Recent federal regulatory changes have enabled Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs), to offer Special Supplemental Benefits for the Chronically Ill (SSBCI) to their members. These benefits could include help with housing food and transportation. A recent report proposed a set of policy options for Medicare to provide D-SNPs with more tools to address social determinants of health.
More than 12 million Americans who are dually eligible for Medicare and Medicaid often have multiple chronic medical and behavioral health conditions, long-term care needs, and significant social determinant of health (SDOH) needs. Unmet social needs can make it difficult for individuals to access care and follow care recommendations and medication regimens, resulting in avoidable hospitalizations and emergency department visits.
The Association for Community Affiliated Plans (ACAP), a national trade association representing not-for-profit safety net health plans, has 24 Medicare Advantage D-SNP members that enroll mostly full-benefit dually eligible individuals. With support from Arnold Ventures, ACAP partnered with the Center for Health Care Strategies (CHCS) on a report and follow-up webinar on Nov. 2 to assesses gaps in the ability of D-SNPs to address their members’ social risk factors and to explore policy options.
Nancy Archibald, M.H.A., M.B.A., a CHCS senior program officer, explained that health plans must fund the costs of these SSBCI service using “rebate dollars, which are generated from the difference between the plan’s bid amount and its benchmark rate, with the percentage of the rebate kept by a plan varying based on its CMS Star Rating. She said this poses several challenges, including geographic and year-to-year variations in rebate dollars; lower rebate amounts available to plans with lower Star Ratings; and the need to use rebate dollars to provide other supplemental benefits such as vision, dental, and hearing services. (D-SNPs are likely to have higher levels of SDOH needs than non-dually eligible Medicare Advantage enrollees, and D-SNPs also tend to have lower Star Ratings than other types of Medicare Advantage plans.) As a result, many D-SNPs retain a lower percentage of their rebate dollars than other Medicare Advantage plans with a smaller proportion of dually eligible members.
A survey of ACAP D-SNP plans found that a lack of resources restricts their ability to address housing, social isolation, and transportation needs. Interventions to address some of these needs are very expensive and require long-term plan investment, while available funding streams tend to support short-term solutions. “They troubleshoot to close gaps, such as finding temporary shelter for a homeless person, but longer-term solutions are harder to find,” Archibald said. “They would welcome more resources to offer whole-person care,” Archibald said.
Potential policy options
The ACAP report identified several policy options, which could be enacted alone or in combination.
• Create New Flexibilities for Plans to Offer SSBCI. ACAP D-SNPs offered suggestions for additional flexibilities, including the ability to tailor SSBCI based on enrollees’ geography (e.g. urban or rural); tailor SSBCI to an individual member’s needs; and offer SSBCI to all D-SNP members instead of only those with a chronic condition. They note that by definition, D-SNP members are low-income and could benefit from services to address their SDOH needs.
• Redesign Star Ratings Comparison Groups. CMS could redesign the comparison groups for awarding Star Ratings through peer grouping. This would create a more accurate and equitable quality rating system for D-SNPs where high-quality D-SNPs would be able to retain a larger percentage of their rebate dollars because their members’ SDOH needs would be accounted for in the quality measurement system.
• Allow D-SNPs to Retain a Higher Percentage of Their Rebate Dollars. CMS could let D-SNPs keep a higher percentage of their rebate dollars by creating an “SDOH add-on” to the rebate percentage.
• Add Indicators of SDOH Need to the Medicare Advantage Risk-Adjustment Model. Incorporating indicators of SDOH need into the CMS Hierarchical Condition Category (HCC) risk-adjustment model could improve the model’s accuracy and could increase payments to plans that enroll individuals with higher SDOH needs that are associated with increased Medicare costs.
Recognizing that policy change takes time, Archibald noted that there are additional research areas to explore, including incentivizing collection of SDOH data through value-based payment arrangements, as well as evaluations of the return on investment of particular SDOH-related interventions.
