05/16/2018

New CMS Guidance on Possible HCBS Options under Medicare Advantage

On April 27, the Centers for Medicare & Medicaid Services (CMS) released sub-regulatory guidance detailing an array of home- and community-based (HCBS) services that Medicare Advantage (MA) plans can offer as supplemental benefits beginning in calendar year 2019. 

CMS’s new interpretation appears to recognize the importance of these services for certain MA plan enrollees while making clear that not every enrollee in an MA plan will be eligible to receive them without a designated need. CMS identified the following list of specific services as allowable supplemental benefits meeting CMS’s new expanded definition of “primarily health related”:

• Adult Day Services provided outside the home including transportation to and from this service. Also, recreational or social activities or meals that are ancillary to the primarily health related services.
  
  
• Home-Based Palliative Care to diminish symptoms for terminally ill beneficiaries with a life expectancy that is greater than 6 months, and so are not eligible for hospice care.
  
  
• In-home support services for individuals with disabilities or medical conditions that need assistance with performing ADLs and IADLs.
  
  
• Support for caregivers of enrollees including respite care provided through a personal care attendant or in a short-term institutional care setting.  CMS specifies this benefit should be for short periods (e.g., a few hours per week or two-week period or four-week period). Counseling and training courses for caregivers of enrollees would also qualify.
  
  
• Medically-approved non-opioid pain management.
  
  
• Memory Fitness Benefit can be offered as a stand-alone benefit or as part of a broader health education benefit.
  
  
• Home and bathroom safety devices and modifications: non-Medicare covered safety devices to prevent injuries with the exception of capital or structural improvements to the enrollee’s home.
  
  
• Transportation to assist with the enrollee’s health needs and may include a health aide to assist during the trip. Does not include transportation for groceries or banking.
  
  
• Over-the-counter benefits that are not otherwise covered under MA plan benefits and permits coverage for assistive devices such as pill cutters, pill crushers, pill bottle openers and personal electronic activity trackers.

However, CMS reiterated that for the above services to qualify as a supplemental benefit under its recently-expanded definition of “primarily health related,” the service must be provided to:

• Diagnose, prevent or treat an illness or injury
  
  
• Compensate for physical impairments
  
  
• Ameliorate the functional/psychological impact of injuries or health conditions OR
  
  
• Reduce avoidable emergency or health care utilization

CMS notes that this list is not exhaustive and so additional services may also meet the new expanded definition.  In addition, CMS is not permitting services that are “solely or primarily used for cosmetic, comfort, general use, or social determinant purposes.”

On the upside, unlike eligibility for certain Medicare services, eligibility for these supplemental benefits does not require an enrollee to have a prior hospital stay, homebound status or a skilled level of care need. However, it does require these services relate to the enrollee’s health care needs and be recommended by a licensed medical professional as part of care plan. So, it is unlikely a package of assisted living services that are available to all residents would qualify under the new interpretation but some of the individual services may qualify if they are documented as part of an individualized care plan. 

To be clear, overall, these services will only be available for enrollees in Medicare Advantage plans that elect to offer them as part of their supplemental benefits in CY2019. These same services will not be paid for through Medicare fee-for service.   

It should also be noted that CMS does not set what rates an MA plan must pay providers for these services so those terms will need to be individually negotiated between these HCBS providers and the plans. Nonetheless, this is an important step that moves us closer to recognizing that older adults’ needs can be more comprehensive than what Medicare has paid for up until now and that those services and supports can play a critical role in better outcomes and lower costs. 

For additional background on this topic, read "Clarifying New Opportunities for HCBS Providers Under Medicare Advantage Plans." (LeadingAge)