BMA in the News
January 31, 2019

CMS Details Supplemental Benefits For Chronically Ill Enrollees in 2020

CMS proposed in a draft call letter Wednesday (Jan. 30) how Medicare Advantage (MA) plans could submit new supplemental benefits specifically for chronically ill enrollees in their 2020 bids.

Director of the Center for Medicare Demetrios Kouzoukas said on a call Wednesday that the proposal comes from a recognition that “beneficiaries have multiple chronic illnesses” and said the supplemental benefits, called Special Supplemental Benefits for the Chronically Ill (SSBCI), would provide enrollees with new options.

In last year’s call letter, CMS began to allow MA plans to offer supplemental benefits, which are benefits not offered under original Medicare, beginning in 2019, including adult day care, support for caregivers, in-home supports, home safety modifications and more, to help with physical impairments. It did not add services that deal with social determinants of health. The 2018 call letter also only includes primarily health-related benefits.

Separately, the Bipartisan Budget Act of 2018 loosened uniformity requirements, allowing MA plans to vary benefits based on the individual enrollee’s needs. It also amended the law to allow MA plans to offer non-primarily health-related supplemental benefits to chronically ill enrollees in 2020.

In the draft letter released Wednesday, CMS differentiated that MA plans will be able to offer separate supplemental benefits (SSBCI) to chronically ill enrollees.

For an enrollee to be defined as chronically ill, they must fit all three of the following criteria: have one or more comorbid and medically complex chronic conditions that are life threatening or significantly limit the overall health or function of the enrollee, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination, CMS said.

CMS said that an enrollee would meet the first criterion if they have a condition defined in the Medicare Managed Care Manual as a chronic condition. Those include: alcohol or other drug dependence, certain autoimmune disorders, certain cardiovascular disorders, chronic heart failure, dementia, diabetes, end-stage liver disease, end-stage renal disease requiring dialysis, certain hematological disorders, HIV/AIDS, certain chronic lung disorders, certain mental health conditions, certain neurological disorders, and stroke.

CMS said MA plans do not need to outline the process they use to determine chronically ill enrollees.

CMS will solicit comments on whether plans should be allowed to determine what chronic conditions are considered life threatening or significantly limiting and whether alternative approaches to the criterion should be considered.

In accordance with the Bipartisan Budget Act, CMS also said MA plans can vary which chronically ill enrollees are offered SSBCI. However, CMS said plans must offer objective criteria and reasoning why one enrollee might receive supplemental benefits over another.

Furthermore, as the Act allowed MA plans to expand supplemental benefits to non-primarily health-related benefits, the draft letter provides guidance on what MA plans might be able to propose as a supplemental benefit.

CMS clarified Wednesday that an SSBCI may be proposed “so long as the item or service has a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic disease.”

CMS gave examples including transportation for non-medical needs, home-delivered meals, food and produce.

CMS said these examples respond to the feedback from stakeholders and said the agency is looking forward to further discussions on what else could be offered.

Last year, Adjoa Adofo, a spokesperson for the Better Medicare Alliance, said the group was disappointed that CMS did not allow plans to offer home meal delivery as a benefit, but said this year the group was encouraged by the proposal to expand supplemental benefits, citing CMS’ interest in expanding access to nutrition, meals, transportation and home care services.

CMS, however, limited items and services that could potentially increase property value, such as permanent ramps “in order to ensure that enrollees are receiving an appropriate level of benefits and to avoid any anti-kickback implications or taxable improvements.”

The agency also said that benefits may not be offered to induce enrollment.

CMS reminded plans that they must incur a non-zero direct medical cost for all supplemental costs. Under the draft letter, SSBCIs can only incur non-administrative costs.

The draft letter also offers guidance to plans on contracting community-based organizations to provide supplemental benefits and to allow such organizations to determine whether an individual meets the requirements for SSBCI. CMS points out that these organizations might already be providing serves and might have contractual agreements with Medicaid managed care or MA plans.

CMS says it will solicit comments on the limits of supplemental benefits and whether other factors, such as financial need, should be considered when determining supplemental benefits.

Just last Friday (Jan. 24), CMS’ Center for Medicare and Medicaid Innovation (CMMI) released an expansion of its Value-Based Insurance Design Model, which also would allow MA plans to provide supplemental benefits based on beneficiaries’ chronic conditions or based only on socioeconomic status. Under the current VBID model, supplemental benefits may only be based on select chronic conditions. The model also allows plans to propose non-primarily health-related supplemental benefits with a sufficient evidence base.

CMS did not provide a response by press time on what the difference is between the supplemental benefits offered in the draft letter and the supplemental benefits offered in the expanded demonstration, but told Inside Health Policy last week that those non-primarily health-related supplemental benefits proposed under the VBID model could be used to address social determinants of health. — Chelsea Cirruzzo (

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