Comparing New Flexibilities in Medicare Advantage with Medicaid Long-Term Services and Supports: Final Report

Prepared for

the Office of the Assistant Secretary for Planning and Evaluation (ASPE)

at the U.S. Department of Health & Human Services

RTI International

Center for Health Care Strategies

January 2022

OFFICE OF BEHAVIORAL HEALTH,

DISABILITY, AND AGING POLICY

Comparing New Flexibilities in

Medicare Advantage with Medicaid

Long-Term Services and Supports:

Final Report

Office of the Assistant Secretary for Planning and Evaluation

The Assistant Secretary for Planning and Evaluation (ASPE) advises the Secretary of the U.S. Department

of Health and Human Services (HHS) on policy development in health, disability, human services, data,

and science; and provides advice and analysis on economic policy. ASPE leads special initiatives;

coordinates the Department's evaluation, research, and demonstration activities; and manages cross-

Department planning activities such as strategic planning, legislative planning, and review of regulations.

Integral to this role, ASPE conducts research and evaluation studies; develops policy analyses; and

estimates the cost and benefits of policy alternatives under consideration by the Department or

Congress.

Office of Behavioral Health, Disability, and Aging Policy

The Office of Behavioral Health, Disability, and Aging Policy (BHDAP) focuses on policies and programs

that support the independence, productivity, health and well-being, and long-term care needs of people

with disabilities, older adults, and people with mental and substance use disorders. Visit BHDAP at

https://aspe.hhs.gov/about/offices/bhdap for all their research activity.

NOTE: BHDAP was previously known as the Office of Disability, Aging, and Long-Term Care Policy

(DALTCP). Only our office name has changed, not our mission, portfolio, or policy focus.

This research was funded by the U.S. Department of Health and Human Services Office of the Assistant

Secretary for Planning and Evaluation under Contract Number #HHSP233201600021I and carried out by

Research Triangle Institute. Please visit https://aspe.hhs.gov/topics/long-term-services-supports-long-

term-care for more information about ASPE research on long-term services and supports (LTSS).

COMPARING NEW FLEXIBILITIES IN MEDICARE ADVANTAGE WITH MEDICAID LONG-TERM

SERVICES AND SUPPORTS: FINAL REPORT

Authors

Molly Knowles, MPP

Jennifer Howard, PhD

Amarilys Bernacet, MPH

Cleanthe Kordomenos, BA

Edith Walsh, PhD

RTI International

Michelle Herman Soper, MHS

Nancy Archibald, MHA, MBA

Center for Health Care Strategies

January 2022

Prepared for

Office of Behavioral Health, Disability, and Aging Policy

Office of the Assistant Secretary for Planning and Evaluation

U.S. Department of Health and Human Services

Contract #HHSP233201600021I

The opinions and views expressed in this report are those of the authors. They do not reflect the views

of the Department of Health and Human Services, the contractor or any other funding organization. This

report was completed and submitted on September 22, 2020.

TABLE OF CONTENTS

ACRONYMS .............................................................................................................................................. iii

1. EXECUTIVE SUMMARY ............................................................................................................... 1

1.1. Main Findings ........................................................................................................................ 2

2. BACKGROUND ............................................................................................................................... 4

2.1. Expanded Supplemental Benefits .......................................................................................... 4

2.2. Medicaid Coverage of Benefits that Address LTSS and SDOH Needs ................................. 5

2.3. Project Purpose ...................................................................................................................... 6

3. METHODS ........................................................................................................................................ 7

3.1. Environmental Scan ............................................................................................................... 7

3.2. Case Studies ........................................................................................................................... 7

4. FINDINGS ......................................................................................................................................... 9

4.1. Current Landscape of MAOs Offering Expanded Supplemental Benefits ............................ 9

4.2. Delivery and Administration of Expanded Supplemental Benefits ..................................... 10

4.3. Opportunities Associated with Providing Expanded Supplemental Benefits ...................... 11

4.4. Challenges Associated with Providing Expanded Supplemental Benefits .......................... 12

4.5. Policy Implications of Overlapping Coverage with Medicaid ............................................. 16

4.6. MAOs’ Future Plans for Expanded Supplemental Benefits ................................................. 17

5. FUTURE CONSIDERATIONS ..................................................................................................... 19

6. REFERENCES ................................................................................................................................ 22

APPENDIX A. LITERATURE SEARCH STRATEGY .................................................................... 25

LIST OF EXHIBITS

EXHIBIT 1. Recent Changes to Supplemental Benefits Potentially Offered by MA

Plans .................................................................................................................................... 5

EXHIBIT 2. Overview of MAOs ............................................................................................................ 8

EXHIBIT 3. Types of Expanded Primarily Health-Related Supplemental Benefits

Targeting LTSS Needs Offered by MAOs ......................................................................... 9

EXHIBIT 4. Types of SSBCI Offered by MAOs .................................................................................. 10

EXHIBIT A-1. Search Strategy ................................................................................................................. 25

EXHIBIT A-2. Publication Selection Process ........................................................................................... 26

iii

ACRONYMS

The following acronyms are mentioned in this report and/or appendix.

ASPE

Office of the Assistant Secretary for Planning and Evaluation

CBO

Community-Based Organization

CHCS

Center for Health Care Strategies, Inc.

CMS

Centers for Medicare & Medicaid Services

COVID-19

Novel Coronavirus

Calendar Year

D-SNP

Dual Eligible Special Needs Plan

FIDE-SNP

Fully Integrated Dual Eligible Special Needs Plan

HCBS

Home and Community-Based Services

LTQA

Long-Term Quality Alliance

LTSS

Long-Term Services and Supports

Medicare Advantage

MA-PD

Medicare Advantage Prescription Drug plan

MAO

Medicare Advantage Organization

MCO

Managed Care Organization

MMP

Medicare-Medicaid Plan

PBP

Plan Benefit Package

ROI

Return on Investment

SDOH

Social Determinants of Health

SME

Subject Matter Expert

SSBCI

Special Supplemental Benefits for the Chronically Ill

VBID

Value-Based Insurance Design

1. EXECUTIVE SUMMARY

The Centers for Medicare & Medicaid Services (CMS) has recently given new flexibilities

to Medicare Advantage (MA) plans to provide supplemental benefits that address long-term

services and supports (LTSS) needs and social determinants of health (SDOH) among their

members. In 2019, CMS expanded its definition of “primarily health-related” benefits to include

additional items or services that are LTSS-type services, such as adult day health, in-home

personal care attendants, and support for beneficiaries’ family caregivers (e.g., respite). The

Bipartisan Budget Act of 2018 (Public Law No. 115-123) further expanded supplemental

benefits to include Special Supplemental Benefits for the Chronically Ill (SSBCI) that are not

primarily health-related and offered non-uniformly to eligible chronically ill enrollees. However,

limited information is available about the extent to which plans have provided or plan to provide

these expanded supplemental benefits. Furthermore, Medicaid managed care plans may be

concurrently offering similar benefits to Medicaid beneficiaries. This potential duplication is

particularly relevant for dual eligible beneficiaries accessing services from Medicare and

Medicaid managed care plans.

