, F and High-Deductible F) for people who are Medicare eligible on or after January 1, 2020.  That means those Medicare beneficiaries will not have a Medigap option with first-dollar coverage and will pay the Medicare Part B calendar-year deductible themselves.

How this impacts our new Mutual of Omaha Georgia Product:

  • Effective April 12th, you can now sell Plans A, F, G and N
  • Effective July 1st, you may begin selling the new High Deductible Plan G for applications with an effective date of January 1, 2020 or later
  • Until December 31, 2019 our High Deductible Plan F, underwritten by Omaha Insurance Company, will still be available in Georgia for individuals who are Medicare eligible prior to January 1, 2020. Only paper applications will be available for submission and can be downloaded on Sales Professional Access, Forms and Materials.

For more information on how MACRA impacts your clients, click here.

Additional Updates:

Tags: Medicare Supplement, Mutual of Omaha Medicare Supplement

Boomers Need Help Living In Retirement

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:15 PM

Boomers Need Help Living in Retirement
Annuities may be the resource to fund a decades-long retirement

couple worrying about moneyMore than 50% of Baby Boomers believe health care costs will consume 20% of their income, or less.

But an annual report by the Insured Retirement Institute shows a healthy 66-year-old couple who retired in 2018 would need 48% of their lifetime Social Security benefits to address total lifetime health care and long-term care expenses.

With nearly one-half of Social Security lost to health care, supplemental income or savings would need to be substantial for health care to be 20%, or less, of total income.


Expectation of Health Care and LTC Costs 
(as a percentage of retirement income)

expectation of boomers healthcare cost


The number one reason Boomers calculating savings goals do not include health care and LTC costs  is that they expect Medicare to cover them – an erroneous assumption on both counts, especially for LTC, for which Medicare provides no coverage.

 The second most common answer is simply that they are unsure of the costs involved and/or they don’t know how to calculate them – a powerful value-added service for insurance agents to provide.


Reasons For Not Owning Annuities

reasons for not owning annuities


The chart above explores why annuity ownership is relatively low despite demonstrable income gaps. About as many boomers say they don’t have enough money to purchase an annuity as say they have no retirement savings, an unfortunate reality.

However, it is more common for boomers to say they simply don’t know anything about annuities than to be biased against them, and this is an opportunity for the insured retirement industry and for financial advisors.

Similarly, some of those who feel they don't think they'll live long enough for an annuity purchase to make sense may be overlooking the possibility that medical advances will result in them living longer than they expect, and that medically underwritten annuities may increase payments to the point where an annuity purchase becomes attractive.



Baby boomers, particularly those who are younger and still working, face an urgent need to save more and create financial plans for retirement.

Most will not have pensions, so it is imperative that they maximize Social Security, create guaranteed lifetime income from their savings, and employ insurance protection and financial management tools to mitigate the risk that health care and long-term care costs will erode their savings and income.

 View the original IRI report



Additional Updates:

Tags: Boomer Retirement, Retirement Planning

Medicare Marketing Guidelines

Posted by www.psmbrokerage.com Admin on Thu, Apr 11, 2019 @ 08:37 AM

Medicare Marketing Guidelines 
- Changes For 2019 -


Rules Renamed to "Medicare Communications &
Marketing Guidelines"

CMS has made some significant changes to the Medicare and Marketing Guidelines (MMG) for 2019. The MMG, which governs Medicare Advantage Organizations (MAO) and Plan D sponsors, was re-named to Medicare Communications and Marketing Guidelines (MCMG) for 2019.

In this article, we’ll take a look at some important changes to the regulations that you should be aware of moving forward.

Below, I have highlighted some of what we consider the most relevant changes to the guidelines. It is not an exhaustive list, but I think it’s a good place to start.


[ Note: Plans/Part D sponsors may impose additional restrictions on their subcontractors, downstream entities, and/or delegated entities, provided they do not conflict with the requirements outlined in the MCMG. ]


Let's look at some changes to the Medicare Communications and Marketing Guidelines:

20 – Communications and Marketing Definitions:

The most obvious change to this section is the distinction between Communications activities and Marketing activities. Communications activities do not need to be submitted for CMS review.

The MCMG defines Communications as:

Activities and use of materials to provide information to current and prospective enrollees. This is the more generic of the two categories and does not require CMS review. This can be seen as a loosening of the restrictions.

  • An example of Communications could be activities/materials that promote awareness of MA plans in general and the fact that you offer that type of plan.

The MCMG defines Marketing as:

Marketing can be considered a subset of Communications and provides more detailed information. Marketing materials are those that could include information on a plan’s benefit structure, cost sharing and measuring or ranking standards. These types of materials are subject to CMS review.

  • An example of marketing materials would be a flyer that provides specific details about a plan’s benefits, cost sharing or ranking standards.

Put another way, marketing materials are those with an intent to draw a beneficiary’s attention to a MA plan or plans to influence a beneficiary’s decision-making process when selecting and enrolling in a plan or deciding to stay in a plan and contain information about the plan’s benefit structure, cost sharing, and measuring or ranking standards.

 30.6 – Electronic communication Policy:

Section 30.6 explains that a sponsor may initiate contact via email to prospective enrollees and to retain enrollment for current enrollees.

It also notes that text messaging and other electronic messaging (social media) is considered unsolicited and is not permitted.

 40.2 – Marketing Through Unsolicited Contacts:

As in 30.6 above, Section 40.2 adds email to the list of allowable unsolicited contact methods, as long as there is an opt-out function in the email.

