by Luke Shulman

What Supplements Health?

Buried in a recent CMS announcement was a seemingly small policy change related to helping Medicare members with their social determinants of health.

Medicare, the insurance program for the elderly and disabled in the United States, is really two independent programs. In one, the beneficiary medical costs are covered directly by the federal government. This is often referred to as Original Medicare or Medicare Fee-For-Service.

The second option is for individuals to obtain Medicare insurance through private insurance companies. This option, formalized as Part C in the law, originally branded Medicare+Choice but now known as Medicare Advantage is very popular and today 13 of Medicare beneficiaries receive their coverage through Medicare Advantage.

Since the program’s inception, Medicare Advantage plans have been required to “provide to members…those items and services for which benefits are available under part A and B.” Basically, these plans had to cover everything covered under original Medicare.

To sweeten the pot, Medicare Advantage plans may offer “supplemental health care benefits” provided these additional benefits would not “substantially discourage enrollment by eligible individuals with the organization.” 42 US Code 1395w-22 emphasis added.

Since 1997 when these provisions were enacted, CMS has interpreted “supplemental health care benefits” as requiring that these benefits be “health related” to “prevent, cure, or diminish an illness or injury.” CMS has typically not allowed items that support daily maintenance. This can include updates to a member’s home or bathroom to prevent a fall or getting a ride to an appointment from Uber or Lyft.

Well, no more. On April 2, 2018, CMS finalized their much discussed revision of this definition.

Under our new interpretation, in order for a service or item to be “primarily health related” under our three-part test for supplemental health care benefits, it must diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. April Call Letter pg 208.

This definition is fantastic in that it is outcome based. It allows plans to try new benefits that may not be seemingly health related, but if they reduce overall utilization can be approved. It allows health plans to take advantage of new research into social and economic pathways that affect people’s health.

Can you imagine your health plan:

  • Renovating your home?
  • Stocking your pantry with healthier food?
  • Cleaning your house?
  • Doing your laundry?
  • Providing child care?
  • Getting you a cellphone?
  • Getting you a job?

These aren’t meant to be jokes - these items are all believed to contribute substantially to a person’s overall health and well-being. Will having your laundry done prevent cancer? Probably not. But will it allow you to remain in your home longer before you require long-term care or full-time nursing assistance? Absolutely.

The challenge now is for health plans and their provider partners to properly match social interventions with patients who can actually benefit from them. Furthermore, these types of interventions should be rigorously evaluated to ensure they deliver reduced utilization. At Algorex Health, we are continuously targeting patients to help them obtain rides, get home visits, or get food assistance. The change to Medicare rules makes it substantially easier for health systems to set up these support structures and ultimately lead to better outcomes for everyone.