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CMS expands Medicare Advantage coverage for social determinants of health

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CMS is expanding coverage for benefits that address social determinants of health, creating savings opportunities for payers and broadening opportunities for new entrants to healthcare.

Medicare Advantage plans in 2019 will be able to provide coverage for a wider variety of non-medical benefits as CMS moves to provide better coverage for social determinants of health. Social determinants of health are the conditions in places where people live, learn, work and play that affect health risks and outcomes. The new definition opens the doors to coverage for new benefits for Medicare Advantage plans, which are projected to cover 22.6 million people in 2019.

Air conditioners for people with asthma, healthy groceries for people on medically-prescribed diets, home-delivered meals for people who are immunocompromised and rides to medical appointments for people without transportation all could fall under CMS’s new criteria. Coverage for services like smoking cessation could expand beyond counseling sessions to also cover over-the-counter products like nicotine patches or gum.

The agency has in the past covered supplemental benefits if they met each of three criteria—the benefit could not be covered by traditional Medicare, it had to be primarily related to health and it had to incur a direct medical cost that was not purely administrative. Beginning January 1, CMS now allows a benefit to be one that can meet any one of four criteria—the benefit must diagnose, prevent, or treat an illness or injury; compensate for physical impairments; act to ameliorate the functional or psychological impact of injuries or health conditions; or it can reduce avoidable emergency and healthcare utilization.

In surveys conducted by HRI, both providers and patients said depression or other mental health concerns were the most common kind of social determinant of health they discussed with each other, though providers were far more likely to report having a conversation with their patients (67 percent) than consumers were to report having the conversation with their provider (24 percent). Providers were more likely to report talking about transportation to and from medical appointments with 53 percent reporting discussing the topic, while only eight percent of consumers said they had the same conversation.

Medicare patients often said they believed some topics were important to discuss with a provider, even if they reported not having those conversations. For example, 59 percent of patients said that it is important to discuss depression or other mental health conditions with their providers while 56 percent said the same about accessing healthy foods. When asked if they were having conversations about depression and mental health, 67 percent of providers said they were, while 45 percent said the same about accessing healthy foods.

CMS's new interpretation of supplemental benefits provides better coverage for social determinant of health
Providers are more likely than patients to say they've discussed addressing social determinants of health

Implication highlights

Savings requires more than updating EHRs. The new regulations from CMS afford payers an opportunity to achieve reductions in costs, however doing so will require new data sources to track new kinds of information.

Opportunities for new entrants will grow, but along existing lines. The regulations are more likely to facilitate existing business for new entrants, such as ride-sharing services, meal delivery services, housing organizations and local food markets, than create new business opportunities.

Systems should adopt strategies to bridge the gap between providers and consumers. Providers should carefully consider the ways in which they can effectively incorporate strategies to improve the health of entire populations in ways that will be receptive and heard.

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