The 2020 Opportunity: Medicare Advantage as a Market for SDOH Innovation

Supplemental Benefits Never Sounded So Good

Patchwise Labs
Feb 7 · 8 min read

Making the Sausage: MA + SDOH = SSBCI

There are actually two new, and slightly different updates to the supplemental benefits provision under MA. In 2018, CMS announced they would expand reimbursements starting this year (2019) in the MA program for non-clinical supports that promote the health of chronically ill beneficiaries who meet certain eligibility criteria.

Introducing: Special Supplemental Benefits for the Chronically Ill (SSBCI)

Starting in 2020, SSBCI will amend the 2019 requirements to encompass “supplemental benefits that are not primarily health related and/or offered non-uniformly to eligible chronically ill enrollees […] if certain conditions are met.”

Product: What Counts as an SSBCI?

If you’re wondering what “not primarily health related” jargon means in plain English, CMS’s explanation may not help:

Market: Which Beneficiaries (and How Many) are Eligible?

If defining what will be paid for is one key variable in this equation, then the other is defining who is eligible. From the regulation:

Deeper Challenges: Money & Member Engagement

While MA represents a buzzy market to PE and VC, one thing is important to understand: This is not “new money,” it’s a redistribution of existing dollars. CMS is not offering additional funding for new supplemental benefits, but rather providing plans with more flexibility to match resources to needs.

2020 & Beyond: Legislation → Law + Innovate → ROI

As part of this rule, Congress is authorizing a five year study by the General Accountability Office (GAO) to analyze frequency of utilization, impact on quality of care, clinical outcomes, and the impact on plans bidding rates for Part C. The report will go on to inform subsequent decisions on funding SDOH supports, ultimately influencing their expansion into Medicare or other insurance programs.

Patchwise Labs

Stories and analysis of emerging innovations to address the social determinants of health (SDOH)

Patchwise Labs

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Patchwise Labs

Stories and analysis of emerging innovations to address the social determinants of health (SDOH)