Medicare Advantage and the Social Determinants: Reaction vs. Real Coverage?

Medicare Advantage plans have reacted to industry criticism of their limited coverage expansion of SdoH.

I expected a buzz over our recent Monitor Mondays report and RACmonitor article about the limited coverage expansion of the social determinants of health (SDoH) by Medicare Advantage (MA) plans. Actually, there have been a constant series of announcements in recent days.

Direct Response by the Major Players
Two weeks ago, the Urban Institute and Robert Wood Johnson Foundation (RWJF) identified how the five major MA plans were not doing enough to address the SDoH. Ironically, several of these entities have bolstered their offerings, with major press releases to announce their programs. Both Cigna and Humana affirmed their priority to assure appropriate coverage for any social needs impacting their members’ health. Each entity also promised to grow their SDoH programs:

  • Humana’s coverage will vary by region, with benefit expansion for:
    • Caregiving
    • Transportation to medical appointments and fitness centers
    • Acupuncture
    • Home-delivered meals
    • Coverage for over-the-counter personal care items (e.g., pillboxes, vitamins).
  • Cigna’s coverage will also grow and vary by market, with benefits for:
    • Air conditioners
    • Fall prevention
    • Acupuncture
    • Transportation to places of worship and grocery stores

Both plans also expressed a staunch commitment to offer dental and vision options, as well as increase case management for their MA populations.

Not to be outdone, Anthem plans to also broaden service options for members, offering a wide range of benefits targeted to those at risk for the SDoH:

  • Healthy nutrition, upon meeting qualifying clinical criteria, with access to eight sessions with a dietitian annually for providing nutritional education support, plus monthly delivery of pantry staples (nonperishable items) to help make dietary changes. In addition, up to 16 delivered meals, four times each calendar year (64 total), to support members either discharged from an overnight stay at a hospital or having a body mass index (BMI) over 25 or less than 18, or an A1C level over 9.0. 
  • Pest control, with quarterly preventive treatments to regulate or eliminate the intrusion of household pests that may impact a chronic condition. 
  • Health and fitness trackers provided to members, as well as membership in programs to promote improved physical and mind fitness. 
  • Service dog support by up to $500 in annual allowance toward payment for a member’s service dog supplies, such as leashes and vests. The dog must be certified under the Americans with Disabilities Act. 
  • Transportation for up to 60 one-way trips annually to health-related appointments or to obtain a service covered by the health plan. 
  • Personal home helpers for up to 124 hours of in-home personal care aide service for assistance with activities of daily living (e.g., dressing, grooming, bathing). 
  • Assistive Devices with up to a $500 allowance for safety devices (e.g. Americans with Disabilities Act (ADA) toilet seats, shower stools, hand-held showerheads, reaching devices, etc. 
  • Day center visits for up to one visit weekly of adult day center services.
  • Alternative medicine for 24 acupuncture and/or therapeutic massage visits each calendar year.

Telehealth Expansion: What about Consumer Confidence?
Cigna, Humana, and Anthem also plan to expand their telehealth access options, to capture expanded reimbursement available through the Centers for Medicare & Medicaid Services (CMS). However, a recent survey by The National Poll on Healthy Aging could have the potential to impact the plan. The study revealed that:

  • 71 percent of older adult respondents had concerns that their providers could not do a physical exam via webcam or smartphone
  • 68 percent noted that remote care wouldn’t cut it
  • Close to half of respondents (49 percent) did not feel a personal connection to the health professional engaged with via the telehealth platform.

These numbers do not reveal high levels of consumer confidence for the use of telehealth among this segment of the population.

Smaller MA Plans Meeting the Challenge
Not only are the largest MA plans stepping up, but Alignment Health Plan, out of Southern California, is expanding services for their MA beneficiaries, including:

  • Coverage of prescription drugs not typically covered by Medicare (e.g., generic Viagra)
  • Transportation to doctor appointments via ride-share companies (e.g., Uber and Lyft)
  • Companionship for members of specific plans who have diabetes and other chronic illnesses
  • A monthly grocery allowance for some plans
  • The ability to access board-certified doctors from video or telephone on demand through the ACCESS program; an on-demand concierge program providing members a dedicated concierge team, as well as a debit card for eligible items.

I anticipate that the industry will see most (if not all) MA plans put their best foot forward to ensure coverage for the SDoH, especially if they want to continue to enhance their health outcomes for members. Their financial sustainability is at stake.

Programming Note: 

Follow this continuing story weekly on Monitor Mondays, 10-10:30 a.m. EST, for the State of the Social Determinants report.


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