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CMS Okays Non-Skilled Home Care Benefit in Medicare Advantage

Monday, February 19, 2018   (0 Comments)
Posted by: Mandy Rubenstein
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The Centers for Medicare & Medicaid Services (CMS) recently announced that non-skilled in-home care will be included in Medicare Advantage plans in 2019 as a supplemental benefit.

“Our priority is to ensure that our seniors have more choices and lower premiums in their Medicare health and drug plans,” CMS Administrator Seema Verma said in a statement. “We are focused on addressing the specific needs of beneficiaries and providing new flexibilities for Medicare Advantage plans to offer new health-related benefits. This is a big win for patients.”

The CMS decision is an important change to supplemental benefit because it allows payers to cover services like non-skilled in-home support for daily maintenance and activities, which is a first. CMS will also include portable wheelchair ramps and other assistive devices and modifications, as necessary, in the supplemental benefit. These benefits are meant ameliorate the damage caused by physical injuries and ailments and prevent hospitalization or re-hospitalization.

The CMS announcement will allow supplemental benefits if they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

“Home care services continue to demonstrate high value in all care delivery models, including managed care,” said William A. Dombi, President of the National Association for Home Care & Hospice, in reaction to the news. “By allowing Medicare Advantage plans to use caregivers in the home as a supplemental benefit, it can be expected that the plans will reduce overall care costs while improving patient outcomes. These caregivers can be very helpful in making care transitions successful, avoiding initial and re-hospitalizations, and spotting potential exacerbations in the patient’s clinical condition. That happens because they are in home with the patient and capable of assisting with care plan adherence and observing changes in the patient’s condition. If done correctly by the plans, this will be a very positive move by CMS.”

According to CMS, the “proposed updates will result in a payment increase that promotes stability and insures that resources will be available to support beneficiaries enrolled in private Medicare plans.”
While the CMS decision does not mention hospice benefits as supplemental benefits in Medicare Advantage, though the idea has been discussed and further changes could be made to include hospice in the future.

In related news, the Medicare Advantage 2019 Advance Notice, Part 2, includes numerous proposals related to Part D plan oversight of opioid utilization, including a seven-day supply prescribing limit on opioids for acute pain and a seven-day supply, 90 morphine milligram equivalents daily dose limit for non-acute pain. While it would not be anticipated that a high proportion of hospice patients would secure prescription opioids by way of their Part D plans, CMS indicates as part of the notice that, “Sponsors should continue to apply specifications to account for known exceptions, such as hospice care; cancer diagnoses; reasonable overlapping dispensing dates for prescription refills or new prescription orders for continuing fills; and high-dose opioid usage previously determined to be medically necessary such as through coverage determinations, prior authorization, case management, or appeals processes.”

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