How Medicare Advantage Health Plans Can Get Value from the New CMS Home Care Rules

In 2018, the Centers for Medicare and Medicaid Services (CMS) announced an expansion of in-home offerings for Medicare Advantage (MA) plan members.

“Previously, CMS has not allowed an item or service to be eligible as a supplemental benefit if the primary purpose includes daily maintenance. However, in the final Call Letter, CMS discusses a reinterpretation of the statute to expand the scope of the primarily health-related supplemental benefit standard.” - 2018 CMS Announcement.

Non-Clinical In-Home Care Helps Medicare Advantage Plans

This "health-related supplemental benefit" expansion provides patients with new benefits and services that can improve their long-term care options, quality of life and health outcomes. The expansion also offers Medicare Advantage plans unique opportunities in three main areas. We'll discuss each of these in turn:

• Lower overall cost of care by reducing avoidable utilization.
• Improve Star ratings via increased member satisfaction.
• Expand visibility and care management of members in the home.

Lowering Total Costs of Care by Reducing Avoidable Utilization

Ask any patient who has had a non-clinical caregiver in-home remind them to take their medication or prepare a healthy meal and they'll tell you how priceless home care is. Although there are many long-term care options for seniors – nursing homes, assisted living facilities, community-based services, hospice care, adult day care, PACE programs and more – many seniors prefer care at home, where they're most comfortable. Anecdotal evidence supporting the link between preventive care and health has been around for decades.

However, these stories are also backed by research that shows how preventive, non-medical home care and functional support decrease unnecessary utilizations, readmissions, costs, and more.

Medicare Advantage plans can tap into these new non-medical long-term care opportunities quickly by choosing partners with established processes and systems. Partners like CareLinx can make it easy for them to ramp up non-clinical home care benefits quickly and effectively on an enterprise-wide scale.

In-Home Care Can Improve Star Ratings

Home care benefits rank as the second most desired benefit among Medicare Advantage beneficiaries, coming in only behind modification-to-home benefits for medical needs.

Why is it so desirable? The benefit of non-medical home care to this population is personal and monumental. These caregivers offer face-to-face care, basic companionship, assistance with routines, and support of activities of daily living. This assistance allows members to remain at home instead of being institutionalized, leading to improved quality of life, healthcare outcomes, and lower costs.

CMS's supplemental benefits update allows Medicare Advantage plans to garner stronger loyalty with the growing senior population by bringing them personalized, lower-cost in-home support services. Improved member satisfaction means improved quality measures, and that means better Star ratings.

Expand Visibility and Care Management of Members in the Home

Members often need further care after a stay in the hospital. Categorized as post-acute care (PAC), care of this nature might include assistance getting around the house, obtaining food and medications, driving to and from medical appointments, and following post-care regimens. PAC often leads to higher costs for health plans if members are non-adherent to medication, care, and rehabilitation instructions.

Medicare beneficiaries have particularly high rates of PAC needs and episodes – and even higher rates of lapses in adherence to PAC programs. This leads to what are often avoidable readmissions, leading to increased member risks and costs to members and plans alike.

The CMS expansion gives Medicare Advantage plans new options to build out or hire specialized, non-medical resources and programs that utilize the home as an alternative site of PAC to long-term care rehabilitation, adult day care, respite care, and assisted living facilities. In-home care is one of these alternatives.

Some in-home care companies have digital care plans that caregivers use in the home via smartphone to manage post-acute and other care. The data they collect can be shared with health plans whose members opt-in, and used by plans as a "last-mile" extension of their care-management and transition teams. The daily information caregivers collect can help health plans catch problems early, intervene when needed, lower costs of care, and build loyalty. The in-home visibility and care of members could be revolutionary.

What’s Next

With the CMS rule changes, Medicare Advantage plans have a great opportunity to tap into alternative care options for their largest, most vulnerable populations. They can do this by creating non-medical home care programs that meet CMS requirements, decrease total cost of care, improve health and well-being, expand services, and keep members happy.

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