To examine the current landscape of MA plans that offer expanded supplemental benefits,

and how the interaction with Medicaid benefits may affect dual eligible beneficiaries, we first

conducted an environmental scan of publicly available peer-reviewed and grey literature

supplemented with interviews of subject matter experts (SMEs). To gain insight into plans’

initial experiences with implementing expanded supplemental benefits in contract years 2019

and 2020, RTI and the Center for Health Care Strategies (CHCS) interviewed four Medicare

Advantage Organizations (MAOs) offering these benefits among their various MA plans that

also serve a large dually eligible population. The environmental scan and case studies were

guided by the following research questions:

• What LTSS benefits did plans offer in contract year 2019 and why/how did plans select

those specific benefits? How do these decisions about benefits offered in 2019 affect

plans’ decision to offer SSBCI benefits in contract year 2020?

• How are the non-primarily health-related services offered by MA plans as part of SSBCI

in contract year 2020 similar or different from non-primarily health-related benefits

offered by Medicaid managed care plans, including, but not limited to LTSS targeted

benefits? Types of services? Scope? Level of benefit? What are the policy implications of

these similarities/differences for serving dual eligible beneficiaries? How does this vary

by state?

• What challenges, if any, have state policy officials and plan administrators encountered

with regard to the rollout and administration of the expanded supplemental benefits in

contract year 2019 and the SSBCI benefits in contract year 2020? Which of these

specifically pertain to Medicare-Medicaid dual eligible beneficiaries?

This report synthesizes information gathered from the environmental scan and case studies

to provide an overview of early implementation of the expanded supplemental benefits.

Key Takeaways

1. Few MA plans adopted the expanded supplemental benefits in 2019 and 2020, but recent

MA plan bid submissions indicate that the numbers are increasing.

2. Despite the challenges identified by MA plans during the early years of implementation,

plans have found the benefits valuable to addressing the LTSS and SDOH needs of their

members.

3. The impact of the expanded supplemental benefits on dual eligible beneficiaries can vary

depending on the beneficiary’s dual eligibility status (i.e., full or partial benefit dual

eligible beneficiary) and the state’s eligibility criteria for Medicaid LTSS.

1.1. Main Findings

The information we gathered provides insights into the current landscape of MAOs that

provide expanded supplemental benefits, including their initial experiences and challenges with

developing and administering the benefits to their members. Key findings include:

• Current landscape. Approximately 10% of MA plans offered expanded supplemental

benefits in calendar year (CY) 2019 and 2020. Across the case study MAOs, there was

more overlap in expanded primarily health-related benefits than in SSBCI. The types of

SSBCI offered tended to be unique to the MAO’s members. Overall, the MAOs also

offered more primarily health-related benefits (e.g., post-acute discharge benefits and

non-emergency medical transportation) than SSBCI.

• Administration and delivery of expanded supplemental benefits. The MAOs varied

on whether the Medicaid or Medicare divisions of the organization had primary

responsibility for administering the benefits. Reliance on outside vendors versus MAO

providers depended upon the MAO’s internal capacity and previously established

relationships with local community-based organizations (CBOs).

• Opportunities associated with the expanded supplemental benefits. MAOs reported

that the expanded supplemental benefits provided a key opportunity to better target and

address the SDOH and LTSS needs of their members. The MAOs also mentioned their

ability to develop unique benefits might enhance their competitive margin.

• Potential increased benefits for dual eligible individuals. The benefits provide the

opportunity to improve access to needed supports and services for some dual eligible

individuals. The expanded supplemental benefits can fill gaps in care and reduce future

needs for more intensive Medicaid covered services among dual eligible individuals not

yet eligible for Medicaid LTSS (e.g., partial benefit dual eligible beneficiaries). One

MAO developed a process to build Medicare supplemental benefits to wrap around

Medicaid LTSS benefits. Expanded supplemental benefits can also support full benefit

dual eligible individuals who have some LTSS needs but who are not enrolled in a

comprehensive home and community-based services (HCBS) Medicaid waiver.

• Challenges associated with the expanded supplemental benefits. We identified

several challenges associated with MAO administration of the expanded supplemental

benefits. These challenges included limitations with relying on rebates to fund the

benefits; difficulties in identifying additional benefits to offer; inadequate data systems to

track and differentiate between benefits; limited data to support return on investment

(ROI) analyses; requests for more regulatory guidance and focus on beneficiary

education; and specific challenges related to implementing the benefits during the

COVID-19 pandemic.

• Monitoring overlapping coverage with Medicaid. States have limited ability to

monitor and respond to their concerns about MAOs offering benefits similar to the state

Medicaid program, and few states actively monitor MAOs’ supplemental benefit

offerings. Some of the MAOs have developed processes to monitor potential overlap of

supplemental benefits.

• Potential challenges for dual eligible individuals. Beneficiary advocates and

government officials reported concerns that overlapping benefits may confuse

beneficiaries who are enrolled separately in a MA plan offering expanded supplemental

benefits and their state’s Medicaid program. If there is no coordination between Medicaid

and the MAO, confusion about which payer covers a service may result in a barrier to

access and denied claims for dual eligible individuals.

• Future plans for expanded supplemental benefits. Updated analyses of MA plan bid

submissions indicate that an increasing number of MAOs are planning to offer some

expanded supplemental benefits, both expanded primarily health-related benefits that

target LTSS needs and SSBCI (ATI Advisory, 2020). The MAOs discussed plans to

maintain their current benefits, and in some instances, add new benefits for 2021.

2. BACKGROUND

2.1. Expanded Supplemental Benefits

CMS has recently given new flexibilities to MA plans to provide supplemental benefits that

address LTSS needs and SDOH among their members. MA plans have long been allowed to

offer extra benefits (e.g., dental care, vision services, and gym memberships) (Noel-Miller &

Sung, 2018; CMS, 2018a; CMS, 2018b). However, with the enactment of the Bipartisan Budget

Act of 2018 (Public Law No. 115-123, henceforth referred to as the Chronic Care Act) that

introduced SSBCI, and new guidance issued by CMS including the reinterpretation of “primarily

health-related” and benefit uniformity, MA plans can now cover a wider array of extra benefits

than was previously allowed. In addition, the Chronic Care Act required that the Medicare

Value-Based Insurance Design (VBID) model be included in all 50 states and territories by 2020

(CMS, 2019b). The VBID model allows MA plans to target certain benefits to enrollees based on

conditions and/or income level (e.g., low-income subsidy eligibility or dually eligible for

Medicare and Medicaid).

CMS historically had required a supplemental benefit to: (1) not be covered by original

Medicare; (2) be primarily health-related; and (3) require the MA plan to incur a non-zero direct

medical cost. In 2019, CMS expanded its definition of “primarily health-related” benefits to

include additional items or services used to “diagnose, compensate for physical impairments, act

to ameliorate the functional/psychological impact of injuries or health conditions, or reduce

avoidable emergency and health care utilization” (CMS, 2018a). Some of these benefits are

LTSS-type services, such as adult day health, in-home personal care attendants, and support for

beneficiaries’ family caregivers (e.g., respite) (CMS, 2018b).

