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Saturday, April 13, 2019 11:05

Is Medicare Advantage a Best Option for Senior Living Residents?

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Posted in the Senior Care Topics Series by Everbrook Senior Living

Seniors reading or watching the news are informed that Medicare, through its parent agency, Centers for Medicare and Medicaid, CMS, is now covering some essential non-medical services such as in-home care, transportation, and soon phone consultations with the doctor. In brief, Medicare following passage of the CHRONIC Care Act of 2017 and through reinterpretation of its own rules, has empowered only Medicare Advantage Plans, “MA”, to offer a broader array of supplemental benefits including vision/hearing screens to name a few and now non-skilled home-health to beneficiaries who demonstrate a medical need for such services. A supplemental benefit under Medicare is defined as: 

  • A service or benefit not covered by traditional Medicare 
  • A service or benefit that is primarily health-related, and
  • A service or benefit in which the MA plan incurs a non-zero direct-medical cost.

Although seen universally as a positive step toward the continuing trend to reform coverage rules so medical providers can be paid to treat longer term chronic illness, in reality, seniors in need of home-health aides to support disabilities or who hope to talk to their doctor over the phone instead of having to travel their office will likely have to wait several years to receive those benefits in manners which make real improvements to their quality of health and life. Yet, for seniors with complex chronic illness which includes many senior living residents, MA plans appear to be the best option to get the most comprehensive coverage including essential supplemental benefits not available in traditional Medicare like in-home care or telehealth benefits, although with some uncertainties to work through. Medicare Part D amendments and other payment models being tried at CMS are not discussed here.

Medicare Does Not Pay for In-Home Care or Telemedicine 

Seniors may ask how can Medicare offer services like home-care without paying for them and why are Medicare Advantage plans authorized to provide these supplemental benefits while traditional Medicare is not? To answer the question requires explanation as to what Medicare is attempting to accomplish with its policy shift away from the traditional fee-for-service reimbursement structure and into more chronic care management. Essentially, experts in health care policy all agree that with seniors living longer with more chronic health issues, the current fee-for-service system, is unsustainable in its current form. Yet, there is little political will to add supplemental or quasi-long-term care benefits to an already expensive system. 

The recent trend in legislation is to introduce methods and services supportive of long-term illness, “supplemental benefits”, through private insurance contracts provided that the insurer agrees to assume the financial risk in providing supplemental benefits to enrollees without looking to Medicare to pay for the services. Beginning with the Affordable Care Act, Obama Care, and continuing with the passage of the Chronic (CHRONIC) Care Act the federal government has been slowly broadening coverage of care and services as long as new programs are cost-neutral to Medicare. While CMS authorizes its Medicare Part C plans to offer supplemental benefits, the insurer can only use surplus funds it claws out of the plan utilizing techniques like PPO’s, HMO’s which is calculated to create a gap between what Medicare pays it, and what it pays providers, to fund the additional coverage. Medicare Advantage or Medicare Part C, is private insurance through which insurers like Humana, Anthem or UnitedHealthcare are required to implement the same Medicare Part A and B coverage offered in traditional fee-for-service (FFS) Medicare yet with prescribed authority to invest savings (the difference in what beneficiaries cost Medicare in FFS and what the MA plan spends) in a list of approved supplemental benefits.   

How Medicare Advantage is Structured 

How the system works is that MA Plan insurers are paid a monthly payment for each enrollee based on what that person is likely to incur in Medicare costs for the up-coming year if their medical providers were billing the traditional fee-for-service reimbursement system, adjusted to compensate for things like high risk, high-need as well as cost-of-living in certain regions. Insurers which have a higher star rating also receive quality bonus incentive payments. Insurers bid to a benchmark set by Medicare, which is increased if the star-rating is higher. When the bid is below the benchmark the insurer carves-out surplus funds (savings are split with Medicare) it may invest in non-traditional services as a way to lure customers and in theory to lower costs. Insurers are not required to offer supplemental benefits but when there is a surplus of funds, it can only reinvest into the extras which now includes telehealth or in-home-care. But, insurers assume the financial risk that payments to non-medical providers and the costs to set up telemedicine can be funded through the savings it is able to produce through expert management; thus, MA plans must find ways to leverage these less expensive services to reduce utilization of more expensive treatments or they risk losing money. Medicare denies traditional FFS Medicare the same option as MA plans out of concern for cost increases mainly from overutilization and other wasteful practices. 

