Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

CMS recently announced it will change its policy regarding Medicare Advantage plans and the scope of “supplemental benefits” these plans may offer. As of the 2019 plan year, CMS says it is reinterpreting existing law and expanding the options that Medicare Advantage plans may offer to enrollees.

In the past, CMS has not allowed an item or service to be eligible as a supplemental benefit – an additional benefit beyond the standard benefits under traditional Medicare – “if the primary purpose includes daily maintenance,” the agency says.

However, in the 2019 final Call Letter for Medicare Advantage, CMS says the policy change will “expand the scope of the primarily health-related supplemental benefit standard” to allow benefits used to “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.”

Items and services under this expanded scope could include things like “air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals,” a recent article in Kaiser Health News notes.

Transportation, different food options, and items such as grab bars in bathrooms might be covered options now. While a physician’s order or prescription is not necessary, the new benefits must still be “medically appropriate” and recommended by a licensed health care provider.

While public health types (me included) often focus on explaining what a social determinant of health is and how it could be addressed in order to improve health equity, this policy change is significant in that it attaches payment to interventions – even if they are not clinical – that could lead to improved health.

Separately, the most recent federal budget agreement lifts the annual caps on the amount Medicare pays for physical, occupational, or speech therapy, and streamlines the medical review process. This policy change will apply to both traditional Medicare and Medicare Advantage enrollees.

As of Jan. 1, Medicare beneficiaries will be eligible for therapy indefinitely as long as their provider confirms their need for therapy and they continue to meet other requirements. Also, under a 2013 court settlement, enrollees will not lose coverage “simply because they have a chronic disease that doesn’t get better,” KHN says.

In an interview with KHN, Judith Stein, executive director, Center for Medicare Advocacy, said, “Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that.”

These are innovative moves on CMS’s part; they show the agency recognizes the need for a more holistic approach to health care for Medicare enrollees and that it’s willing to address the social determinants of health, such as the impact of the home environment on a patient’s health.

CMS is now moving beyond purely “medical” treatments for Medicare Advantage enrollees and addressing broader aspects of health. We get what we pay for, and by covering different types of care, CMS is encouraging actions that may lead to improved health outcomes and avoidance of some preventable health events for patients.