- Health plan executives expect only modest expansions of SDOH benefits in 2020.
- Among factors limiting SDOH benefits are challenges in creating networks of vendors that can offer them.
- CMS is watching to ensure MA plans’ marketing materials don’t promise all enrollees they can obtain such benefits.
Medicare Advantage (MA) health plans are expected to add few new benefits to address social determinants of health (SDOH) in 2020, despite the expanding opportunities to do so under federal rules.
The Centers for Medicare & Medicaid Services (CMS) has been expanding the nonmedical services that MA plans can cover, including 2019 options to cover temporary home modifications and bathroom safety devices.
But only 270 out of about 3,700 plans started providing enrollees with those new types of supplemental benefits in 2019, according to John Gorman, founder of the Gorman Health Group.
In 2020, new rules will allow MA plans to offer additional evidence-based benefits that help enrollees’ health, including services for transportation, food security and housing, and programs to address loneliness. The 2020 rules are based on legislation and so are seen as a much bigger incentive to plans than the earlier rules, which were based solely on CMS reinterpretations of MA regulations, according to policy experts.
However, Charles Milligan Jr., executive director of national dual-eligible special-needs plans for UnitedHealthcare, warned this week at a Bipartisan Policy Center event in Washington, D.C., that the 2020 rollout of such benefits would remain slow.
“It takes time to build networks of vendors to provide nonmedical benefits,” Milligan said.
His comments echoed July 24 comments to investors by Felicia Norwood, president of the Government Business Division of Anthem, which was a 2019 leader in adding SDOH benefits.
“We will be making some modest improvements with respect to those offerings because we believe that they certainly can be differentiators with respect to our products in the various markets,” Norwood said.
Anne Tumlinson, CEO of Anne Tumlinson Innovations, said at the Bipartisan Policy Center event that comprehensive national data is unavailable to track the extent to which MA plans are offering new SDOH benefits. So, analysts depend on health plans to publicize such benefits.
Milligan noted that a slow rollout of SDOH benefits in 2020 should not be seen as a lack of interest in adding such benefits.
One challenge UnitedHealthcare has found involves funding for community organizations that have provided SDOH services. Those organizations traditionally were funded through government grants. So, they have difficulty switching to an invoice-based claims model to fund such activities for health plans, Milligan said.
Approaches to SDOH benefit development
Key areas of focus for UnitedHealthcare as it develops its SDOH benefits include:
- Avoiding offering benefits too broadly
- Basing availability of benefits on health risk assessments
- Linking benefits to specific needs identified in patient care plans
Tumlinson agreed that SDOH benefits need to be carefully targeted to enrollees who can benefit from them. Otherwise, tracking data required by CMS will make such initiatives appear to have failed.
The challenge of steering benefits to the appropriate enrollees was underscored by Shawn Martin, a senior vice president for the American Academy of Family Physicians. He noted that primary care physicians report finding it very difficult to identify high-need patients in their own practices.
The highly individualized nature of SDOH needs means that plans can’t broadly make such benefits available to all patients within certain categories because not all will benefit from them, said Tim Engelhardt, director of the Federal Coordinated Health Care Office at CMS.
Among health plan efforts to effectively target SDOH benefits was the May announcement by Humana, which covers 440,000 Medicare beneficiaries, that from 2015 to 2018 it had screened more than 500,000 enrollees for SDOH needs, including social isolation, loneliness and food insecurity.
Other SDOH challenges
Another limitation on SDOH benefits is that many of the high-cost, medically complex Medicare beneficiaries who need such services live in rural areas, where non-healthcare service vendors are much sparser. And far fewer MA plans are available in rural areas to develop vendor networks because they struggle to meet CMS network adequacy standards, said Milligan.
New CMS rules somewhat lightened network adequacy rules and will better balance “flexibility and accountability,” Engelhardt said.
Engelhardt said CMS will be watching MA plans’ marketing materials to ensure they are not advertising the new SDOH benefits as being broadly available to plan enrollees, when only certain beneficiaries will qualify to receive them.
The marketing limitations create issues for providers, Martin said.
“Often the doctor has to say, ‘You’re not eligible,’” Martin said.