The Chronic Care Act further expanded supplemental benefits that may be offered by MA

plans, which are referred to as SSBCI. SSBCI include supplemental benefits that are not

primarily health-related and can be offered non-uniformly to eligible chronically ill enrollees.

Although supplemental benefits must still focus directly on an enrollee’s health care needs, as of

2020, MA plans can cover a wider range of benefits that target SDOH. The regulations also

made it possible for MA plans to target additional supplemental benefits to groups of chronically

ill enrollees without having to provide the benefit to all plan participants (CMS, 2019b). Exhibit

1 provides an overview of the differences in the new types of supplemental benefits MA plans

can offer.

For the purposes of this report, the new flexibilities offered to MAOs are collectively

referred to as “expanded supplemental benefits.” Within the umbrella term of expanded

supplemental benefits, the report distinguishes between two types of expanded supplemental

benefits: (1) expanded primarily health-related benefits that target LTSS needs; and (2) SSBCI.

These categories were generally used in discussions with MAOs.

EXHIBIT 1. Recent Changes to Supplemental Benefits Potentially Offered by MA Plans

Announcement

Description

Example Benefits

CY2019 Call Letter:

Reinterpretation of benefit

uniformity and the scope of the

“primarily health-related”

supplemental benefit definition

(CMS, 2018a, 2018b, 2018c).

Beginning in CY2019, CMS reinterpreted the

benefit uniformity requirement and expanded the

definition of “primarily health-related” to consider

an item or service as primarily health-related if it is

used to diagnose, compensate for physical

impairments, acts to ameliorate the

functional/psychological impact of injuries or health

conditions, or reduces avoidable emergency and

health care utilization. A supplemental benefit is

considered not primarily health-related under the

previous or new definition if it is an item or service

that is solely or primarily used for cosmetic,

comfort, general use, or social determinant

purposes.

In order for CMS to approve a supplemental benefit,

the benefit must focus directly on an enrollee’s

health care needs and be recommended by a licensed

medical professional as part of a care plan, if not

directly provided by one. MA plans can also offer

benefits that target specific health status or disease

states as long as similarly situated individuals are

treated uniformly.

• Adult day health

• Home-based palliative care

• In-home support services

• Support for caregivers

• Medically approved non-

opioid pain management

• Standalone memory fitness

benefit

• Home and bathroom safety

devices

• Transportation for non-

emergency medical needs

CY2020 Call Letter:

Announcement of the ability to

offer SSBCI beginning in 2020

(CMS, 2019a)

The intended purpose of the new category of

supplemental benefits--SSBCI--is to enable MA

plans to better tailor benefit offerings for the

chronically ill population, address gaps in care, and

improve specific health outcomes. SSBCI include

supplemental benefits that are not primarily health-

related and/or offered non-uniformly to eligible

chronically ill enrollees.

MA plans do not have to submit the processes by

which they identify chronically ill individuals. CMS

expects MA plans to develop and document

mechanisms to identify chronically ill enrollees

based on the definition used in Chapter 16b of the

Medicare Managed Care Manual, including 15

specific chronic conditions (CMS, 2016).

• Transportation for non-

medical needs

• Home-delivered meals

(beyond the current allowable

limited basis)

• Produce, frozen foods, and

canned goods

• Access to community-based

programs (e.g., community or

social club memberships,

access to companion care)

• Home modifications

• General supports for living

(e.g., housing)

VBID Fact Sheet CY2020

(CMS, 2019c)

In 2017, CMS tested the VBID model, allowing MA

plans in 7 states, and later 3 more in 2018 and 15 in

2019, to target certain benefits to enrollees based on

conditions and/or income level. In 2020, VBID was

expanded to all 50 states and territories. Plans can

test one or more of the following interventions:

• VBID by Condition, Socioeconomic Status, or

both

• Rewards and Incentives Programs

• Telehealth Networks

• Wellness and Health Care Planning

• Reduced cost-sharing/copays

for individuals with targeted

conditions

• Incentive to participate in a

disease state management

program

• Telehealth services for

behavioral health

2.2. Medicaid Coverage of Benefits that Address LTSS and SDOH Needs

Services that address LTSS and SDOH needs have historically been covered under

Medicaid. Medicaid is the primary payer for LTSS in the United States, covering 51% of total

LTSS expenditures in 2013 (Reaves & Musumeci, 2015). In addition to LTSS, many state

Medicaid programs look for ways to address SDOH among their Medicaid beneficiaries to

improve health and cost outcomes because social needs disproportionately affect low-income

individuals who are often served by Medicaid (Schroeder, 2007; ACAP & CHCS, 2018). Many

Medicaid managed care plans have also developed interventions that address SDOH by linking

clinical and non-clinical services to improve health outcomes and cost efficiencies among their

beneficiaries (Gottlieb et al., 2016). States have also encouraged Medicaid managed care plans to

focus on SDOH through state managed care contracts (Crumley et al., 2018). In May 2016, CMS

finalized regulations that require Medicaid managed care plans to incorporate practices that look

beyond clinical care to address the SDOH (Machledt, 2017).

2.3. Project Purpose

This study provides the Office of the Assistant Secretary for Planning and Evaluation

(ASPE) with a better understanding of the current landscape of MA plans that offer expanded

primarily health-related supplemental benefits that target LTSS needs and SSBCI, how these

Medicare benefits interact with Medicaid managed care plans offering similar benefits to dual

eligible beneficiaries, and the opportunities or challenges this presents. We used the following

research questions to guide the study:

• What LTSS benefits did plans offer in contract year 2019 and why/how did plans select

those specific benefits? How did these decisions about benefits offered in 2019 affect

plans’ decision to offer SSBCI benefits in contract year 2020?

• How are the non-primarily health-related services offered by MA plans as part of SSBCI

in contract year 2020 similar or different from non-primarily health-related benefits

offered by Medicaid managed care plans, including, but not limited to LTSS targeted

benefits? Types of services? Scope? Level of benefit? What are the policy implications of

these similarities/differences for serving dual eligible beneficiaries? How does this vary

by state?

• What challenges, if any, have state policy officials and plan administrators encountered

with regard to the rollout and administration of the expanded supplemental benefits in

contract year 2019 and the SSBCI benefits in contract year 2020? Which of these

specifically pertain to Medicare-Medicaid dual eligible beneficiaries?

3. METHODS

We conducted two main activities: (1) an environmental scan of publicly available peer-

reviewed and grey literature supplemented with interviews of SMEs; and (2) case studies of four

MAOs. The methods for each of these activities are described in detail below.

3.1. Environmental Scan

The environmental scan consisted of a thorough review of the peer-reviewed and grey

literature, and discussions with SMEs. The literature review was guided by the best practices

described by Haby et al. (2016) and entailed a comprehensive review of the peer-reviewed

literature as well as several grey literature sources that focus on expanded supplemental benefits.

See Appendix A for a detailed description of the methods employed for the literature review.

