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Aug 2, 2018

The Door Opens For SDOH in Medicare Advantage

In deference to the growing body of research that supports addressing the Social Determinants of Health (SDOH), CMS recently announced it will expand the definition of “supplemental benefits” for Medicare Advantage (MA) plans in 2019. This means covering an air conditioner for someone with asthma is not at all far-fetched. The new definition allows coverage of supplemental benefits if those benefits:

“ … compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization … ”

The supplemental benefits must “increase health and improve the quality of life.” Previous MA language tied plans to “preventing, diminishing or curing an illness.”

The new language allows Medicare Advantage plans the flexibility to cover provider-arranged transportation services, such as using Uber to ferry patients to and from medical appointments, and grab bars for showers and tubs to prevent dangerous falls. It might include something as simple as meal delivery and healthy groceries. MA plans will have to decide for themselves which allowances will attract beneficiaries and bring down costs.

“This change in the reimbursement policy validates what social determinants advocates in the industry have been clamoring for,” said Munish Khaneja, MD, Altruista chief medical officer and lead, clinical innovation. “It injects a large dose of common sense and support the “whole-person” model of caring for people and reducing costs. It’s a really a new day for Medicare Advantage.”

SDOH strategies are gaining rapid traction as it’s recognized that an estimated 20 percent of health is shaped by SDOH. Payers are capitalizing on the success found in public models to mimic their strategies. The door is now open for all the extras – beyond the dental care, hearing aids and eyeglasses MA plans have been using to attract beneficiaries and support health.

“Plans that take advantage of this opportunity clearly understand the broad issues associated with one’s health and healthcare,” said Jan Berger, MD, MJ, and chief executive officer of Health Intelligence Partners. “Incorporating SDOH services into their benefits and taking a holistic, patient-centered approach will likely bring them greater market share.”

Building out MA plans may sound like a daunting task for payers, but the promise of SDOH can be fulfilled with the right technology and a robust set of social resources. Altruista Health’s GuidingCare® platform is the first to offer a turnkey solution that payers can tap into quickly to connect with local social services networks that include housing, transportation, food and more. Care managers at health plans can track a member’s progress using these services and report on outcomes. 

“Until now the conversation has been focused on how SDOH ‘should’ be incorporated into care delivery,” said Dr. Khaneja. “Now the focus is on how it ‘must’ be a part of care.”