Specifically, Medicare Advantage insurers derive profits by designing plans to extract higher quality care from providers while simultaneously reducing projected payments on behalf of each enrollee: in-home care or telemedicine in theory are preventative strategies intended to support ongoing management of chronic illnesses in ways which breaks the cycle of repeat hospitalizations without reducing quality. The riskiest enrollees have complex needs which necessitates regular involvement of medical teams to control fluctuations in symptoms related to chronic conditions like CHF, diabetes, or COPD, which portends to higher admission rates at hospitals. Medicare Advantage is enabled by congressional action to focus on early interventions into chronic disease to divert enrollees away from higher-cost care sites and treatments. Medicare is rewarded because in theory it will eventually lower the benchmark. Enrollees are offered a variety of MA plan choices, most of which are no more expensive than what is charged to seniors enrolled in traditional Medicare, but with additional benefits being provided to suit the unique needs of seniors. Many MA plans combine Part D drug benefits within the plan. 

High-risk MA enrollees are offered MA plans which are designed specifically to address the special health and treatment needs of seniors with multiple chronic conditions, in what is termed a Chronic Conditions Special Needs Plan, C-SNP or Institutional Special Needs Plan, I-SNP, including Institutional Equivalent Plans, either or all of which require enrollment criteria which fits a majority of the senior living population.  I-SNP’s or equivalent plans are available to residents living within assisted living communities. Availability of A plans and scope of coverage varies by company, state, and even county. Many enrollment requirements are not addressed here.   

Medicare Expands Coverage for Non-Medical Home Care in 2019

Because of a shifting landscape to improve chronic care and following passage of the CHRONIC Care Act, Medicare in 2018 re-interpreted its own rules to authorize MA plans beginning in 2019 to expand coverage into non-medical supportive services like in-home care. MA plans may now offer supplemental benefits to support complex chronic conditions. The potential for additional coverage includes: 

  • Adult-day care;
  • Home-based palliative care;
  • In-home care;
  • Home and bathroom safety devices;
  • Transportation; and 
  • Over-the-counter medications

The CHRONIC Care Act Expands Coverage for Telemedicine in 2020

Seniors may often wonder why to receive medical advice they must find their way to the doctors’ office and see staff face-to-face even for routine problems. This custom and practice was shaped by Medicare coverage rules which conditions payment to the doctor upon a show of proof that he/she examined the patient face-to-face. Medicare beginning in 2015 relaxed the face-to-face requirement rule if a beneficiary with at least two chronic illnesses treated with a doctor who was approved to practice chronic care management services. Unfortunately, not enough doctors have shifted into practicing chronic care management although more and more are now embracing this model. Medicare has traditionally denied reimbursement to physicians who perform medical services over the phone except in rural regions. The CHRONIC Care Act has loosened telehealth reimbursement rules but only through Medicare Advantage Plans and Accountable Care Organization structures. 

The new law changes the rules as follows: 

  • Eliminates geographic restrictions when treating stroke patients over the phone;
  • Expands telehealth coverage under Medicare Advantage Plan B beginning in 2020; 
  • Gives Accountable Care Organizations more flexibility to use telehealth services;
  • Expands telehealth monitoring to in-home dialysis without geographic restriction; and
  • extends for two years the Independence at home Pilot.