We conducted seven semi-structured interviews with federal and state government

officials, managed care organizations (MCOs) representatives, beneficiary advocates, providers,

and other stakeholders. Interview participants were identified based on recommendations from

team members and ASPE staff and from the literature reviewed. We created interview guides

tailored to each participant’s expertise and shared the guides with participants prior to their 60-

minute scheduled discussion. Interviews were recorded and transcribed for analysis.

3.2. Case Studies

We conducted case studies with four MAOs. Representatives from three MAOs

participated in a series of semi-structured interviews and the fourth submitted written feedback.

Across the three organizations available for interviews, we conducted a total of 19 semi-

structured telephone interviews with MAO representatives. Telephone interviews were typically

between 45 and 60 minutes long and were conducted using Zoom, an audio-video conferencing

platform. The four MAOs were selected by the following factors:

• The organization offered expanded primarily health-related benefits and SSBCI.

• Types of MA products offered (e.g., Medicare Advantage Prescription Drug Plan (MA-

PD), Special Needs Plan).

• The geographic location of the MAOs.

Due to the evolving international COVID-19 pandemic and associated restraints and burdens on MAOs during this

time, one MAO was not able to participate in the series of semi-structured telephone interviews, but instead

submitted responses via email.

We also selected organizations that operate in diverse Medicaid markets to determine

variation and extent to which the expanded supplemental benefits overlap with Medicaid benefits

for dual eligible beneficiaries. The case study MAOs are described in Exhibit 2 below.

EXHIBIT 2. Overview of MAOs

MAO

Market Characteristics

MAO 1

MAO 1 offers a traditional MA-PD plan and Dual Eligible Special Needs

Plan (D-SNP). It also offers a Fully Integrated Dual Eligible Special Needs

Plan (FIDE-SNP), which covers all Medicaid benefits, including LTSS.

MAO 2

MAO 2 offers MA-PD plans, D-SNPs, a Medicaid MCO that is part of a

managed LTSS program, and a Medicare-Medicaid plan (MMP)

participating in the state demonstrations under the Financial Alignment

Initiative.

MAO 3

MAO 3 offers MA-PD plans, a FIDE-SNP, and an MMP participating in

the state demonstrations under the Financial Alignment Initiative.

MAO 4

MAO 4 offers a MA-PD plan, D-SNPs, Medicaid MCOs, and an MMP

participating in the state demonstrations under the Financial Alignment

Initiative.

4. FINDINGS

4.1. Current Landscape of MAOs Offering Expanded Supplemental

Benefits

Multiple publications report only a modest number of MA plans offering expanded

supplemental benefits during the initial years plans were able to offer expanded supplemental

benefits (Crook et al., 2019; Meyers et al., 2019; Murphy-Barron & Buzby, 2019). According to

an analysis of MA plan benefit package (PBP) data conducted by Milliman on behalf of Better

Medicare Alliance, Inc. (November 2019), in CY2019, 102 plans offered

one of the new

primarily health-related supplemental benefits under the expanded definition: 51 offered in-home

support services, 29 offered home-based palliative care, and 22 offered non-opioid pain

management. In CY2020, 364 plans offered these expanded primarily health-related

supplemental benefits (Murphy-Barron & Buzby, 2019). Results of similar analyses conducted

by other organizations have pointed toward a similarly modest trend and similar supplemental

benefit offerings as well as caregiver support, personal care services and adult day care (Crook et

al., 2019; Avalere, 2018).

The types of primarily health-related benefits the case study MAOs offered were consistent

with the literature findings. The most common types of primarily health-related targeting LTSS

needs offered across the four MAOs were post-acute discharge benefits, which generally

included meal delivery for a set amount of time (e.g., two weeks), and non-emergency medical

transportation (see Exhibit 3). There was greater benefit overlap among the national MAOs

compared to the regional-based plans. Additionally, the national MAOs offered adult day

services and bathroom safety devices (e.g., grab bars).

EXHIBIT 3. Types of Expanded Primarily Health-Related Supplemental Benefits

Targeting LTSS Needs Offered by MAOs

Benefits

MAO 1

MAO 2

MAO 3

MAO 4

Post-acute discharge benefits

Respite services

Occupational therapy

Adult day

Non-emergency medical transportation

Personal care assistance

Bathroom safety devices

Education classes

iPads

NOTE: MAOs did not confirm all benefits as being primarily health-related expanded supplemental benefits versus

SSBCI. In some cases, the distinction is based on team’s best judgement.

1. MAO 1: personal care assistance, post-discharge meal benefit, and care coordination; MAO 2: home-delivered

meals; MAO 3: home-delivered meals; MAO 4: readmission prevention.

2. MAO 2: Health education; MAO 4: Healthy aging classes, including cooking classes.

3. iPads are delivered preloaded with health educational applications and socialization tools.

It should be noted that these plans were the only ones in which a new expanded supplemental benefit could be

distinguished.

Recent analyses of the CMS PBP files indicate that the number of plans offering SSBCI in

CY2020 was low, with only 245 plans offering these benefits (ATI Advisory, 2020). The case

study MAOs all offered SSBCI, but they offered a more limited number of these benefits

compared to their expanded primarily health-related benefits (Exhibit 4). Additionally, while

there was some overlap across the organizations offering meal delivery and non-medical

transportation, the remaining SSBCI offered were unique to the MAO. MAO 4 offered the

largest number of SSBCI; many of these benefits were targeted toward people living with

dementia and their caregivers. Alternatively, MAO 3 offered SSBCI broadly to beneficiaries

with any of the qualifying chronic conditions, instead of limiting SSBCI to one chronic

condition.

EXHIBIT 4. Types of SSBCI Offered by MAOs

Benefits

MAO 1

MAO 2

MAO 3

MAO 4

Non-medical transportation

Meal delivery

Personal emergency response system

Air conditioner allowance

Pest control

Service dog support

Caregiver support services

Bathroom safety devices

Adult day and transportation

Animatronic cat

Independent living skills

Personal emergency response system

1. Includes respite care; psychotherapy, training/education, and coaching for caregivers; and transportation for

caregivers.

2. Adult day and transportation benefits are SSBCI because the MAO targets the service for people living with

dementia.

As described below, several factors--including insufficient federal guidance, data, and time

to adequately design and price the benefits--discouraged plans from expanding supplemental

benefit offerings in CY2019. Government officials and experts believed it was too early to know

if MAOs’ experiences designing and implementing SSBCI in CY2019 influenced their decisions

about whether to offer SSBCI in CY2020. Those decisions were predicted to rely heavily on

whether the initial benefits offered helped to keep beneficiaries out of the emergency department

or hospital (Daly, 2019) and whether plans view the benefits as prudent investments (Abrams &

Bishop, 2019).

4.2. Delivery and Administration of Expanded Supplemental Benefits

The case study MAOs’ administration and delivery of supplemental benefits varied by

several factors. The MAOs varied on whether the Medicaid or Medicare divisions of the

organization had primary responsibility for administering the benefits. In some cases, the MAOs

included the benefit design and oversight functions within their Medicaid teams. In other cases,

the MAOs assigned primary responsibility to their Medicare teams.

