Expanded definition of primarily health-related benefits alters the Medicare Advantage marketplace

In April 2018, the Centers for Medicare and Medicaid Services (CMS) published a revised definition of “primarily health related” (PHR) benefits as applicable to Medicare Advantage (MA) organizations. CMS expanded the definition of a primarily health-related service starting in calendar year (CY) 2019 as one that 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 healthcare utilization.” These services are often used by individuals with chronic conditions in need of long-term services and support (LTSS). Many of these services are the same ones that private long-term care (LTC) insurance covers and reimburses.

CMS’s April 27, 2018, guidance letter presented nine possible supplemental benefits that could be offered starting in CY 2019 under the expanded “primarily health-related” definition. Many plans are offering some of these supplemental benefits in 2019. Six of the nine supplemental benefits mentioned in the memorandum are:

1. Adult day care services
2. Home-based palliative care
3. In-home support services
4. Support for caregivers
5. Medically approved non-opioid pain management
6. Standalone memory fitness

In addition to CMS’s list of nine potential new benefits under the revised PHR definition, there are additional “other supplemental benefits” for 2019 that appear to qualify under the expanded PHR definition:

1. Activity tracker/fitness tracker
2. Alzheimer/dementia bracelet: Wandering support service
3. Backup support for medical equipment
4. Housekeeping
5. Non-skilled home health
6. Personal care/personal care services/personal home care
7. Restorative care benefit
8. Social worker line
9. Therapeutic massage
10. Vial of Life program

In this article, Milliman’s Pedro Alcocer, Robert Eaton, and Pamela Laboy address in more depth how the MA marketplace responded in 2019 to CMS’s expanded definition of primarily health-related benefits, including which supplemental benefits plans are offering and where these benefits are offered.