guide for medicare advantage plans - mom's meals meals guide for ma plans.pdf4 5 mom's...
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GUIDE FOR MEDICARE ADVANTAGE PLANSHow to Design a Home-Delivered Meals Benefit for 2021Including Special Supplemental Benefits for the Chronically Ill
Table of Contents
1 Introduction
2 Understanding the Options for Including aMealsBenefitinYourPlanDesign
3 Step1:IdentifyYourTarget
5 Step 2: Forecast Cost and Utilization
6 Step3:DetermineMeasurementCriteria
8 Step4:IncludeaMealsBenefitinYourBid
9 Step5:CommunicateYourBenefit
Theinformationcontainedhereisprovidedforinformationalpurposesonly,andshouldnotbeconstruedaslegaladviceonanymatter.
Thismaterialmaynotreflectthemostcurrentdevelopments.ThecontentandinterpretationofthelawsandCMSguidanceaddressedin
thisdocumentissubjecttorevision.Donotactorrefrainfromactinguponthisinformationwithoutseekingprofessionallegalcounsel.
DearColleague:
Therehasbeenanever-growingawarenessabouttherolenutritionplaysinoverallhealth.
Thelinkbetweentheaccesstohealthyfoodsandtheabilitytomanageachronicconditionto
avoidflare-upsandpoorhealthoutcomesistooimportanttoignore.It’snosurprisethatan
increasingnumberofhealthplansnowofferbenefitstomeettheneedsofindividualswith
chronicconditions.
Asyoumaybeaware,manychangesresultedfromtheBipartisanBudgetActof2018,which
includedtheCreatingHigh-QualityResultsandOutcomesNecessarytoImproveChronic
(CHRONIC)CareAct.Thelawexpandedwhatqualifiesasasupplementalbenefittomeetthe
needsofchronicallyillMedicareAdvantage(MA)enrollees.Atthesametime,theCentersfor
Medicare&MedicaidServices(CMS)issuedsimilarMArulechanges.
Today,MAplanshavegreaterflexibilitythaneverbeforetooffersupplementalbenefitstomembers
withspecificchronicillnesses.Onesuchbenefitishome-deliveredmeals.
That’s where Mom’s Meals fits in.
Mom’sMealsispleasedtosharewithyouaGuideforMedicareAdvantagePlans:HowtoDesign
aHome-DeliveredMealsBenefitfor2021(includingSpecialSupplementalBenefitsforthe
ChronicallyIll).
Wearealeadingnationalproviderofrefrigerated,home-deliveredmealsandnutritionservicesfor
individualsrecuperatingathomeafteraninpatienthospitalstayorpersonsmanagingachronic
condition.Our team works with hundreds of health plans nationwide, including MA and
Medicaid plans, that have implemented or plan to implement a home-delivered meals benefit.
Wehavedeepknowledgeoflegislativepolicysurroundingnutritionservicestopopulationsin
needandarepassionateaboutimprovinghealthoutcomes.
The 2021 benefit year is around the corner. Let’s work together to design a home-delivered
meals benefit under Special Supplemental Benefits for the Chronically Ill (SSBCI) for your
members with chronic conditions.
1
2
GO TO MARKET IN 2021 WITH YOUR HOME-DELIVERED MEALS BENEFIT
ManyMAplansarealreadyunderwayintheireffortstoestablishahome-deliveredmealsbenefitforthe2021
benefityear.Whereareyouinthisprocess?Now is the time to get started.
UNDERSTANDING THE OPTIONS FOR INCLUDING A MEALS BENEFIT IN YOUR PLAN DESIGN
Historicallyandeventoday,manyplanscovermealsbenefitsonalimitedbasis.Often,membersreceive
home-deliveredmealsforaperiodoftimesubsequenttoaninpatienthospital,skillednursingorrehab
stayinanefforttohelpthemrecoverafteranillnessorinjuryandavoid areadmission.
OnApril24,2019,CMSissuedamemotoMAplansponsorsdetailingnewbenefitsthatmaybeofferedto
enrolleeswithchronicconditions.Itdefinedthescopeunderanewcategoryofsupplementalbenefit,called,
“Special Supplemental Benefits for the Chronically Ill” (SSBCI).1 FilingyourbenefitunderSSBCIallowsyou
totailorbenefitsformemberswithchronicconditionsandinnovatewiththenewlyavailableflexibilityin
benefitdesign.
CMSgivesMAplansnewflexibilitytoofferbenefits
that"haveareasonableexpectationofimprovingor
maintaininghealthoroverallfunctionofanindividualas
itrelatestotheirchronicconditionorillness,"including:
• Mealsfurnishedtotheenrolleebeyond
alimitedbasis
• Transportationfornon-medicalneeds
• Pestcontrol
• Indoorairqualityequipmentandservices
• Benefitstoaddresssocialneeds
CMSmakesseveralclarificationswithrespect
tospecificSSBCIbenefits.Theseareimportant
tounderstandsincetheydifferfromprevious
years.2Whenitcomestomealsbenefits
under SSBCI:
• Mealsbenefits“maybeofferedbeyond
alimitedbasis.”
• Mealsbenefitsdonothavetobe
“uniform.”Plansmaytailorbenefitsto
theneedsofspecificenrolleesbased
upontheircondition.