An MAO’s internal organizational capacity and established relationships with local CBOs

largely influenced how the MAO delivered expanded supplemental benefits. According to

available literature, although only a limited number of community-based providers interact with

MA plans (only around 9% of CBOs had contracts with MA plans in 2018), these plans represent

an important opportunity for CBOs, particularly with the new flexibility for plans to provide

HCBS through the SSBCI (Aging & Disability Business Institute, 2020). The literature and

conversations with SMEs indicated there may be limited experience among MA plans with

regard to working with CBOs and third-party vendors (Kunkel et al., 2018).

The MAOs reported relying on a variety of providers, including existing and new

partnerships with local CBOs to deliver the expanded supplemental benefits. Reliance on outside

vendors versus MAO staff depended upon the MAO’s internal capacity and established

relationships with local CBOs. For example, one MAO’s previous experience offering benefits

addressing LTSS and SDOH needs of beneficiaries enabled them to offer SSBCI without many

challenges. As the case study MAO noted, offering non-medical transportation to a portion of

their members under SSBCI was “really easy to do because we already had a transportation

contract in place.”

Beneficiary advocates mentioned their concern about the potential for MA plans to

exacerbate existing disparities for Medicare beneficiaries among underserved, under-resourced

areas that do not have the CBOs required to provide these benefits. However, even in areas that

have CBOs available, CBOs’ limited MA plan contracting experience and capacity may prove

challenging (Crook et al., 2019). Available research indicates that it will be important for MAOs

to select CBO partners that are able to scale services to a plan’s members (Thomas et al., 2019).

4.3. Opportunities Associated with Providing Expanded Supplemental

Benefits

4.3.1. Potential to Address Members’ LTSS and SDOH Needs

Several SMEs and case study MAOs highlighted that the key opportunity provided by the

expanded primarily health-related benefits and SSBCI was plans’ ability to better target and

address their members’ LTSS and SDOH needs. As one MAO explained, the new flexibilities

had in effect “given [plans] permission to go a bit outside of the box” and that they “have a lot of

opportunity to expand.” According to another MAO, the SSBCI allowed them to provide support

for SDOH needs that care management staff had identified through screenings and assessments.

4.3.2. Improve Market Competitiveness

In addition to improving the MAOs ability to meet their members’ needs, several MAOs

pointed out that the expanded supplemental benefits improved their competitiveness in highly

competitive MA markets. The expanded supplemental benefits enabled MAOs to think through

their member needs and provide available resources to develop unique additional benefits that

might enhance their competitive margin. As one MAO noted, “supplemental benefits are

important in differentiating plans.”

4.3.3. Potential to Increase Benefits for Dual Eligible Beneficiaries

Although there is some potential for overlap, one subject matter expert raised several

potential opportunities for expanded primarily health-related benefits and SSBCI to improve

access to needed supports and services for some dual eligible individuals. However, the impact

of these benefits differs depending on beneficiary characteristics. For example, for partial benefit

dual eligible beneficiaries not yet eligible for Medicaid LTSS, the expansion of MA plans’

supplemental benefits offers the potential to fill needed gaps in care and reduce future need for

more intensive Medicaid covered services. For individuals with a certain degree of functional

decline, expanded supplemental benefits can provide interventions that have the potential to

delay institutionalization. The impacts of these benefits typically differ for partial versus full

benefit dual eligible beneficiaries. Partial benefit dual eligible beneficiaries receive help with

Medicare cost-sharing, but they are not eligible for Medicaid services, including Medicaid LTSS.

As a result, MAO supplemental benefits could make some LTSS-type services available to

partial benefit dual eligible beneficiaries, where full benefit dual eligible beneficiaries have

access to LTSS available under Medicaid, depending on programmatic eligibility requirements

like functional status. Lastly, these benefits can support full benefit dual eligible individuals who

have some LTSS needs but who are not enrolled in a comprehensive HCBS Medicaid waiver.

The impact of expanded supplemental benefits can vary depending on a state’s eligibility

criteria for Medicaid LTSS. For states with stricter criteria that require high levels of functional

impairment among Medicaid beneficiaries to qualify for HCBS, MAOs’ ability to offer LTSS-

type benefits may provide an opportunity for expanded access to certain services. HCBS waivers

also have waiting lists, so MAOs can provide services in states with waiting lists to those who

have demonstrated needs but do not yet have access to care.

Even in states with generous Medicaid coverage, MAOs can design targeted benefits to

wrap around Medicaid benefits to expand services to dually eligible beneficiaries. One MAO

developed a process, using the state’s generous Medicaid LTSS benefits as a foundation, to build

Medicare supplemental benefits to wrap around Medicaid LTSS benefits. However, keeping

track of benefits across programs is onerous, and includes extensive crosswalk work across each

program’s policies to determine through which pathway to cover services.

4.4. Challenges Associated with Providing Expanded Supplemental Benefits

4.4.1. Funding Based on Rebates

Reliance on rebates to fund expanded supplemental benefits creates limitations and

challenges to MAOs seeking to offer these benefits. All supplemental benefits, including the

expanded primarily health-related benefits and SSBCI, are funded through rebates.

Rebates can

vary substantially by region of the country. In collaboration with the Robert Wood Johnson

Foundation, the Urban Institute released a report (2019) stating that the average MA plan

received $107 per member per month in rebates to spend on cost-sharing reductions or

supplemental benefits. However, rebate amounts substantially varied across states. For instance,

MA plans in North Dakota received $2 per member per month, whereas in Florida, they received

$159 per member per month (Urban Institute, 2019). One provider SME commented on this

variation, adding that provider practice patterns largely contributed to the state-by-state variance

in rebate amount, and would likely influence the geographic spread of MA plans offering

expanded supplemental benefits and SSBCI in CY2020. Several representatives of one MAO

remarked that they lacked the funds (i.e., rebate dollars) to offer many expanded supplemental

benefits.

Rebates are also time-limited, and the rebate amount allotted to each plan can change from

year to year. The variability can make it difficult for MAOs to determine the amount of

supplemental benefits they can offer. MAOs may hesitate to provide a certain level of benefits in

one year if they may have to cut the benefits offered in the next year. Experts and the MAOs

mentioned their concerns regarding the instability associated with the funding for expanded

supplemental benefits. The MA plan members with LTSS and SDOH needs who these benefits

target often require consistent access to needed benefits.

4.4.2. Determining Appropriate Benefits

Two MAOs reported difficulty in identifying viable and marketable supplemental benefits

to offer. Representatives from one MAO explained that the state’s Medicaid benefits package

was robust and added that where coverage is not robust, such as dental, plans were already

offering extended benefits. They further explained that “the majority of the benefits

recommended [by CMS] were already covered for us by Medicaid, so we had a limited starting

point of what to offer.” Therefore, the MAO focused its expansion of supplemental benefits on

SSBCI, where they had more flexibility to target specific populations.

