CMS official hints at LTC and chronic condition type benefits for Medicare Advantage

Starting in 2019, Medicare Advantage plans can cover adult day care services, and in-home help with activities such as dressing, bathing and managing medications, a top Trump administration official said recently. In addition, uniform flexibility changes may allow for benefits in traditional MAPD plans only previously seen in Chronic-Condition SNP (C-SNP) plans.

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services (CMS), talked about the Medicare Advantage program’s new benefits flexibility at a Medicare conference at CMS headquarters, in Baltimore. Verma told insurance company executives at the conference that CMS hopes its new “reinterpretation” of the Medicare Advantage program benefits rules will help unleash private-sector innovation and creativity.

Supplemental Benefits and Uniformity Flexibility are both optional. Organizations may choose to offer benefits related to one, both, or none of these new policies.

CMS defines a mandatory or optional supplemental health care benefit as an item or service:

  1. Not covered by Original Medicare,
  2. That is primarily health related, and
  3. For which the plan must incur a non-zero direct medical cost.

Supplemental Benefit Examples

Adult Day Care Services Services provided outside the home, such as assistance with ADLs/IADLs. Provided by staff whose qualifications and/or supervision meet state licensing requirements.
Home-BasedPalliative Care Services not covered by Medicare in the home for palliative care to diminish symptoms of terminally ill members with a life expectancy of greater than six months. Services may include palliative nursing and social work services in the home that are not covered by Medicare Part A.
In-Home Support Services In-home support services performed by a personal care attendant or by another individual that is providing these services consistent with state requirements in order to assist individuals with disabilities and/or medical conditions with performing ADLs and IADLs as necessary to compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. Services must be performed by individuals licensed by the state to provide personal care services, or in a manner that is otherwise consistent with state requirements.
Transportation for Non-Emergent Medical Services Transportation to obtain Part A, Part B, Part D, and supplemental benefit items and services. The transportation offered must be used exclusively to accommodate the enrollee’s health care needs. Transportation for non-medical services, such as groceries and banking, are not permitted.
Home& Bathroom Safety Devices and Modifications Specific, non-structural, non-Medicare-covered safety devices to prevent injuries in the home and/or bathroom. In addition to providing and installing appropriate safety devices, the benefit may include a home and/or bathroom safety inspection conducted by a qualified health professional, in accordance with applicable state and Federal requirements, to identify the need for safety devices and/or modifications, as well as the applicability to the specific enrollee’s needs and home.


Uniform Flexibility

  • Targeted benefits must be offered uniformly to all enrollees with a specified health status or disease state
  • Treating similarly situated enrollees equally preserves the uniformity of the benefits package
  • In identifying eligible enrollees, must use medical criteria that are objective and measurable
  • Must follow Medicare marketing guidelines for communication and marketing materials in communicating these benefits to potential enrollees
  • Cost sharing reductions and targeted supplemental benefits must be for health care services that are medically related to each disease condition
  • Must ensure compliance with non-discrimination rules and regulations
Previous Interpretation Reinterpretation (Effective 2019)
MA plans must offer the same benefits and cost sharing to all plan enrollees.


MA plans may:

  • Reduce cost sharing for certain covered benefits,
  • Offer specific, tailored supplemental benefits, and
  • Offer different deductibles for beneficiaries that meet specific medical criteria.



Allowed: Not Allowed:
  • May reduce or eliminate cost sharing or deductible requirements for items or services.
  • May make coverage for certain supplemental benefits available only to targeted populations.
  • May offer targeted benefits to enrollees who participate in a plan-sponsored wellness or care management program.
  • May offer targeted benefits to enrollees when they visit providers identified by the plan as being high-value.
  • May not reduce or eliminate premiums. Plan premium and Part B premium buy-down amounts must be the same for all enrollees in the plan.
  • May not offer targeted benefits based on socio-economic status or any other state other than health status or disease state. May only provide access to targeted benefits based on health status or disease state (specific medical criteria).
  • May not reduce cost sharing across all benefits for the targeted population.


CMS announced the rule reinterpretations in April, in a memo sent to potential 2019 Medicare Advantage plan issuers. It is not yet clear whether any issuers will add significant chronic care supplemental benefits for 2019, although executives from Humana Inc. hinted during their first-quarter earnings call that they might be able to work with partners to do so.