Who, What, & How: Understanding New SDOH Payments in Medicare Advantage

Eligibility, Coverage, and Determination in SSBCI

Patchwise Labs
Apr 18 · 6 min read

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) finalized the rule to allow Medicare Advantage (MA) plans to pay for certain non-clinical supports and services as “supplemental benefits” to address the social determinants of health (SDOH) for chronically ill patients.

source: CMS.gov

The wonky acronym for the new rule: SSBCI, which stands for “special supplemental benefits for the chronically ill.” The punchline is easier to understand: MA plans can pay for meals, transportation, home modifications, pest control, and other non-clinical stuff starting next year.

The vast majority of this new rule is very similar to CMS’ initial proposal, though the final reg contains some new clarity around how plans can determine which members qualify for these new benefits, as well as some new leeway around what types of benefits qualify. For the general nuts and bolts, our summary from February offers a quick recap of how this will work.

With the rule finalized, the wheels are officially in motion for 2020. The MA industry has begun thinking about how to add these new supplemental benefits into their annual bids for CMS approval, and then deliver them to the members in need. Usually the devil is in the details, but here the devil’s in the doing: The rules here are pretty straightforward, but implementing them will be the challenge, especially in the first couple of years.

Let’s zoom out and take a look at what this means at the broadest level. For health plans, consultants, technology vendors, and community partners, there are three major facets to this new rule: Who, What, and How.

source: Patchwise Labs analysis

Who: Determining Eligibility

This is relatively straightforward: First, only members with a “qualifying chronic condition” from this list (p. 5) qualify. This may seem like a tight leash at first glance, but click the list — it’s basically anything. CMS even points out that this list covers about 73% of the current MA population.

Secondly, in addition to making sure that members have been diagnosed with a condition from that list, MA Plans must also develop and maintain their own assessment that these members health status also meets three key criteria of the program:

1) has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee;

2) has a high risk of hospitalization or other adverse health outcomes; and

3) requires intensive care coordination.”

✏️ Key Detail: Plans will have to have a “process” to match members with qualifying chronic conditions from the list to the three pronged definition above.

Note that while plans do NOT have to submit this process in writing as part of their annual bid to CMS, they DO have to document their determination for each member who enrolls in SSBCI. Think of it as an internal policy mechanism or filter to screen in people in need of extra services or supports.

✏️ Key Detail: For Certain Plans (e.g. SNPs), community-based partner organizations can help determine eligibility according to the MA plan’s particular process.

What: Determining Coverage

CMS offers a lot of wiggle room here. The goal of this new rule was to provide plans with a lot of flexibility to determine which non-clinical supports they want to include. The criteria in this case amounts to a sniff test:

“MA organizations have broad discretion in developing the items and services they may offer as SSBCI provided that the items or services have a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic illness”

An update in the final rule is that plans WILL be allowed to offer benefits that include “capital or structural improvements” like in-home modifications that could improve or maintain health (e.g. walking ramps, tub handrails, etc.)

✏️ Key Detail: Plans can spend whatever they want to on SSBCI, but they have to pay for it as a “non-zero direct medical cost.”

In effect, SSBCI will count towards plans’ medical loss ratios as opposed to counting as administrative expenses.

✏️ Key Detail: Plans must describe any new SSBCI in the plan benefits package (PBP) as part of their annual bid.

How: Determining Determinations (aka “Matching”)

Here is where things get trickier. While a new waiver of “uniformity requirements” give MA plans more flexibility to customize benefits to the individual, they are not allowed to confer new benefits on any chronically ill member from the list. Instead, each customized benefit they’re not directly linked to “the process” above. For example, transportation or meals can’t be provided to every beneficiary who has a chronic condition — only those for whom it would improve their specific health condition.

CMS’s word of choice is “Determinations:”

“There must be a determination by the MA plan that the non-primarily health related benefit will have a reasonable expectation of improving the chronic disease or maintaining the health or overall function of the enrollee receiving the benefit”

“MA plans may make these beneficiary-specific determinations using internal criteria”

“We expect MA plans to develop objective criteria (e.g. health risk assessments) and maintain detailed documentation for determining when one chronically ill enrollee is eligible for a particular service or item and another is not.”

✏️ Key Detail: MA plans will have to develop an internal “matching” process that accounts for two things: 1) What are the non-clinical needs of this person as related to their chronic condition? 2) Does a specific benefit match up with those non-clinical needs?

As always, with great challenge comes great opportunity: While the compliance on filtering and matching will be onerous to stand up, it allows plans to develop their own unique approach to addressing SDOH at scale. In theory, could an MA plan use a PRAPARE assessment or other screening tool to identify specific non-clinical needs instead of an HRA? Would a loneliness screening be used to match someone with a peer coach, or perhaps a culturally tailored benefit, like a Promotora?

If You Build It…Will They Come?

Just because CMS will allow plans to start paying for some new stuff, that doesn’t guarantee it will work smoothly in the real world.

Questions remain around member engagement and the nearly invisible line CMS has drawn between making sure people know about these new benefits (which is encouraged) and making sure plans are not using these new benefits to market their plans to people (which is illegal).

And while there is plenty of flexibility built into this new rule, the vast majority of MA plans are not likely to take a highly experimental approach (at least not early on) — so novel uses of this program will likely be a couple of years away. Anecdotally we’ve heard from consultants of all types across the budding SDOH industry who are now scrambling to gather data on the cost of providing meals and rides (and so far, little else).

But over time, perhaps these new SSBCI will promote a diversity of social supports and services. CMS is running an experiment on value-based insurance design that will inform how some of these policies work n the real world. Moreover, as we saw in-depth, it’s quite difficult to put together a multi-year cost-benefit analysis on SDOH in MA given the speedbumps of an annual bidding cycle. The bidding process in general discourages risk-taking, and most plans (particularly smaller plans serving dual-eligibles) will play it safe to start.

The good news is that as tech-enabled service platforms start conquering the administrative “how” and moving from proof of concept to proof of scale, MA plans will hopefully have an easier time focusing on the who and the what: our most vulnerable patients, and their social determinants of health.

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Patchwise Labs

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

Patchwise Labs

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We are a creative strategy firm with one simple goal: To make the healthcare system work better for the people who need its help. http://www.patchwiselabs.com

Patchwise Labs

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