Another MAO noted that aligning benefits with required criteria that were also attractive to

beneficiaries shopping around for plans could be challenging. According to a representative from

this plan, “the beneficiaries those benefits would be ideal for are not shopping for them. And

seniors that are shopping are not looking for those things because they don’t feel they yet need

them.” Two MAOs discussed difficulty in operationalizing benefits, including developing rates

for a bid, staffing care managers to assess eligibility, and contracting with the right providers to

offer services that would address key SDOH needs. Both MAOs noted being aware of specific

SDOH needs, such as housing, but not yet understanding how best to address these needs as a

Rebates are a key component of MA payment rates. All plans that bid below the benchmark receive a percentage

of the difference between the bid and benchmark as a rebate, ranging from 50% to 70% of the difference between

the bid and the benchmark. The amount of the rebate paid to the plan is determined by the plan’s quality star rating.

Plans are required to use rebates to provide supplemental benefits, such as hearing, dental or vision, to reduce

beneficiary cost-sharing, or to provide innovations in care delivery, such as telemedicine or home care (Better

Medicare Alliance, 2018).

health plan. Two MAOs reported only selecting benefits that the MAO knew they could

operationalize.

4.4.3. Inadequate Data Systems

Current data systems are not adequate to accurately track the use of these expanded

benefits. The types of benefits offered, including expanded supplemental benefits, are included

in the Medicare PBP bid submissions. Several studies used this database to determine the

adoption of supplemental benefits across MA plans. However, because of differences in

methodology and interpretations of services that qualified as supplemental benefits, the research

varied when quantifying supplemental benefit uptake. As MAOs adopt supplemental benefits

with greater frequency, this variation will make it difficult to accurately monitor MA plans’

benefit expansion. For instance, where one study reported that 507 plans offered expanded

primarily health-related supplemental benefits that targeted LTSS needs in CY2019 (Crook et al.,

2019), another reported that 102 plans were offering expanded primarily health-related

supplemental benefits (Murphy-Barron & Buzby, 2019).

The PBP files also lack templates to capture benefit details, preventing analyses of benefit

saturation to better understand the nuances of supplemental benefit uptake. One SME familiar

with the data noted that the PBP data files included information on coinsurance and copayment

required as part of a benefit offering, but no additional benefit detail such as quantity, setting,

type, etc. For example, policymakers and researchers are currently unable to analyze PBP data

files to examine how many rides and to which locations are being provided under a

transportation benefit or how many hours or the type of respite are being offered under the

caregiver support benefit.

One expert emphasized the challenge around creating a consistent count and labeling

system for supplemental benefits--one that accounts for the wide interpretation of services that

qualify as an expanded supplemental benefit. For instance, this expert explained that on the one

hand, “home care” can imply that extra care is afforded during transitions from the hospital back

to the patient’s home (i.e., short-term), yet it also could be interpreted as ongoing in-home

services and supports. Representatives from one MAO mentioned that due to limitations with

current data systems, staff had to “get creative” to differentiate between benefits. MAOs must

also increase coordination between departments to capture claims in the correct buckets.

4.4.4. Limited Data to Support Evidence Base

Several studies have identified MAOs’ concerns about the expanded supplemental benefits’

ROI, both in terms of financial viability and improved health outcomes for their members.

Though medical services are understood in the current health system as a direct benefit to

consumers, non-medical, health-related services, in contrast, are not as readily accepted as

offering the same benefit of improved outcomes for consumers. As a result, MA plans that wish

to address social needs through supplemental benefits will need to provide clear expectations for

Authors of the latter analysis indicated that the caregiver support benefit was not included in their analysis because

“some of the benefits now classified as support for caregivers could have been classified differently and offered as a

benefit to enrollees in prior years” (Murphey-Barron & Buzby, 2019, p.2).

member benefits. This will prove especially challenging given that determining ROI for

prevention interventions, and health-related social needs in particular, is relatively new (Martinez

et al, 2019). Several studies have called attention to the scarcity of evaluations examining the

financial implications of addressing MA beneficiaries’ SDOH, and even less is known about ROI

for MA plans themselves (Sorbero & Kranz, 2019; Thomas et al., 2019).

One MAO commented on the rigorous research studies needed to determine ROI and

medical cost savings for SSBCI before including them in the bid proposal. Speaking to this

challenge one MAO representative shared, “Sometimes I get pushback on ROI… We need to

support [what’s included in the bid] with scientific evidence. My actuarial team will not allow

me to take data from a vendor unless it’s done via an independent study.” In another MAO, a

representative explained that since 90% of their business is conducted with fully capitated

providers, any ROI that may accrue, such as reduced emergency utilization and expenditures,

accrues on the provider side, and not for the plan.

4.4.5. Need for More Regulatory Guidance

Plans that chose not to include expanded supplemental benefits in their CY2019 bids

shared that it was difficult to design and price these benefits, especially given the lack of clarity

and guidance in CMS’ original 2019 Call Letter (LTQA, 2019). This was echoed in a study that

interviewed MA plan representatives--most interviewees expressed a need for additional CMS

guidance before committing to addressing enrollees’ social needs through supplemental benefits.

Particularly, plan representatives were concerned with ongoing changes to CMS’ regulations,

and how SDOH would be defined in the final regulations (Thomas et al, 2019). MA plan

representatives have reported that CMS’ reaction to their submitted bids was more restrictive

than what was implied in the original guidance documents (LTQA, 2019; Thomas et al, 2019).

According to one SME, plans were expecting to be able to provide some of the supplemental

benefits listed in CMS’ 2019 Call Letter, but faced difficulty getting these new benefits approved

in the audit process; they were “surprised… that they were turned down for something that they

thought was going to be allowable.”

4.4.6. Need for More Beneficiary Education

Experts and the MAOs discussed the need for a stronger focus on beneficiary education

and federal oversight. Several experts suggested that CMS provide clearer guidelines for how

MA plans should educate consumers about supplemental benefits, eligibility criteria, and appeals

processes. CMS could address these concerns by: (1) developing transparency and oversight

provisions in future regulations; (2) making information on eligibility requirements for approved

supplemental benefits publicly available; and (3) providing education to MAOs about effective

strategies for communicating the details of supplemental benefits that are not universally

available and are often provided on a case-by-case basis to their members.

Additionally, there are marketing and enrollee engagement challenges for the plans. Many

MAOs develop communications about plan benefits for the broad membership that is not tailored

to specific enrollees. While plans may develop member materials to highlight new benefit

offerings, it is important to be careful representing who is eligible, which can be very

complicated for the plans to describe and for beneficiaries to understand. Instead, MAOs often

depend on brokers awareness and understanding the benefits, how the benefits connect to the

needs of clients, and “hope that the agent/broker would make sure benefits that might be

important would be highlighted for an individual.” Experts mentioned that enrollment brokers

need very clear education and training to ensure they understand eligibility criteria for the

members and how they connect to the needs of clients to able to communicate eligibility and the

value-add of these benefits accurately. Several MAOs noted that they depended on their care

managers to educate and communicate with members about benefit availability. One MAO

mentioned that they had provided extensive training and materials to their care managers to

support communication with their members about the expanded supplemental benefits.

4.4.7. COVID-19 Challenges

The current pandemic has also created novel challenges to implementation of the expanded

benefits. COVID-19 has impacted utilization patterns, such that plans are unable to reliably

predict utilization and member uptake of the new offerings. MAO representatives discussed how

the pandemic may lead to larger than expected increased use of tablets and other technologies to

address social isolation. By contrast, other MAOs shared that COVID-19 had reduced uptake of

or suspended some benefits such as transportation and fitness benefits. A representative from one

of these MAOs noted concerns about home care workers having adequate personal protective

equipment and training.