The Availability of New Supplemental Benefits is Uncertain

Consumers enrolled in a MA plan particularly higher-risk enrollees may be left to wonder why the promise of being covered when in need of in-home care or telemedicine to better manage chronic illness fluctuation is made readily available. However, because Medicare is not directly involved in rolling-out new benefits and offers insurers rather broad guidelines within which to work, there is much uncertainty as to the viability and sustainability of this cost-neutral strategy. Prior to reinterpreting its own guidelines, CMS (Medicare) issued guidance suggesting that supplemental benefits could not be used for “daily maintenance”: Medicare now interprets is guidelines more broadly such that beginning in 2019, it authorized MA plans to offer in-home care to support daily maintenance of chronic conditions and functional impairment  and allows greater flexibility to target benefits to specific disease states without violating uniformity rules. This new flexibility opens-up opportunity to add supplemental benefits to enrollees who have diabetes, COPD, CHF, stroke, lower back pain, kidney disease, nicotine addiction, asthma, and hypercholesterolemia. However, insurers are still evaluating plan architecture and roll-out methodology. 

The CHRONIC Care Act expands options to offer supplemental benefits to support more types of chronic conditions. The benefits must have a reasonable expectation of improving or maintaining the health or overall function of chronically ill enrollees. Chronically ill enrollees are those who have demonstrated disabilities, has high risk of having adverse health outcomes or increased hospitalization and/or requires intensive care coordination. Telehealth coverage is to be part of the original bid to the benchmark and not subject to additional premium charges. However, there remains to be seen how insurers interpret the new guidelines and how insurers can adapt benefits to fit within the new landscape in a way which produces a predictable rate of return to the insurer. 

As MA plan insurers look at methods to operationalize the new supplemental benefits such as in-home care or telehealth, there is a long list of issues to address. Thus, for example, in telehealth, the following is but a short-list of questions to be answered: 

  • which consumers will buy-into the notion that the doctor can diagnose a new medical issue over the phone? 
  • Which doctors will feel it safe to diagnose and treat a complaint remotely? 
  • Which doctors will be willing to invest in technology such as IT or blue-tooth to meet standards set by insurers? 
  • Which medical conditions make the most sense in providing telemedicine options? 
  • How can consumers be trained to access telemedicine appropriately? 
  • How can providers demonstrate that use of telemedicine reduces overall costs of care for that patient? 
  • How can providers, insurers, and patients achieve success through telemedicine? 

For In-home and other supplemental benefits, the questions posed include: 

  • How to segregate patients with complex needs and enroll them into a plan?
  • How to integrate non-medical providers into medical networks and plans of care?
  • How to define the clinical basis to approve coverage for non-medical services?
  • How to successfully market the plan so there is scale?
  • How can providers demonstrate that use of in-home care and other benefits reduces overall costs of care for that patient? 
  • How can insurers protect against overuse of the benefit?

Is Expansion to Add Supplemental Benefits a Boon to Senior Living?

Many of the challenges MA insurers have designing and implementing supplemental benefits successfully (achieving a high rate of return through lower costs) senior living communities are well-equipped to help address. Senior living residents particularly those admitted into private-pay rental communities, pay for nursing oversight and personal care to support continued community-based living. Nursing staffs within senior living work autonomously in most cases, that is, not in a master-servant relationship with the medical teams which issue medical plans of care to residents. Thus, what nurses do within senior living is help manage the fluctuations of chronic conditions and impose preventative services such as falls assessment and prevention: these are the types of preventative care MA plans seek to implement as a strategy to reduce overall costs. 

Moreover, many senior living residents have or develop the types of conditions for which the expansive coverage into in-home care and telemedicine would benefit and many residents would be eligible to enroll in a C-SNP or I-SNP where supplemental benefits could be not only tailored to need but customized to be integrated with AL program services. For example, senior living residents’ often need additional in-home care to address acute exacerbations of chronic illnesses-breathing problems associated with COPD and would benefit significantly if the nurse responding to a health status change could access the medical team by phone or email, describe symptoms, and await orders. This rapid response capability though a core mission in senior living, is precisely the type of response which can prevent a costly hospital visit. However, being autonomous to the residents’ medical teams, gaps exist in communication and care as for example, after-hours when a resident experiencing a health crisis has no access to their doctor’s office, the only viable and safe option may be a call to 911, a trip to he emergency room and increased expense. An I-SNP in particular can customize coverage to better integrate medical care including supplemental benefits to AL program service plans such as around-the-clock remote monitoring or additional non-medical home-care in ways that when working in tandem, can decrease high-cost incidences like falls, pressure ulcers, delirium and other geriatric syndromes which lead to unnecessary hospitalizations and redundant care.          

