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Home care providers slow to chase Medicare Advantage business opportunities may now be motivated to speed up their pursuits.

Last week, the Centers for Medicare & Medicaid Services (CMS) announced it was broadening the range of supplemental benefits Medicare Advantage (MA) plans can offer in 2020. Starting next year, health care policymakers will allow MA plans to cover any benefits that “have a reasonable expectation of improving or maintaining the health or overall function” of beneficiaries with chronic conditions.

While the language is brief, its implications are enormous, CareLinx President and CEO Sherwin Sheik told Home Health Care News. Burlingame, California-based CareLinx is a nationwide online care platform with more than 300,000 caregivers in its network.

“No one has been able to quantifiably show in a peer-reviewed journal … exactly how addressing social determinant factors of health provides strong ROI and returns,” Sheik said. “With the language of ‘have a reasonable expectation of improving,’ what CMS is doing is allowing health plans to really experiment.”

In April 2018, CMS announced it was for the first time adding non-medical in-home care as a supplemental benefit for MA plans for the 2019 plan year. While providers immediately viewed the news as a win for the home care industry, health plans were left with little time to put benefit plans together and with questions on what services they were actually allowed to offer.

As a result, just 3% of MA plans offered in-home support services such as personal care or housekeeping in 2019, according to an AARP analysis.

“Health plans were asking CMS for clarification,” Sheik said. “’Are we ok trying to do this? Can we do that?’ What CMS is basically saying now is, ‘We know you’re experimenting. We know you’re learning. We want you to invest here and see what happens.’”

Not waiting until 2021

CareLinx — purchased by Generali Global Assistance, part of the Generali Group, in 2017 — has been among the more active companies in the home care space in terms of Medicare Advantage positioning.

In December, CareLinx launched a turnkey offering for MA plans looking to incorporate non-medical home care as a supplemental benefit. In line with that launch, CareLinx in February acquired the Optimal Aging platform from Providence St. Joseph Health, one of the country’s largest health systems.

“We’ve been working with and helping some of the largest health plans in the country trying to figure out how to roll this out,” Sheik said. “This is all new.”

Omaha, Nebraska-based Right at Home and Denver-based Homewatch CareGivers are equally bullish on what Medicare Advantage could mean for their businesses moving forward. Both have had conversations with insurers about the value of in-home services and supports.

“While we were a bit surprised the government was already expanding the range of services that can be covered in an MA plan, we certainly view it as a positive,” Kerin Zuger, vice president of business development and strategic partnerships at Right at Home, told HHCN. “This illustrates that CMS recognizes the inclusion of non-skilled services in the home, will reduce the cost of care and enable Medicare Advantage members to remain at home longer.”  

After several discussions within health plans following CMS’s initial MA announcement last year, Right at Home began working on a home care pilot with one unnamed insurance carrier, Zuger said. The franchise system hopes to go to market with benefits developed as part of the pilot as early as 2020, with collected data also being used to pitch Right at Home to other MA plans in the future.

“As data from these programs begin proving how [new benefits] reduce the use of more acute care, we suspect home care benefits will expand further,” she said.

Meanwhile, local Homewatch Caregivers offices have been connecting with Medicare Advantage organizations in their markets with the goal of becoming in-network providers. The overall franchise company is likewise touting home care’s ability to help with social determinants of health, activities of daily living, pain prevention, cognition and fall risk on a national level.

“It is great to see that the health care system and payers, including CMS, are recognizing that far less expensive and invasive care is valuable to outcomes, as well as beneficiary engagement and satisfaction,” Homewatch CareGivers COO Jennifer Tucker told HHCN. “With that said, we understand this is just a first step and it will be an evolution as we objectively demonstrate the ROI of in-home support services specifically on outcomes and costs, particularly for those patients with chronic conditions.”

Jennifer Ramona, Homewatch CareGiver’s vice president of strategy and health care innovation, told HHCN the franchise is “doubling down” on Medicare Advantage, including taking the step of creating a new position to support offices with pursuing MA business.

“We want to be engaged with the MA plans early in order to help inform the expectations of a home care partner to be able to demonstrate value to the plan and their enrollees, and in return for home care providers to be able to expect fair requirements and reimbursements from the plans,” Ramona said. “We are not waiting for 2021.”

Not an easy business

Apart from home care providers, the Better Medicare Alliance has also been among the groups praising CMS for expanding supplemental benefits under Medicare Advantage.

Washington, D.C.-based Better Medicare Alliance is an association of more than 130 health care organizations and more than 400,000 beneficiaries. President and CEO Allyson Schwartz called the finalized MA policies for 2020 are “a game-changer” in health care delivery.

“The announcement offers a continuation of a positive and stable environment for Medicare Advantage that allows plans and providers to continue to offer high quality, affordable care for millions of beneficiaries,” Schwartz said in a statement.

Despite ambitious plans, home care providers and franchise networks should take a comprehensive look at their operations before pursuing MA opportunities, Sheik said, noting some may struggle with certain logistical challenges from insurers.

“It’s not easy business,” he said. “The MA program is not what traditional home care is set up for. Traditional home care wants that 20- to 30-hours-per-week client who lasts about a year. That’s definitely not what Medicare Advantage is.”

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