4.5. Policy Implications of Overlapping Coverage with Medicaid

Despite the limited number of MAOs offering expanded supplemental benefits in 2020,

there is potential for interaction with and overlap between Medicaid coverage and supplemental

benefits that provide LTSS and SDOH related services. In addition to creating challenges for

MAOs and government officials in monitoring benefits across plans, this can also cause

confusion for dually eligible beneficiaries and providers.

4.5.1. Extent to Which MAOs and States Monitor Overlap

States face limitations with monitoring and responding to any concerns with MAOs

offering benefits similar to their state Medicaid program. Few states actively monitor MAO

supplemental benefit offerings, although some require D-SNPs with which they have State

Medicaid Agency Contracts

to report to the state all supplemental benefits offered (e.g.,

Arizona, Minnesota and Pennsylvania). A few other states require MAOs to submit bids to the

state for review. However, most states do not have this requirement. There are even more limited

mechanisms for states to monitor and/or require information from MAOs that are not D-SNPs,

such as examining the limited information available in the Medicare data files. MAOs that offer

integrated or aligned Medicare and Medicaid services are in a stronger position to reduce

potential duplication.

The Medicare Improvements for Patients and Providers Act of 2008--as amended by the Affordable Care Act--

required all D-SNPs to have contracts with the Medicaid agencies in the states in which they operate.

Some plans have developed processes to monitor potential overlap of supplemental

benefits, although this varies across MAOs, and MAOs may not have a formal system in place to

track Medicaid services and monitor overlap. Some MAOs have developed a single case

management system in markets in which the potential for overlap currently exists. Others have

developed system edits to monitor overlap between benefits and to ensure that duplication does

not occur. One MAO created a benefits system that tracks coordination between its Medicaid and

Medicare plans to check that claims are paid by the correct payer. MAOs might design a system

to review potential benefits prior to Medicare bid submission to ensure that supplemental

benefits are not currently being offered under Medicaid benefits. They can also educate care

managers about different benefits to help them assist dually enrolled beneficiaries in the benefit

selection, including determining whether a new supplemental benefit duplicates an existing

Medicaid benefit.

Other plans may choose to discontinue supplemental benefits if overlap occurs. One MAO

described an example in which benefit overlap occurred. To streamline coverage for enrollees,

the plan chose to discontinue one of the benefits going forward.

4.5.2. Potential Challenges for Dual Eligible Beneficiaries

Beneficiary advocates and government officials have expressed concerns about the overall

confusion that the potential for overlapping benefits may cause beneficiaries trying to determine

which payer is covering a needed service. Medicare and Medicaid grievance and appeals

processes for service denials differ. If there is no coordination between the two payers, the

confusion may result in a barrier to access and denied claims for dual eligible beneficiaries.

4.6. MAOs’ Future Plans for Expanded Supplemental Benefits

The MAOs all reported that CY2020 was greatly impacted by the COVID-19 pandemic.

Due to the pandemic, there had been lower utilization of benefits overall. Therefore, in order to

create stability for a population harder hit by the pandemic and properly assess the impacts of

these newly offered supplemental benefits, CY2021 benefit decisions would not be based just on

ROI. Rather, examining feedback from beneficiaries collected from care managers, conducting

member satisfaction surveys, and piloting new benefits for at least two years were strategies

described for benefit planning for CY2021.

While the MAOs were hesitant to divulge too many details regarding CY2021 benefits,

MAOs indicated that in most cases current benefits would be maintained, and in some instances,

new benefits would be added. One MAO mentioned that although Medicare payments may be

reduced if the COVID-19 pandemic results in lower risk scores, leaving few dollars available for

supplemental benefits, the MAO would continue to offer current benefits and expand to remain

“appealing in the marketplace.” This MAO discussed expanding nutrition (i.e., grocery benefit

and additional meals), in-home supports, and telehealth benefits.

All of the case study MAOs discussed expanding to other supplemental benefits. One

MAO indicated a desire to use supplemental benefits to address housing. Supporting caregivers

was described by multiple MAO representatives as another focus area for future supplemental

benefit offerings. One MAO discussed how they were considering expanding their support

through SSBCI to target caregivers of people with certain chronic conditions. Benefits targeting

social isolation and loneliness were other areas MAO plan representatives pointed to for future

supplemental benefits.

5. FUTURE CONSIDERATONS

While the study findings indicate MAOs’ relatively modest adoption of expanded

supplemental benefits during the initial years these flexibilities were made available, recent

analyses of the MA plan bid submissions and our discussions with MAOs indicate their

increasing interest to offer benefits. Policymakers and researchers may wish to consider the

following as MAOs more widely adopt expanded supplemental benefits:

• Data Collection and Analysis. Currently no consistent taxonomy exists for expanded

supplemental benefits. These expanded supplemental benefits are entered into the PBP

data files under a set of categories (separate categories for expanded primarily health-

related supplemental benefits and SSBCI). However, plans may offer very specific

benefits, such as providing eligible beneficiaries with animatronic cats as surrogate pets.

As one expert explained, benefit descriptions may vary, leading to inconsistencies in the

data entered and subsequent analyses. As a result, policymakers and researchers may face

difficulties in accurately capturing trend details in MAOs offering expanded

supplemental benefits.

• Communication. All stakeholders could benefit from improved communication from

CMS and MAOs. The study results point to insufficient guidance from CMS to MAOs

regarding expanded supplemental benefits as a factor for the MAO’s initial conservative

approach to benefit offerings decisions. Conversely, policymakers and other stakeholders

lack information from MAOs regarding their decision-making processes and plan

offerings. For example, if policymakers had detailed information regarding MAOs’

offerings, they would be better positioned to potentially minimize duplication with

Medicaid benefits and reduce provider burden and beneficiary confusion. Improved

communication would allow MAOs to better prepare to offer expanded supplemental

benefits, and would help policymakers and other stakeholders to understand future

benefit possibilities and support providers and beneficiaries accordingly.

• Equity. As plans can now target certain beneficiaries for services, some beneficiaries

who do not meet selected eligibility requirements may be excluded. Policymakers and

other stakeholders may wish to continue to examine ways to balance the benefits of these

expanded supplemental benefits with ensuring all beneficiaries’ health and well-being are

equitably addressed and educate them about options to appeal eligibility determinations.

• Medicare and Medicaid Coordination. Several experts suggested there may be

instances in which, “both parties [MA plans and Medicaid] dropped the ball” because

each is working under the assumption the other will tend to the needs of their

beneficiaries. Increased coordination between Medicare and Medicaid regarding these

benefits can help ensure dual eligible beneficiaries access to needed supports and

services. States may consider increasing their involvement with monitoring D-SNPs

through their contracts with these plans, including requiring the plans to report their

supplemental benefit offerings to the state or to offer certain supplemental benefits to

their members.