There is recognition as to the possibilities of improving coordination between senior living and insurers who offer MA plans. Four companies have already teamed up to launch an MA plan intended to cater to seniors appropriate for assisted living: Christian Living Communities, Juniper Communities, and Ohio Living partnered with a benefits manager AllyAlign Health to form The Perennial Consortium, an operator-owned Medicare Advantage network scheduled to be operational in 2021. The intent is to launch special-needs plans state-by-state, then sell ownership interests to other senior living communities. Special-needs plans were made permanent in 2018. 

Senior Living can Help MA Plan Enrollees Get Better Care

A primary challenge in senior assisted living is providing adequate care and services to very frail residents, many of whom may need either 24-hour caregiver support, the assistance of two-persons for transfers or high-need transportation for medical treatments. Senior living is well-positioned to leverage non-medical interventions in ways which maximizes the opportunity to reduce emergency-room visits and other high-cost treatments and thus improve quality of life. AL nurse programs can help MA plan insurers resolve implementation challenges such as: 

  • In relation to telemedicine, AL nurse programs can reduce resident concerns about the ability of doctors to adequately diagnose and treat conditions remotely because an AL nurse can describe symptoms and offer a nursing diagnoses to doctors over the phone which bolsters the integrity of remote monitoring thereby making such practices safer to implement: AL nurses can also reduce concerns of doctors about the ability to diagnose and treat patients remotely;
  • In relation to telemedicine, AL nurse programs can work cooperatively with medical providers to create better communications pathways, utilizing text, email, and e-records more effectively when responding to resident/patients’ changes in health status: 
  • In relation to marketing plan benefits effectively, AL nurses can advocate for residents about the benefits a special needs plan can offer them over traditional Medicare: 
  • In relation to in-home care, AL nurse programs typically establish preferred provider relationships with non-skilled home care agencies and would be well-suited to help medical teams devise plans of care which integrates non-medical home-care in it: 
  • In relation to verifying a clinical basis for needing a supplemental benefit like in-home care, AL nurse programs are uniquely situated to identify how functional disability can fbe helped with non-medical services such as for example, to address chronic illness exacerbations whether its depressive illness, behavioral disturbances, breathing instability (COPD), weakness (CHF), or other chronic conditions. 
  • In relation to concerns for overuse, AL nurse programs are uniquely suited to help MA plan insurers establish cost controls. 

The increased utilization of medical care to help control fluctuating symptoms of chronic illness and help manage a slow but steady decline in health experienced by very old adults will increasingly become a financial drag on Medicare particularly traditional Medicare. Although there is poor history of coordination of care among medical providers, payers, and patients in traditional Medicare, the shift in policy to enable private insurers to design Medicare Advantage Plans which better integrate medical care with nonmedical services will improve care for seniors particularly those higher-risk seniors who are appropriate for assisted living admissions. Senior living can enhance the effectiveness of treatment protocols if AL nurse programs are allowed to collaborate with Medicare Advantage insurers and its list of providers. AL nurse programs can assist residents to evaluate the advantages of a MA plan, transition residents onto a MA special needs plan appropriate for their unique medical conditions and can work cooperatively with residents’ medical providers to integrate medical plans of care with non-medical service plans. 

Senior living residents can benefit greatly if the potential for integration of AL services with managed medical care through insurance is operationalized. A well-coordinated system that allows AL nurse programs to help residents gain access to additional personal care supports through insurance will improve quality of life but also reduce increases of residency fees when residents experience higher-needs for care and oversight. In terms of consumer choice, as MA plan insurers operationalize the additional supplemental benefits into MA plans, older Medicare beneficiaries will have but one choice and that is to enroll into a MA plan which best addresses their unique health issues. 

Read 2863 times Last modified on Tuesday, July 16, 2019 11:38
Robert Kelley

In-House Legal Counsel & Founder of Wellness-4 Later Life


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