With Focus on Future, MA Plan Innovations Hold Promise for Aging in Place

Outside of serving seniors through a Special Needs Plan geared toward institutional/institutional equivalent enrollees, Medicare Advantage plans are not fundamentally designed to support seniors’ long-term care needs. But with their inherent focus on care coordination and recent innovations in nonmedical benefits that can support aging in place, MA plans are uniquely positioned to address gaps in the continuum between Medicare and Medicaid, which is the primary payer of long-term services and supports (LTSS).

Speaking during a prerecorded session of the upcoming Virtual Fifth National Medicare Advantage Summit, panelists agreed that while nonmedical benefits were initially perceived as marketing tools to differentiate plans from their competitors, there is great potential for them to serve enrollees in the long term. Participants in the panel discussion, “The Opportunity for Medicare Advantage Plans to Address Long-Term Care Needs,” which will be livestreamed and archived on July 10, discussed a variety of benefit innovations and the mounting evidence around their impact to costs, outcomes and quality of life.  

Tenbit Emiru, M.D., executive vice president and chief medical officer with Minnesota not-for-profit insurer UCare, suggested that serving long-term care needs can also help move the needle on health equity.

“Wanting everyone to have complete, full, healthy, happy lives, addressing health-related social needs is very critical to achieving health equity. That means addressing the physical, social, emotional [and] mental well-being and the support for the social drivers of health.…That’s what it means to provide whole-person care,” said Emiru during the panel, which was hosted by AIS Health, a division of MMIT. “The movement now is ‘not only do we care about your multiple chronic conditions, but we also care about your whole health, you as a person,’ and therefore availability of equitable long-term services and support needs is critical to achieving this mission.”

Medicare beneficiaries with LTSS needs are twice as likely to have a hospitalization or an emergency department visit as people without such needs, and they on average cost Medicare about 250% more than their non-LTSS counterparts, pointed out Allison Rizer, who is executive vice president of payer solutions with ATI Advisory. Nonmedical benefits “help to create a holistic set of services that Medicare Advantage plans can use to start to move upstream to prevent those hospitalizations or to prevent those emergency department visits.”

Through an ongoing partnership with the Robert Wood Johnson Foundation, ATI Advisory has conducted research “drilling down into the intersection of having LTSS need or having a disability and other circumstances…or disparities in health care,” explained Rizer. “Having just LTSS need often creates disparities for a person and it really can be exacerbated when you layer in things like being transgender or speaking a different language, having Black or brown skin.”

While its latest report found that lower spending among MA members versus their fee-for-service Medicare counterparts occurs across racial and ethnic groups, ATI Advisory research published in April looked at MA beneficiaries’ access to and utilization of “LTSS-like” supplemental benefits, such as home modifications and service dog support for the chronically ill, adult day services, in-home support services and caregiver support. Within Medicare, “the space that we focus is on supplemental benefits because as of the last few years that really is the opportunity that MA plans specifically have to provide some LTSS-like benefits,” explained Rizer, referring to regulatory changes in 2018 and 2019 that gave plans more leeway to offer nonmedical benefits. But plans are still “very limited in the number of dollars [they] can spend on these benefits,” and their funding may be further compressed by payment changes for 2025.

Plans Need to Look Further ‘Down the Road’

In its April report, ATI Advisory observed that while 82% of MA enrollees live in a county where at least one MA plan offers at least one of the LTSS-like benefits, just 9% of MA beneficiaries were enrolling in one.

“Partly that’s because [not everyone in that] 82% of people have LTSS,” noted Rizer. But the report didn’t fully explore the why, she added, observing that “it created a space for us to be very curious about, what do we ask next? Why is that the sort of distinction that we’re seeing in terms of [access and enrollment]? Is it an opportunity to educate people about these benefits? Is it a lack of understanding…? Is it because we think of LTSS as we’re going to need that down the road?”

“The way that Congress and Medicare have defined long-term services and supports, they think that people need them at a certain time and they’ll continue forever,” remarked Jill Selby, who is founder of JVS Consulting and a former senior vice president at SCAN Health Plan. “But individuals have what we call inflection points or events. So somebody who has an unexpected fall and gets a hip fracture at 65 wouldn’t really be what you would think [of as] the candidate for long-term services supports.” But there’s an opportunity for health plans “to give them some in-home services to prevent another fall, help them recover better,” she suggested. “A lot of those services can help people at any point in the continuum, not just those that are frail and elderly.”

