Aetna To Scale Up Medicare Advantage Senior Living Referral Platform

Picture an 83-year-old woman in Wisconsin who is increasingly prone to falls, researching assisted living communities. Unable to cut through a pool of options, she calls a referral service offered by her Medicare Advantage plan, where a consultant is able to narrow her choices based on select criteria she provides.

This scenario is already coming to pass, thanks to services such as “Resources for Living,” offered by Aetna (NYSE: AET).

Medicare Advantage plans are growing in popularity with seniors seeking insurance coverage, and private insurers offering MA plans are competing hard for their business by offering additional services. Some MA plans are now adding referral services to their offerings, connecting customers to senior housing as well as meal delivery, adult daycare, housecleaning and community activities.

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Hartford, Connecticut-based Aetna may have one of the largest referral programs of any insurance company, and is betting this will be an essential component of its biggest Medicare Advantage expansion in its history next year.

The Resources for Living program began three years ago as a pilot program in Texas and New York markets, Aetna Vice President Alan Roberts told Senior Housing News. The company’s own research determined that 60% of factors that can affect a member’s health happen outside of a doctor’s office or clinical setting.

“This program is a way for us to provide an additional support structure for members that are non-clinical in nature, but still have a direct impact on their quality of care,” Roberts said.

As Aetna saw the impact the pilot program was having on its members’ level of care, it implemented the program across its entire Medicare Advantage platform last January.

“Anyone enrolled in a Medicare Advantage plan has this service available to them,” Roberts said. “As we expand, this will be a tightly integrated component moving forward.”

Aetna’s program is just the latest example of increasing integration between Medicare Advantage and senior living. An MA rule change last April opened the door for senior living providers to be reimbursed directly by MA plans for some services. Even before this rule change was announced, some senior housing providers had already launched their own Medicare Advantage plans, as a way to offer more wrap-around services for their residents and gain greater influence in the overall health care system.

The majority of senior living residents today are not Medicare Advantage beneficiaries, but this could change as MA gains momentum in the years ahead. More than 20 million Medicare beneficiaries — 34% of all beneficiaries — are enrolled in a Medicare Advantage plan, according to an October report from the Kaiser Family Foundation. And 2019 will offer more options than ever: 2,734 Medicare Advantage plans will be available nationwide.

A team of experts at the ready

To determine which members qualify for the Resources for Living program, Aetna employs consultants who are part of the company’s behavioral health organization within a dedicated call center operation.

At a minimum, a consultant must have a bachelor’s degree in the field of early childhood development, geriatrics, education, social work, developmental disabilities, counseling or social services, according to information provided to SHN by Aetna. Many consultants have a master’s degree in their field and licensing in social work. Additionally, consultants have at least three years of experience in a child, elder and/or other counseling field.

Aetna members may be referred to consultants through three ways, Roberts said. The first and most important route is directly, through one of Aetna’s care service programs and clinicians. These clinicians pick up on clues provided by members such as managing chronic or multiple health issues, or financial difficulties, that prevent them from receiving the care they need to maintain their health, and are referred to a consultant.

A member may also call in directly to learn more about the program. The third route Aetna uses is leveraging its member database to identify customers who would most benefit from the Resources for Living program.

“Now that we have a better understanding of the members who have benefited, we can look across our membership and segment those who fit a profile we believe can benefit from the service,” Roberts said.

A detailed vetting process

The interaction between a Resources for Living consultant and a beneficiary is thorough, as is the process of generating a list of possible senior housing options, according to the information provided by Aetna.

Consultants ask the member or caregiver to describe the concern or care need. While the client explains the situation, the consultant will ask for clarity on certain points, what solutions may have been tried so far, and assess financial restrictions or parameters.

When appropriate, the consultant will educate the client about subjects such as different types of elder and adult care, prevailing costs of various services, and other family care topics. Depending on the type of request, there are a series of questions that the consultant will ask as part of this consultative assessment.

With the care needs established, a consultant then begins the search for appropriate solutions starting with Aetna’s provider database, which is tracked to a granular, local level. All providers in the database are licensed, regulated, certified or otherwise accredited.

Resources for Living does extensive database maintenance through private organizations, non-profit organizations, government agencies on the federal, state, county and local level, as well as community organizations in order to populate this information, and completes regular updates on all data to ensure the most current information is available from lead agencies. Consultants are also able to add to and update the database in real time as they research services for a member.

“Resources for Living does not have any financial or contractual relationship with any of the service providers,” Roberts said.

The consultant calls every potential provider and asks about the specifics of the provider’s services, costs, availability of service when the client needs it, and any other questions tailored to the individual needs of the member. The member name is never given.

When a provider’s qualifications meet the member’s needs, the consultant completes a detailed profile of essential provider characteristics. Each profile follows the same format (provider’s name, address, fees, services, etc.) so that when members receive several profiles, they will find it easy to compare and contrast them.

The consultant researches and calls providers to find the best 3-5 matches for the member’s needs, and often makes 50 or more phone calls to narrow the field.

A growth market

The Resources for Life program is not unique as a Medicare Advantage offering. There has been an uptick in family caregiving benefits in Medicare Advantage plans, Anne Tumlinson Innovations founder Anne Tumlinson told SHN. An example is UnitedHealthCare Group (NYSE: UNH), whose “Solutions for Caregivers” program connects members with care managers and support services.

Resources for Living also allows Aetna to compete with innovative state supplemental Medicare programs offering long-term caregiver support, such as TennCare and South Carolina Healthy Connections Prime.

The program may one day emerge to be a competitor to longstanding caregiver referral groups, such as Caring.org and A Place for Mom. Caring.com CEO Jim Rosenthal, however, views Aetna’s entry into the referral game as part of the evolving care spectrum.

“It’s about finding the right solution for a person’s needs, and we can help people find the right solution,” Rosenthal said. “Where we can help is to understand the choices and cost benefits, and develop a plan moving forward.”

In a statement to SHN, A Place for Mom VP of Brand Marketing Charlie Severn said the company’s referral service is “best in class” and the largest resource of its kind, with over 18,500 senior living community partners across the country.

What other referral services may need to concern themselves with, regarding Resources for Living, is the scale at which Aetna is implementing the program. And senior living providers should be aware that Medicare Advantage plans may become a more important referral source.

“This is a huge opportunity for Aetna,” Tumlinson said. “If they’re serious about adding value, they’ll start to form actual partnerships and meaningful relationships with providers in those markets.”

Written by Chuck Sudo

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