Coming CMS Decisions to Shape Medicare Advantage Opportunities for Senior Living

Several recent policy changes could mean that Medicare Advantage (MA) plans will start to cover more senior living services in the years ahead, but big questions remain as to what these new MA benefits will entail and how they will be introduced.

A new report from the Bipartisan Policy Center lays out some of the key decisions that the Centers for Medicare & Medicaid Services (CMS) still must make about how these MA changes are implemented.

One of the recent MA policy changes was announced in a call letter released by CMS in April. This allows Medicare Advantage plans to start covering non-skilled in-home services as of 2019; assuming that senior living communities meet the definition of “home,” it appears that MA plans will be able to start paying for certain services offered in these settings.


But even before that April call letter came out, important Medicare Advantage policy changes had been made via the Bipartisan Budget Act of 2018, signed by President Trump on Feb. 9. These changes are the focus of the issue brief from the Bipartisan Policy Center, a nonprofit think tank based in Washington, D.C.

Specifically, the Budget Act gives MA payers more flexibility to offer non-medical health-related services and supports to people with multiple chronic conditions starting in 2020.

“This new flexibility for health plans has significant potential to provide access to non-medical health-related benefits, including those that have proved successful in keeping patients in their homes,” the issue brief states.


The goal is to short-circuit the “cycle of emergency department visits, hospital admissions, and discharges to home” that patients with multiple chronic conditions often find themselves in, which drives up costs across the health care continuum and compromises quality of life and health outcomes for these individuals.

“The new supplemental benefit flexibility means that an MA plan could target enrollees who have certain chronic conditions that are highly prevalent in seniors housing—i.e., dementia— and offer them non-medical supplemental benefits,” Anne Tumlinson, CEO of Anne Tumlinson Innovations, told Senior Housing News. “These benefits could include, for example, private pay home care (often offered in seniors housing).”

Going forward, CMS will serve as the lead office for how provisions of this law are implemented. The Bipartisan Policy Center conducted roundtables, public events and individual interviews with current and former agency officials, Congressional staff, health plan administrators and other experts to compile its brief. These stakeholders identified a number of key questions that CMS will have to address.

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One major decision point centers on the level of flexibility that MA providers will have in defining what new supplemental benefits they will offer and who is eligible for them.

“The new law opens the door to non-medical, health-related services, such as transportation, meals, and home modifications, and health plans may determine that some make economic sense and others do not,” the brief states.

CMS could collect data on costs and associated savings of providing certain supplemental benefits as part of the implementation, which would create an evidence base going forward for insurers as they design benefits packages, the brief suggests.

In terms of eligibility, CMS will have to decide whether plans will have latitude in deciding which enrollees qualify for the new supplemental benefits, or whether CMS itself will decide this.

One option would be to base eligibility on a person’s diagnoses, but insurance providers might object that this would make benefits available to people who might not need them. A more precise way to determine eligibility might be to measure a person’s ability to do activities of daily living, such as preparing meals or driving.

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Also of interest to senior living providers, the Bipartisan Budget Act permanently authorized Medicare Advantage Special Needs Plans (SNPs). These include I-SNPs, which cover seniors who live in institutional settings such as assisted living or skilled nursing communities. Some senior living providers—including Marquis Companies, Sunrise Senior Living and Erickson Living—have already have launched their own I-SNPs. These providers may be especially well-positioned to take advantage of the new MA benefits that are currently taking shape, Senior Housing News recently reported in its comprehensive analysis of the Medicare Advantage opportunity.

I-SNPs could also be the primary vehicle by which the new supplemental benefits flow to senior housing, according to Tumlinson, a noted expert on senior housing and care, who led the post-acute and long-term care consulting practice at Avalere Health for 14 years.

“It would be unlikely that MA plans or CMS would allow these benefits to substitute for services that are already financed—in other words MA plans do not want to subsidize the food services in assisted living for high income residents,” she said. “The way I see this playing out is more on the I-SNP side—as these plans mature over time, they may find some strategic opportunities in offering non-medical supplemental benefits that are high value to senior living residents.”

The Bipartisan Budget Act calls for more integration of Medicare and Medicaid services, which could affect SNPs in various ways. For instance, D-SNPs, which enroll people who are eligible for both Medicare and Medicaid, must integrate long-term services and supports and behavioral health into their care models by 2021, “to the extent feasible.” It will be up to CMS to define what “feasible” means in various cases, the issue brief notes.

Written by Tim Mullaney

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