CMS Changes Pave The Way For Medicare Advantage Transportation Benefits in 2020.

Three legislative provisions introduced by the Center for Medicare and Medicaid Services (CMS) have significantly expanded the scope and flexibility of supplemental benefits that Medicare Advantage (MA) plans can offer to their members, opening the door for plans to improve population health outcomes by introducing transportation benefits in 2020.

The Medicare Advantage landscape is rapidly changing. The total number of Medicare-eligible beneficiaries is expected to increase from 59.1 million in 2018 to over 80 million by 2030. At the same time, the percentage of those enrollees who participate in Medicare Advantage has been steadily climbing annually since 2004.

In the context of this shifting landscape, the CMS has recently announced three significant changes to the way that supplemental benefits are administered and managed by MA plans. Namely, the CMS has (1) expanded the scope of “primarily health-related” supplemental benefits for MA members, (2) introduced non-health-related benefits for chronically-ill members, and (3) given plans significant flexibility in structuring benefit packages by population cohort.

In this report, we will detail each change and analyze each of its impacts on non-emergency medical transportation (NEMT) benefits that Medicare Advantage plans choose to offer.

CHANGE 1: REDEFINITION OF “PRIMARILY HEALTH-RELATED” INCREASES THE SCOPE OF ALLOWABLE MA BENEFITS

The CMS has three requirements for eligible MA supplemental benefits, one of which is that the benefit is “primarily health-related.” In their Call Letter for 2019, the CMS pointedly reinterpreted their definition of that term, which took effect on January 1, 2019. While the prior definition only allowed benefits that “[supplemented, cured, or diminished] illness or injury,” the new definition adds the following language (bold emphasis ours):

“[A primarily health-related benefit] must diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

HOW THIS CHANGE AFFECTS TRANSPORTATION BENEFITS

The above reinterpretation now defines benefits that are preventative in nature as “primarily health-related.” The Call Letter further cites examples of new benefits that are now eligible under this new definition, including “items and services for enrollees who have been diagnosed with needing assistance with Activities of Daily Living (ADL),” “medically-approved non-opioid pain treatment alternatives, including therapeutic massage furnished by a state licensed massage therapist,” and “transportation to obtain non-emergent… and supplemental benefit items and services to accommodate the enrollee’s health care needs.”

Essentially, this change has opened the doors for Medicare Advantage plans to begin offering medical transportation benefits to their members. It further emphasizes that transportation can be used not only for critical care services, but also for preventative services, trips to massage therapy, and other wellness visits.

CHANGE 2: INTRODUCTION OF NON-HEALTH-RELATED BENEFITS FOR CHRONICALLY-ILL MA ENROLLEES FURTHER INCREASES BENEFIT SCOPE

The CHRONIC Care Act, set to take effect on January 1, 2020, as part of the Bipartisan Budget Act, contains a provision unique to chronically-ill Medicare Advantage enrollees. Starting next year, plans will be allowed to begin offering benefits that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically-ill enrollee and [are not] limited to primarily health-related services.”

HOW THIS CHANGE AFFECTS TRANSPORTATION BENEFITS

Like the reinterpretation of primarily health-related benefits, this change is intended to give plans flexibility in the benefits they can offer - in this case, it expands the benefit scope even further for chronically-ill patients. The CMS doesn’t cite specific benefits allowed under this expansion, but providing transportation for non-health-related purposes (for example, trips to fitness facilities, grocery stores, etc.) is expected to be allowable beginning in 2020.

CHANGE 3: EXPANSION OF VALUE-BASED INSURANCE DESIGN MODEL ENABLES CUSTOMIZED BENEFIT STRUCTURE SETTING

A separate provision in the CHRONIC Care Act expands testing of the Medicare Advantage Value-Based Insurance Design Model from seven pilot states to all 50 The VBID model allows plans to design customized benefit offerings for a given enrollee population by specific condition and/or socioeconomic status. Traditionally, the same benefits (and benefit structure) had to be offered to all enrollees in a plan regardless of condition or socioeconomic status.

HOW THIS CHANGE AFFECTS TRANSPORTATION BENEFITS

Beginning in 2020, accepted plans will have the ability to offer transportation benefits to specific segments of their member population rather than to all members. By allowing benefit structure flexibility, the CMS is signaling to plans that they can roll out transportation to those patients whose health outcomes will be most positively impacted, which can help control benefit costs.

WHY ARE THESE CHANGES BEING MADE?

The CMS is sending a clear message with these proposed changes: they want to encourage enrollment in Medicare Advantage plans while providing more flexibility to the benefits those plans can offer to their members.

“Expanding the benefits that Medicare Advantage plans can offer to members is a clear win-win-win for the CMS, for payers, and for enrollees.”

Unlike original Medicare, Medicare Advantage is based on a value care model rather than a fee-for-service model. In a value-based world, services are directly tied to health outcomes, and plans who effectively improve outcomes can drastically reduce overall costs (both for themselves and for the federal government). In 2018, just over one-third of Medicare beneficiaries were enrolled in Medicare Advantage plans; a shift in that mix to a higher percentage of Medicare Advantage enrollees would enable the government to more effectively control future costs while improving health outcomes. Expanding the benefits that Medicare Advantage plans can offer to members is a clear win-win-win for the CMS, for payers, and for enrollees, especially as Medicare-eligible population pool continues to grow.

WHAT DO THESE CHANGES MEAN FOR THE MEDICARE ADVANTAGE MARKET IN 2020?

The Medicare Advantage landscape is already increasingly competitive, and these changes further reinforce the need for plans to offer innovative, full-spectrum benefits to their members moving forward. The increased flexibility in MA plan benefits has created more ways by which plans can differentiate themselves: plans who are able to offer benefits that improve member health outcomes while simultaneously reducing costs will find themselves rising above their competitors and attracting greater numbers of new enrollees. Conversely, plans who do not take advantage of the broadening CMS regulations will soon find that they are not able to attract new enrollees because they do not fully enrich the member experience.

This year, we saw a total of 243 payers across the MA landscape introduce a transportation benefit to their members. We fully expect this number to increase significantly in 2020 as the CHRONIC Care Act takes effect and payers have more time to build out the new benefits.