Tag Archives: LTC

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.

Improving financial projections for long-term care insurance with predictive analytics

Predictive analytics has the potential to help long-term care actuaries develop more accurate projections via an automated robust process. This article by Milliman’s Missy Gordon and Joe Long walks through an illustrative case study for a company that transitions from using traditional techniques to using predictive analytics to develop a claim termination assumption.

This article was originally published in the August 2018 issue of Long-Term Care News.

CMS guidance presents Medicare Advantage plans with new LTC benefits considerations

In April, the Centers for Medicare and Medicaid Services (CMS) provided guidance for Medicare Advantage (MA) plans regarding the scope of the “primarily health related” supplemental benefit definition. The guidance clarified the types of long-term care (LTC) benefits that MA plans can provide as a supplemental benefit for individuals needing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

These plans face various challenges as they contemplate offering LTC coverage under the new CMS definition for primarily health related supplemental benefits. In this paper, Milliman’s Chris Giese and Al Schmitz examine some of these challenges and explain what MA plans must consider to make choices that benefit both plans and consumers.

Utilizing LTC projection methods

Estimating future claims usually entails using historical data as a starting point to develop an assumption about the future. Developing financial projections of long-term care (LTC) insurance utilization is similar. In this article, Milliman’s Jeremy Hamilton and Tim Kempen focus on two methods for using current utilization levels to develop utilization assumptions for future durations: an “average utilization” method and a “distribution” method. They also outline the advantages and disadvantages of both methods.

Calculating LTC utilization assumptions

Utilization is a key aspect of long-term care (LTC) insurance assumptions that can impact insurers’ pricing, profitability, and reserves. Several nuances can make it challenging to develop and set appropriate utilization assumptions. In the article “Utilization: Long-term care’s ‘middle child’,” Milliman actuaries Mike Bergerson and Michael Emmert discuss some factors involved with calculating utilization and how they affect LTC reserves.

Improving financial projections for long-term care insurance with predictive analytics

In the world of long-term care (LTC) insurance, making financial projections is challenging for two main reasons: a long projection horizon and complex interactions. This article by Milliman actuaries Missy Gordon and Joe Long walks through the progression from developing LTC projection assumptions using traditional methods to doing so using predictive analytics.

This article was originally published in the December 2017 issue of Long-Term Care News.