• D-SNP Look-Alike Plans. Some MAOs offer D-SNP look-alike plans, which offer

reduced premiums and beneficiary cost-sharing amounts similar to D-SNPs. These look-

alikes may now also offer supplemental benefits to address LTSS and SDOH needs,

making them appear even more like an integrated D-SNP that provides Medicaid

benefits. However, because these are traditional MA plans, they are not required to

coordinate with Medicaid. Offering expanded supplemental benefits may enable the D-

SNP look-alike plans to market their benefits in a way that could cause confusion among

dual eligible beneficiaries and enrollment counselors. CMS has proposed several

provisions to restrict D-SNP look-alike plans (CMS, 2020), but these plans may continue

to grow in the meantime.

MAOs considering expanding their supplemental benefit offerings may also want to

consider the following:

• Involvement of Medicaid teams. Medicaid expertise is important for designing “LTSS-

like” supplemental benefits, or benefits that otherwise address SDOH. MAOs that either

house benefit design or oversight functions within Medicaid teams, or that demonstrate

robust collaboration with Medicaid divisions, appear to have faced fewer challenges with

benefit implementation. Conversely, the MAO with less Medicaid experience appears to

have less knowledge about how these supplemental benefits interact with Medicaid and

what types of LTSS-like benefits would be most useful to members.

• Use of benefits as wrap around to Medicaid benefits. One MAO explicitly uses some

Medicare supplemental benefits to wrap around Medicaid LTSS benefits. They use the

state’s generous Medicaid LTSS benefits as a foundation on which to build their

supplemental offerings. However, keeping track of benefits across programs is onerous,

including extensive crosswalk work across policies in each program to determine through

which pathway to cover services.

• Developing a process to target eligibility for benefits. SSBCI eligibility criteria

requires that an individual receiving a benefit have a specific diagnosis and in turn,

requires a process across different plan staff to validate that a member receiving the

services meets those eligibility criteria. Expanded primarily health-related supplemental

benefits can be available to all members regardless of whether an individual has a

specific diagnosis. In programs in which each member has an individual care manager,

like in a D-SNP, it can be easier for care managers to identify benefit recipients and

provide necessary information for authorization and reporting. But, in most traditional

MA plans, fewer members have a designated care manager and identifying and tracking

eligible members becomes more challenging.

• Increased investments needed. While plans appreciate the flexibility to offer new

benefits, several MAOs discussed the increased efforts and investments a MAO must

account for when considering expanding their supplemental benefit offerings. All four

MAOs reported that they have more work to do to understand the ROI for services that

address SDOH. Although plans with missions to serve low-income and/or high-need

beneficiaries have made progress on this research and are more open to offering benefits

that target social needs with limited evidence, they acknowledged that rebate dollars are

generally insufficient to cover the true investment needed to have a system-wide impact.

 
22 
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https://www.urban.org/sites/default/files/publication/101067/sdh_medicare_advantage_1.pdf.

Wright, L., Vance, L., Sudduth, C., & Epps, J. (2015). The impact of a home-delivered meal program on

nutritional risk, dietary intake, food security, loneliness, and social well-being. J Nutr Gerontol

Geriatr, 34(2), 218-227.

APPENDIX A. LITERATURE SEARCH STRATEGY

A1.1. Identification of Relevant Publications

The two searches were composed of multiple steps that included developing preliminary

lists of search terms, exclusion and inclusion criteria, and databases and organizational and

agency websites for conducting the searches. Exhibit A-1 shows the organizations, agencies, and

publications searched as well as the search terms used.

EXHIBIT A-1. Search Strategy

Source

Keywords

Peer-reviewed

Literature

PsychINFO, ScienceDirect, Google Scholar, JSTOR,

Web of Science, PubMed

English, since Jan 2009

Medicare Advantage OR Medicaid

Managed Care OR value-based

purchasing OR value-based

insurance design OR managed long-

term services and supports OR

chronically ill OR Medicaid benefits

OR Medicare Part C OR value-

based insurance OR value-based

health insurance OR chronic illness

AND supplemental benefits OR

social determinants of health OR

((adult day health OR home-based

palliative care OR in-home support

services OR support for caregivers

OR medically approved non-opioid

pain management OR standalone

memory fitness benefit OR home

and bathroom safety devices OR

transportation for non-emergency

medical needs OR transportation for

non-medical needs OR home-

delivered meals OR produce, frozen

foods, and canned goods OR

companion care OR home

modifications OR housing) AND

(Medicare OR Medicaid)) AND

challenges OR opportunities OR

perspectives

Grey Literature

• ASPE

• CMS

• CDC

• MedPAC

• MACPAC

• AARP

• MedicareResources.org

• JusticeinAging.org

• MedicareAdvocacy.org

• Milliman

• Bipartisan Policy

Center

• Association for

Community Affiliated

Plans

• Special Needs Plan

Alliance

• Avalere

• National Academies of

Science, Engineering,

and Medicine

• America’s Health

Insurance Plans

• National Council on

Aging

• Medicare Rights

Center

• N4A

• Community Catalyst

• AHRQ

• Commonwealth Fund

• LTQA

• Fierce Healthcare

• Better Medicare

Alliance

• Urban Institute

• Kaiser Family

Foundation

Once we identified an initial list of studies, we completed a high-level review of the

resulting publication titles. After we agreed that all relevant studies were identified from all

relevant sources, a team member imported the publication information and abstracts from

selected relevant publications into the data charting tool, created to capture and organize

information collected from the review. Concurrent with this review, we completed a search of

the grey literature. Our team developed a list of 28 organizations, governmental agencies and

health insurance companies to review (see Exhibit A-1 above). All resources identified from the

grey literature search were included in the data charting tool for additional review.

A1.2. Selection of Publications

Three members of the team reviewed the study abstracts to: (a) further refine the

inclusion/exclusion criteria; and (b) begin the process of eliminating studies from further

analysis. We then selected studies for further review and noted our reasoning for all publications

we excluded from further analysis. Following the abstract review, each included article was

reviewed in its entirety.

Through our search of the peer-reviewed and grey literature, we identified 139

publications. We reviewed in full 51 of those articles for relevance, and further culled 22 articles

based on determination that the study population (4) was outside of our study’s focus, or they

were otherwise not relevant (18). Data were extracted and synthesized from the 29 publications

that met our inclusion/exclusion criteria. The publication selection process is summarized in

Exhibit A-2 below.

EXHIBIT A-2. Publication Selection Process

Grey Literature Review Published Literature

139 Unduplicated Abstracts

139 Abstracts Screened

88 Abstracts Excluded

Reasons: relevance (n=81);

publication focus (n=6); year (1)

51 Full Articles Assessed

29 Full Articles Included

22 Full Articles Excluded

Reasons: relevance (n=18);

population focus (n=4)

Abstract Review

Data Extraction

Resource Identification

A1.3. Data Extraction, Charting and Synthesis

The final step of our review process was to extract, chart, and synthesize the data. We

began by extracting relevant content by research question and then charting the information in

the data charting tool. We then synthesized the data by conducting a qualitative thematic

analysis. This was done by identifying and documenting themes and subthemes within the

content extracted by the research question. The initial themes were shared with ASPE for

feedback.