Thanks to CMS Rule Change, MA Takes SDOH to a Whole New Level

Change happened, says Brent J. Sanders, who oversees Cigna–HealthSpring, Cigna’s Medicare Advantage (MA) offering, because CMS and health insurers talked about what needed to be done to better address the social determinants of health (SDOH) for beneficiaries. That led to a policy, implemented last year by CMS, that allows for the provision of daily maintenance care using nonskilled in-home providers, the kind of services usually given in assisted-living facilities.

“If you look over the past 18 months or so, CMS has increasingly requested information from the industry,” says Sanders. “They are proactively engaging all sorts of stakeholders in the health care ecosystem to provide insights on some very specific topics.”

CMS wants reports from the front lines, he believes. “It’s a bit of a change in pattern and practice relative to openness to hearing and seeing that the needs of the customers and the patients are evolving. And there’s a desire to drive quality of care for those individuals in a very affordable way.”

“We want to make it easier for our customers” to better understand and utilize their benefits, says Brent J. Sanders of Cigna–HealthSpring.

This dialogue makes implementation easier, says Sanders. “Some of the decisions that CMS puts out in their initial recommendations [come] in the early part of the year, but their final call letter doesn’t come out until the final April timeframe. That creates a fairly tight timeline relative to getting the bid submissions or benefits filed with CMS in June. But I think there’s evidence that CMS is hearing and beginning to create the flexibility with what they’re enabling their health plans to provide.”

The goal is better quality, rendered in a simpler, less expensive way. “We want to make it easier for our customers to not only understand their benefits, but also to be able to effectively use them by engaging in their own care,” says Sanders. “We are increasingly investing in digital experiences for customers who are looking to engage through technology, such as telehealth.”

About 1,500 Cigna–HealthSpring employees report directly to Sanders, and there are about 4,500 Cigna–HealthSpring employees whose primary responsibilities involve serving the needs of Medicare and Medicaid customers. (Cigna employs more than 40,000 people overall.)

Cigna–HealthSpring isn’t just expanding benefit packages, however; it’s also expanding into new markets. Sanders mentions specifically Orlando. “And we’re doing it off the backs of a longstanding proven approach of partnering with providers,” says Sanders. “That results ultimately in having 80% of our customers in those four-star-or-higher plans.”

Cigna–HealthSpring continues to look for other geographical areas in which to expand, or to expand its foothold in places where it already has a presence.

“Some examples include expanding existing commercial partnerships with health care providers, developing new value-based provider partnerships, and designing benefits or services that meet evolving customer needs,” says Sanders. “We also consider the size of the market, number of people eligible for Medicare and competitors.”

Cigna–HealthSpring offers a transportation benefit in more than 50% of its plans, including some plans in Alabama, Arkansas, Arizona, Florida, Georgia, Delaware, Maryland, the District of Columbia, Pennsylvania, North Carolina, Tennessee, and Texas. The number of rides available varies by plan. The transportation benefit currently includes rides to doctors and pharmacies. Over the last 11-month period, the average number of trips utilized per person has been about 15.

In addition, “we have increased the number of plans that include fitness, dental, transportation, and over-the-counter drug benefits,” says Sanders.

Anthem sings SDOH praises

With 436,000 enrollees, Cigna’s MA footprint is relatively small compared to its competitors, though, as Sanders’s comment and those of Cigna CEO David Cordani make clear, the company plans a major incursion into the market. Anthem’s major incursion into MA garnered headlines in February when the insurer reported that enrollment in its MA plans jumped by 35% to more than 1 million at the end of 2018, compared with 746,000 at the end of 2017. That’s the biggest jump for any MA provider.

Struggling to meet needs

SDOH plays a big part in Anthem’s efforts, says Martin Esquivel, vice president of Medicare product management.

“We recognize that there are entire segments of the population that are struggling to meet some of their needs and some of the things that perhaps some [other] segments of the population take for granted,” says Esquivel.

There’s a learning curve when health plans address SDOH, says Martin Esquivel, who oversees Anthem’s Medicare products.

Anthem’s package of new SDOH-related benefits is known by two names, depending on where they’re being sold and who, exactly, is selling them. Essential Extras is sold by Anthem Blue Cross Blue Shield plans in Georgia, Indiana, Kentucky, Missouri, Ohio, Virginia, and Wisconsin. Everyday Extras is sold by Anthem affiliate Amerigroup in Tennessee, Texas, and New Jersey.

With the Essential Extras/Everyday Extras packages, enrollees can pick one of the following six benefits (the exception is Amerigroup in New Jersey, where the package does not include transportation and adult day care center services):

• Up to 64 meals a year; 16 meals per event up to four events a year. An event includes being discharged from a hospital, a BMI of more than 25, and/or an HbA1c level of more than 9.
• Up to 24 acupuncture and/or therapeutic massage visits per year.
• Up to 124 hours of an in-home aide or respite care to help with chores and assist with daily living.
• A $500 allowance for safety devices, such as ADA toilet seats, shower stools, handheld shower heads, reaching devices, and temporary wheelchair ramps, that meet federal disability law standards.
• Up to 60 one-way trips per year to health-related appointments or to obtain a service covered by the health plan.
• Up to one visit per week for adult day center services.

Anthem Blue Cross Blue Shield plans in California (Anthem Blue Cross) and Arizona (Amerigroup) provide a slightly broader benefit package.

Looking at 2019, the thing that most excites Anthem’s Esquivel are SDOH programs. But there is a learning curve, he admits. “Being first in the health insurance market means you get to learn first,” he says.

Seniors don’t have to pay more for the Essential Extras/Everyday Extras benefits. “The inclusion of what we did for the SDOH and what we’ve done for Silver Sneakers or any of the other benefits, they did not have an impact on premiums,” says Esquivel.

Funding streams from CMS are not changed either. “There are a lot of factors that go into how the revenue flows from CMS,” says Esquivel. “The factors are much broader than any individual benefit. There’s a lot that goes into the calculation.”

Approximately 80 people report to Esquivel, but in order to execute the rollout, “the work is touched by hundreds or even thousands of people who are ensuring that the claims systems are set up.”

Esquivel adds: “The challenges associated with rolling out the new benefits are, frankly, not dissimilar to challenges that we see every year. It’s important to make sure that beneficiaries receive access to benefits on January 1 that was permitted by CMS. That’s just part of what we do.”