1. Medicare Advantage & the New Supplemental Benefits
October 1, 2018

2. Types of Coverage Medicare Original Fee-For-Service (FFS)
Medicare Advantage
Traditional Medicare Advantage
MA only
MA PD (includes Part D)
Special Needs Plans
Institu-tional
(ISNP)
Dual Eligible
(DSNP)
Chronic Condition
(CSNP)
Original Fee-For-Service (FFS)
Medicare Supple-mental Insurance
Prescription Drug Plan (PDP)
Medicare Advantage: sometimes called "Part C" or "MA Plans," are offered by private health plans approved by and contracted with CMS. These private plans accept financial risk and administer the Medicare program benefits plus some optional supplemental benefits.
Enrollees receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage plan and not traditional Medicare Fee For Service.
Most Medicare Advantage plans also include Medicare Part D Rx drug coverage (MA-PD plans)
“Special Needs Plans” are a type of Medicare Advantage plan that target enrollment of certain individuals: individuals requiring nursing home level of care for 90 days or more, individuals eligible for both Medicare and Medicaid, and individuals with specified chronic conditions.
Special Needs Plans:
Institutional Special Needs Plan – individual must reside in LTC facility for at least 90 days or meet nursing facility level of care and reside in the community/Assisted Living
Chronic Condition Special Needs Plan – targets specific chronic conditions, individual must have diagnosis of specific condition to qualify
Dual Eligible Special Needs Plan – individual must have both Medicare and Medicaid coverage. Most commonly used in conjunction with State roll out of Medicaid Managed Long Term Services and Supports (MLTSS)
Traditional Medicare (Fee For Service) Parts A and B; Deductibles; Coinsurance
Can be partnered with a Medicare Supplemental and/or Prescription Drug Plan
Medicare Supplemental Benefits/Plans: Sometimes called Med Supp or Medigap plans, these plans supplement or wrap around traditional Medicare FFS coverage for non-Medicare covered services (deductible, co-insurance, added benefits under purchased plan). Medicare (CMS) pays first and supplemental provider coordinates benefits w/ Medicare
Beginning in 2020 two types of Medigap/Med Supp plans are no longer to be sold (no new enrollment). Plan C and Plan F which represented 53% of the enrollment in Medigap polices in 2010.
These plans covered Part B deductibles (in 2018, $183/year)
Plan G covers same things as F with the exception of the Part B deductible.
Prescription Drug Plan (PDP): A managed care plan for the prescription drug or Medicare Part D benefit

3. Expanded Medicare Advantage Supplemental Benefits 2019 and Beyond
CMS and Congress are expanding what Medicare Advantage plans can offer as supplemental benefits (including some HCBS).
CMS reinterpreted “primarily health-related” for CY2019
Congress, via the Bipartisan Budget Act, takes it further for CY2020
Supplemental benefits:
Can’t be Part A or B covered services
Must be primarily health-related AND
MA plan must incur a cost for providing the benefits.

4. Pre-2019 CMS Interpretations
Supplemental Benefits
Primarily Health-Related
Those items or services that:
Are not covered by Medicare A or B
Are primarily health-related AND
The MA plan must incur a cost for providing the benefit.
Prevents, cures or diminishes illness or injury
Excludes daily maintenance items or services
Pre-2019 supplemental benefit offerings included: Eyeglasses, hearing aids, dental care, gym memberships

5. Bipartisan Budget Act of 2018
CMS 2019 Medicare Advantage and Part D Final Rate Notice and Call Letter (CY2019)
Bipartisan Budget Act of 2018
(Implement CY2020)
Defining “primarily health-related” supplemental benefits
Supplemental benefits are considered “primarily health-related” if they will:
Diagnose, prevent or treat an illness or injury
Compensate for physical impairments
Ameliorate the functional/psychological impact of injuries or health conditions OR
Reduce avoidable emergency or health care utilization
Expanded definition to include benefits that:
Have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee
Cannot be limited to being primarily health-related benefits.
Believed to allow healthy meals and transportation to medical appointments.  

6. Bipartisan Budget Act of 2018
CMS 2019 Medicare Advantage and Part D Final Rate Notice and Call Letter (CY2019)
Bipartisan Budget Act of 2018
(Implement CY2020)
Defining “primarily health-related” supplemental benefits
Supplemental benefits under this broader definition must be:
Medically appropriate
Ordered or directly provided by a licensed provider as part of a care plan
CMS also suggests in the Call Letter that these benefits may:
Be targeted or time limited
Enhance quality of life
Improve health outcomes
Also, permits the plan to target some of its supplemental benefits to specific chronically ill populations.

7. April 27 CMS Memo
New interpretation does not include items or services that are “solely or primarily used for cosmetic, comfort, general use, or social determinant purposes.”
Prior to the above clarification plans were considering the following under new option:
Transportation to doctor’s office
Better food options
Simple home modifications (e.g., grab bars)
Help with Activities of Daily Living

8. 2019 List of Newly Qualifying Supplemental Benefits
Adult Day Services
Home-based palliative care (life expectancy > 6 months)
In-home support services for short periods of ADL/IADL assistance needed due to medical condition or disability
Pain management (medically-approved, non-opioid)
Memory Fitness benefit
Home & Bath Safety device & modifications
Transportation to help with health needs
Adult Day Services
Assistance with ADLs/IADLs provided outside the home
Education to support performance of ADLs/IADLs
Physical maintenance/rehabilitation activities
Social Services to ameliorate impact functional/psychological impact of injuries or health conditions, reduce ER use
Recreational and social activities or meals – as long as purpose is primarily health related and provided by licensed/qualified staff
On April 27, CMS guidance provided the following list of services that it explicitly deemed to meet the new interpretation
List is not exhaustive

9. What you need to know
New supplemental benefits are not available to all Medicare beneficiaries, just those in applicable Medicare Advantage plans
These benefits are options, not requirements
Providers must negotiate the payment for these services (no rate schedule) and manage the contract
Keep in Mind:
New benefits are NOT for all Medicare beneficiaries
This is an option , not a requirement.
Providers will need to negotiate and managed contracts with MA plans to deliver these supplemental benefits.

10. 2019 MA Plan Offerings
Approximately 270 of 3,700 MA plans (roughly 7%) offered in the US have:
An expanded HCBS supplemental benefit
Including some adult day services, in-home caregiver support services
Reduced cost sharing and other benefits for enrollees with certain conditions
Conditions such as diabetes or congestive heart failure

11. Next Steps Monitor MA plans and benefits announcements: October 1
Identify which plans your clients and/or residents are enrolled in to determine potential plans to contract with for supplemental services
Medicare Advantage open enrollment runs Oct 15 – Dec 7
Evaluate how your services meet the new definition of supplemental benefits and your cost to provide
What does a typical episode look like?
What package of care is optimal for a certain diagnosis or condition?
Approach local Medicare Advantage plans to educate them on your services and why they might want to offer them as a supplemental benefit for the coming calendar year (ideal timing starting in Dec. 2018/Jan for 2020 MA plans)
Payment: Not all payment must be paid per hour/day (e.g., pay for performance, time-limited 14-day respite care package, by diagnosis or health condition)

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