So What’s Going to be Reimbursed?

By Bella Kirchner, Special Projects Manager

As we’ve written about previously in Part One of this series, one of the most significant changes in healthcare reimbursement was CMS’ (Centers for Medicare and Medicaid Services) promise to start reimbursing Medicare Advantage plans for non-medical benefits beginning in 2020. Previously, supplemental benefits reimbursed by CMS for chronically ill beneficiaries had to be health-related services but they expanded that definition in the CHRONIC Care Act, passed back in April 2018, by stating that covered services “may not be limited to being primarily health related benefits.” Now referring to these supplemental benefits as Special Supplemental Benefits for the Chronically Ill (SSBCI), CMS recently provided more clarification in January 2019. Some of the main takeaways:

  • Permanent home modifications aren’t going to be reimbursed but food-related benefits will be; and
  • CMS is encouraging Medicare Advantage Plans and Community Based Organizations (CBOs) to work closely with another to address social determinants of health.

Defining Non-Medical Benefits

While CMS previously released additional information around uniformity rules and qualifying conditions related to SSBCI (which we summarized in Part Two of our series), health plans and industry experts have been waiting for further clarification on what’s actually considered a non-medical related benefit.

Some speculated that home modifications might end up being covered, but the document states that the non-medical benefits “may not include capital or structural improvements to the home of the enrollee that could potentially increase property value (e.g., permanent ramps, and widening hallways or doorways)…”. Although this leaves out reimbursement for major structural projects, this means that there is still some room for non-permanent solutions, such as temporary ramps or assistance with moving furnishings.

The document also includes several examples of what will be allowed for reimbursement, including the following:

  • Transportation for non-medical needs;
  • Home-delivered meals (beyond just post-discharge from a hospital visit); and
  • Food and produce.

It will be interesting to see how “food and produce” will be billed for, how these goods will be provided, and how they will be reimbursed.

While all of this information provides some clarification, questions still remain around other items and services, such as air conditioners, pest control, and mold removal. Where will CMS land on reimbursing for these services?

New Partners: Health Plans and Community-Based Organizations

In addition to clarification around benefits, the document also briefly discusses the potential role Community Based Organizations (CBOs) may take in the new reimbursement landscape. Coordinated care Medicare Advantage (MA) plans (HMOs, POSs, PPOs, SNPs) are already obligated to “coordinate MA benefits with community and social services generally available in the area served by the MA plan.”1 In addition to care coordination, CMS outlines two other ways in which these types of plans can partner with CBOs:

  • Plans can contract with CBOs to provide these new supplemental benefits; and
  • CBOs can help the plan determine if a member meets eligibility requirements for supplemental benefits.  

The continued push for health care plans and CBOs to work closely together is just more evidence of CMS’ growing interest in tackling social determinants of health.

CMS also states that Medicare Advantage plans must make sure they have rigorous and objective criteria for determining eligibility for SSBCI. They must also “maintain detailed documentation” to ensure that all patients are screened equally. Since CBOs will be able to help them with eligibility, they will have to think of ways to ensure that screening and documentation follow these requirements.

The Impact

One consequence of the allowances set forth by CMS is that the relationship between the health plan, healthcare provider, and CBOs becomes extremely important. If done right, this systemic approach to social determinants will mean that more people will get the social services they need outside of the doctor’s office, with support from both their health plan and their community.

Note: CMS is currently taking comments on the Proposals and Draft Letter through March 1, 2019. You can find more information here.


1https://www.govinfo.gov/content/pkg/CFR-2010-title42-vol3/pdf/CFR-2010-title42-vol3-sec422-112.pdf