At her former health plan employer, Selby said plan benefits designed to support people at home included post-discharge personal caregiving to prevent readmission and a “strong referral system” for community-based support outside of their MA plan benefits.

While plans and CMS are still in the early stages of collecting beneficiary-level utilization data on supplemental benefits and understanding their impact on the seniors living at home, there is evidence linking cost avoidance with certain nonmedical benefits. Emiru, who is a practicing neurologist, said she has seen no-show rates of 20% to 25% in the health systems she’s worked at, and much of those can be avoided by providing nonemergency medical transportation. Emiru noted that “this benefit remains highly utilized” by those who have access to it, particularly among Dual Eligible Special Needs Plan (D-SNP) members. Home modifications can have an immediate impact on health, especially for those who have asthma, are at risk of falls or are recovering from a fall-related incident, she added.

One study based on the Johns Hopkins School of Nursing CAPABLE program, which combines services from an occupational therapist, a registered nurse and a handy worker, showed that CAPABLE program costs of about $3,000 per participant yielded more than $30,000 in medical cost savings driven by inpatient and outpatient spending reductions.

Plans Can Address Home Safety, Social Isolation

From UCare’s perspective, one innovative benefit (paid for on the Medicaid side) that has helped dual eligible members at home is an activity tracker with personal emergency response support. The tracker is offered at no added cost to the member, has a 24/7 emergency call-for-help function and does not need to be paired with a smartphone. Members with a diagnosis of high blood pressure who use the activity tracker are eligible for a blood pressure monitor.

An analysis of UCare’s 2023 claims linked use of the device with a 40% lower rate of emergency room visits and inpatient visits, while inpatient readmissions were cut in half, said Emiru. Moreover, 90% of members who were using it on a regular basis reported feeling safer at home, demonstrating the big impact of what she termed “small adjustments.” Adult day services as a supplemental benefit can also help address social isolation and loneliness, providing seniors “regular activities and cognitive stimulation and social engagement,” she suggested. Centers providing those services also lend themselves to in-person opportunities to close gaps in care, such as having care coordinators from the health plan meet with members to perform health risk assessments or having pharmacists meet with members to conduct medication reviews, she added.

When it comes to supplemental benefits, plans and consumers alike tend to make choices for the near term, pointed out Selby. “The sexy stuff sells — dental allowances and over-the-counter benefits, and things that just have cash equivalents,” she said. Because so many MA enrollees live on fixed incomes, the kind of choices they’re faced with are “‘Do I join a plan that’s going to take care of me in my home at some point? I don’t know…but I can get $2,000 for dental today.’ That’s part of the challenge that we’ve posed for the industry and for consumers alike.”

As plans and CMS continue to collect more data on supplemental benefits and their impact to consumers over the long term, Selby suggested a reframing of the current narrative around MA and LTSS in general. It’s asking, “What can we do in addition to traditional medical services and the supplemental benefits that we know today — vision, hearing, etc. — and really provide services to keep people in their home, keep themselves safe, improve health outcomes” and address health disparities.

“Up until the most recent changes for 2025, there’s been a pretty steady, generous revenue stream that has gotten consumers to a place where they’re not focusing on the core of the program, which is health care, and not just health care today but health care in the future,” she continued. Reframing the narrative to make it clear to consumers that “this is what the program can do for you as you’re at these different points in your health and life continuum, and [explaining] why you want to plan for that” is one challenge, she said. Another is “working with regulators to help us further expand the program, so that we could apply different services, [and] kind of let the plans…have more discretion…to do the right thing at the right time for the right person with health equity in mind.”

To that end, Rizer said she hopes to see more focus on growing value-based care in MA and “less volatility” from regulators in the near future. “It’s an election year and because we've had so much market volatility, if you will, even in the last few weeks [with Star Ratings recalculations], maybe plans get a little bit of a reprieve this rulemaking cycle,” she said. “We are few years into these data now. And it really is taking a look…at what works, who’s using what [and] how do you target it appropriately? We’ve had a few years of experimentation. That’s fantastic. And now it’s time to focus. If I were a plan, that’s how I would be doing it and that’s what I would expect to see in the future market.”

This story originally appeared in AIS Health's premium publication Radar on Medicare Advantage.