Sporting new CMS-approved plan designs, Medicare Advantage insurers target enrollee expectations

Medical consultation
Healthcare managers, which help beneficiaries navigate the complexity of the healthcare system, are one major service MA plans can now offer given new flexibility from CMS. (Getty/KatarzynaBialasiewicz)

With new regulatory freedom, Medicare Advantage (MA) insurers are offering a new roster of supplemental benefits in their 2019 plans, including medical advisers, transportation to doctors' appointments and nontraditional treatment options like acupuncture or therapeutic massage.

But with that plethora of choice comes a new challenge: Clarifying that enrollees only have access to those tied to a diagnosed medical condition, not every service on the list.

"The way that supplemental benefits are often listed in plan materials has sort of trained the consumer to think that if they see a supplemental benefit listed, they're eligible to use that benefit," said Steve Warner, VP of Medicare Advantage product strategy at UnitedHealthcare, in an interview with FierceHealthcare. "So the new flexibility—while it can be great at addressing a select population within a plan that has specific needs, it can also be a point of confusion for those are excited about the list of benefits without knowing that they won't ultimately qualify to use the benefits."

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The new plans are a product of the Centers for Medicare & Medicaid Services (CMS) loosening restrictions around MA supplemental benefits earlier this year, giving insurers the opportunity to innovate with new plan designs. But those new MA plans won't cover every service for each enrollee. To qualify, enrollees must have a certain diagnosis that corresponds with that supplemental need. 

RELATED: Medicare Advantage enrollees expected to top 22M in 2019 as premiums drop once again

"In these plans, the definition is driven at healthcare maintenance. It's not driven at the social determinants of health," said Lyndean Brick, J.D., president and CEO of healthcare consultancy The Advis Group, in an interview with FierceHealthcare. "There could be overlaps—if someone has diabetes and needs a special diet, they might get it—but it has to be related to a specific particular condition or diagnosis."

Warner acknowledged that this may pose a challenge—particularly in the first year of new benefits—and said UnitedHealthcare is discussing strategies to manage beneficiaries' expectations. One tactic is setting each beneficiary up with a "healthcare manager," a point of contact with whom members can discuss benefits and receive aid navigating the health system. 

That's a benefit in and of itself—the growing complexity of the U.S. health system has become a strain on patients in recent years—but it's also an approval mechanism. A healthcare manager stays up to date on each patient's care plan and can help guide them toward the services for which they are eligible.

RELATED: Medicare Advantage plans taking advantage of new policies that give them flexibility

Anthem is also using healthcare managers to help members navigate its new offerings—something that's especially helpful when those offerings differ depending on the state in which beneficiaries are enrolled.

For instance, in New Jersey, Anthem's new "Everyday Extras" Plan offers four new benefits. But in Tennessee and Texas, the same-branded plan offers six new benefits: food delivery, alternative medicine, personal home helpers, assistive devices, transportation or daycare visits. The latter two are not available in New Jersey.

Meanwhile, all six of those new benefits are also available to Anthem Blue Cross Blue Shield beneficiaries in Georgia, Indiana, Kentucky, Missouri, Ohio, Virginia and Wisconsin, but there the plan is called "Essential Extras." In Arizona and California, the list is longer still.

But Anthem is also employing one other tactic to manage beneficiaries' expectations: When giving beneficiaries a "menu" of six services, for example, they clarify that each enrollee can receive one of them.

"Certainly some of these benefits might be interesting to some people, but in order to put it in a package and have it be rational in design, we decided on the 'choose one' approach," said Martin Esquivel, VP of Medicare product management for Anthem, in an interview with FierceHealthcare. "The 'menu' component of this is innovative and new for Anthem; … generally, you don't see this in the market."

In Arizona and California, Anthem does not limit patients to one supplemental service in the same way.

A new bar for Medicare

Even though the exact number of eligible benefits will differ from enrollee to enrollee, CMS' new flexibility is still a sea change in the way Medicare Advantage members will receive treatment, Brick said. Once beneficiaries start anticipating novel benefits, it will be hard for future MA plans—and potentially even Medicare plans—to go without them. In fact, supplemental benefits may become the central metric by which seniors choose their plans each year.

"These supplemental benefits often are what distinguish the plan," said Brick. "When seniors decide what to do, they take out the list of perks, and they sit there and look at each plan: Does this have vision? Does that have dental? Does it have pharmacy? Does that have transportation? Does it have health aids?"

"They're going to sit and look at the lists and make a comparison," he said.

RELATED: Medicare Advantage plans cleared to go beyond medical coverage—even groceries

Before CMS relaxed requirements, many MA insurers had already begun offering benefits not covered by traditional Medicare—such as medical transportation and hearing aids—but the letter added to that list many services not previously considered medical care, such as medical advisers. 

And as the definition of healthcare services continues to expand, more social determinants could become covered in the future, Brick said. That could shift the cultural conversation around the future of healthcare and benefit design, but the industry is still in the early stages of that transformation.

"While this is a step in the right direction, we haven't jumped into the lake yet," she said. 

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