This section also clarifies that unsolicited text messages are not permitted.

50.3 – Personal/Individual Marketing Appointments:

There is no longer any language preventing an agent from asking for referrals during a one on one appointment. (No more excuses)

60.4 – Plan/Part D Sponsor Activities in the Healthcare Setting:

Section 60.4 clarifies that waiting rooms are considered part of the common areas and common areas are approved for sales activities.

It also states that Communication materials may be distributed and displayed in all areas of the healthcare setting.

90.1 – Material Identification:

Section 90.1 includes a new material identification process, as well as guidance on what types of materials will require submission to HPMS. 


The section relating to the rules that apply to referral programs (30.9)  has been removed. This will allow for some flexibility in gaining referrals.

If you offer a gift for referrals, just remember, you will still need to abide by the Nominal Gift standards (40.4).


Appendix 2, Disclaimers:

Disclaimers have been simplified and are now located in Appendix 2 of the MCMG. Some of the relevant proposed changes are listed below.

The following disclaimers may be removed from your materials:

  • “A sales person will be present with information and applications.”

The following disclaimer may be removed from your advertising materials:

  • “This is an advertisement”

The following disclaimer may be removed from your materials:

  • “Non- health or non-plan related information”

The following disclaimer may be removed from your materials:

  • “Medicare has neither reviewed nor endorsed this information.”

You no longer have to put the following text in email subject lines. As long as the material is not considered Marketing.

  • “Marketing”


Appendix 3, Pre-Enrollment Checklist:

The Pre-Enrollment Checklist was added to consolidate disclaimers on a given plan. The Checklist is designed to help enrollees understand important rules before making an enrollment decision.



This update marks a significant change to the MCMG. There are new additions, several sections have been moved around and others removed entirely.

We recommend reading through the entire guidelines to ensure you’re aware of any possible impact to your business.

As always, our experienced marketers are here to answer any questions you may have.

Additional Updates:

Tags: Medicare News, medicare marketing guidelines

UnitedHealthcare, AMA unveil more medical codes for social determinants

Posted by www.psmbrokerage.com Admin on Fri, Apr 05, 2019 @ 03:59 PM

UnitedHealthcare, AMA unveil more medical codes for social determinants-1

 By Shelby Livingstone – ModernHealthCare – April 3, 2018

UnitedHealthcare and the American Medical Association said Tuesday they want to expand the set of ICD-10 diagnostic codes to include more specific diagnoses related to a person's social determinants of health.

The hope is that these codes would allow clinicians to document patients' social determinants in a standardized way, which would allow them to better tailor care plans or refer patients to community organizations that could meet those social needs.

"If someone has a transportation barrier and they are unable to get to their doctor's appointment or to pick up their prescription, today in the ICD-10 codes, there isn't a way to diagnose that," said Sheila Shapiro, senior vice president for national strategic partnerships in UnitedHealthcare's clinical services team. "There is no common way for the system to communicate around not only that barrier, but the solutions that can be brought to assist that individual."

Today, a clinician may use medical code that identifies a patient as low-income, but that's as granular as it gets. UnitedHealthcare's proposed set of codes would more specifically identify the person as unable to pay for transportation for medical appointments of prescriptions, for instance.

That would then tell the healthcare provider they should order prescriptions mailed to the home or possibly provide some form of transportation, explained Dr. Tom Giannulli, chief medical officer at the AMA's Integrated Health Model Initiative, which is supporting UnitedHealthcare's proposal.

Expanding diagnostic codes related to social determinants of health is another step in the healthcare industry's journey to address those factors outside of the doctor's office that often have a greater impact on outcomes than clinical care. In recent years, social determinants have become a buzzword in the healthcare industry as insurers and providers have looked for new ways to control health spending. Now insurers and health systems are moving beyond initial pilot projects to address those factors in a sustainable, scalable way.

The existing ICD-10 family of diagnostic and procedural codes includes 11 codes that identify social and environmental barriers to a patient's care, but they are broad categories. UnitedHealthcare's proposal would add 23 more codes to that list. Some of those codes would indicate a patient's inability to pay for prescriptions, inadequate social interaction, or fears about losing housing.

Trenor Williams, the founder of Socially Determined, a company that uses data to help organizations build programs to address their patients' social needs, said expanding the codes to include more specific diagnoses is a good start and an opportunity to better document social risk factors among a population.

It also could prompt more discussion among stakeholders about providing reimbursement that is risk-adjusted based on a patient's social determinants, Williams said. Some groups, including the National Academy of Medicine and the Medicare Payment Advisory Commission, have explored the feasibility of adjusting Medicare payments for socioeconomic status. Congress has also commissioned reports on the subject. But so far Medicare payments remain unadjusted for social factors.

UnitedHealthcare presented its recommendation to expand the codes at the ICD-10 Coordination and Maintenance Committee meeting in March. Following a 60-day comment period, the committee will determine whether to act on UnitedHealthcare's recommendation in the early summer. The new codes would be available to use as early as 2020, if the committee approves them, Shapiro said.

Source: https://www.modernhealthcare.com/technology/unitedhealthcare-ama-unveil-more-medical-codes-social-determinants?utm_source=modern-healthcare-daily-dose-tuesday&utm_medium=email&utm_campaign=20190402&utm_content=article3-headline

Image: www.Canva.com

Additional Updates:

Tags: Medicare Advantage, UnitedHealthcare

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