Benefit Type
Eligibility
Benefit Flexibility
Uniformity Flexibility
2019 2020
“Targeted”
AllMAbeneficiariesSpecifichealthstatus
or disease state
Abilitytotailorsimilarlysituatedbeneficiaries
Supplementalbenefits areuniformacross allbeneficiaries
Benefitsmust:(1)notbecoveredbyoriginalMedicare; (2)mustbeprimarilyhealth-related(new,moreflexibledefinition)
(3)MAplanmustincuranon-zerodirectmedicalcost
“Chronic”
“Chronicallyill” beneficiaries
(definedinstatute)
Benefitthathasareasonableexpectationofimprovingor
maintainingenrolleehealthoroverallfunction
Abilitytotailortoindividualbeneficiaries’specificmedical
condition & needs
“Standard”
SUPPLEMENTAL BENEFITS FLEXIBILITY3
About 73% of MA enrollees have one or more of the identified chronic conditions.5
Chronic ConditionsEnrolleesmeetthisrequirementiftheyhaveaconditiondefinedin
theMedicareManagedCareManual(MMCM)asachroniccondition.4
• Alcohol or other drug dependence
• Cancer
• Certainautoimmunedisorders
• Certaincardiovasculardisorders
• Certain chronic lung disorders
• Certainhematologicaldisorders
• Certain neurological disorders
• Congestiveheartfailure
• Dementia
• Diabetes
• End-stageliverdisease
• End-stagerenaldiseaserequiringdialysis
• HIV/AIDS
• Stroke
Hasahighriskof
hospitalization
orotheradverse
healthoutcomes
Hasoneormorecomorbid
andmedicallycomplex
chronic conditions that is life
threateningorsignificantly
limitstheoverallhealthor
function of the enrollee
1 2
Thereisnorequirementthatan
individualparticipatesincare
coordination.AslongasanMA
planhasestablishedaprocess
todetermineifanindividual
meetsthestatutorydefinition
andclearlydocumentsits
determinationthatabeneficiary
meetsthedefinition,theplan
isnotrequiredtoensurean
individualis“participating”in
intensivecarecoordination.
Requiresintensive
care coordination
3
Definition of a Chronically Ill EnrolleeToqualifyforSSBCI,beneficiariesmustmeetallthreeofthesecriteria:
3
STEP 1: IDENTIFY YOUR TARGET
54
Mom's Meals provides detailed reporting on benefit utilization and
can help you ensure your benefits are being utilized at anticipated rates.
Indefiningtheirbenefit-eligiblepopulation,
somehealthplanschoosetonarrowtheir
focusandofferhome-deliveredmealsto
thoseforwhomthebenefitcanhavethe
greatestimpact.
Consider:
• Mostexpensivediseasecategories
• Memberswithahighrisk
ofadmission
• Riskscores
• Readmissionsrates
• Comorbidities
• Memberswithsocialdeterminants
ofhealth(SDOH)needs
CMSallowsplansflexibilityandhasnotsetforthspecificrules
fordefiningcriteria.However,allorganizationsmustclearly
definewhoiseligibleforSSBCI,andmustdocumenteligibility
criteriatoensurecommunicationtomembersisconsistent
andnon-discriminatory.
Ensure that enrollees who meet eligibility requirements
can access benefits, despite cultural or language barriers,
use of assistive technology, disabilities or health disparities.
Thisgoalshouldbebalancedwithavoidingunnecessary
administrativeburdenonproviders,plansorenrollees.
5
Mom’s Meals is happy to share with you studies proving home-delivered meals positively impact the lives of chronically ill enrollees and contribute to overall lower health spending.
How much will it cost to add a home-delivered meals benefit? How many meals should be included? Who will take advantage of the benefit? What kind of outcomes could your health plan expect?
Asyoudesignyourbenefit,youneedanswerstokeyquestionslikethese.Inpartneringwithyouractuarialteam,
Mom’sMealscanhelpyouforecasttheimpactofyourhome-deliveredmealsbenefitbasedonourworkwith
hundredsofhealthplansacrossthecountry.
Foryourhealthplan,home-
deliveredmealscantranslateinto:
• Fewerreadmissions
• Shorter lengths of stay
in the hospital
• Lowertotalcostofcare
Atypicalprogramdesignforchronic
careenrolleesmaylooklikethis:
• 12-weekcycleofmeals
• 2–3condition-appropriate
mealsperdayuntilthe
condition is controlled
Anexampleofreturnoninvestmentforchroniccaremealsmaylooklikethis:6
Without Meals With Meals
Investment $0 ~$588,000
Hospitalizations 125 63
(25%admitrate) (12.5%admitrate; 50%reduction)
Lengthofstay(days) 5.2 3.1 (40%reduction)
IPcosts($2,500/day) $1,625,500 $488,250
Net cost savings, annual $0 $1,137,250*
DoesnotincludecostsavingsonER,emergencytransportationorothercosts,orqualitybonuspayments.
ThereisnoguaranteethatyourprogramdesignorbenefitwillresultinsimilarROIresults.
ROI RANGE = 2:1-4:1 BASED ON BENEFIT DESIGN
PATIENTS = 500 QUALIFYING 500 HIGHEST-RISK MEMBERS
FOR 12 WEEKS OF MEALS WITH 2 MEALS/DAY
STEP 2: FORECAST COST AND UTILIZATION
6
1 MEMBER SATISFACTION & ENGAGEMENT
How satisfied are members with your home-
delivered meals benefit? Were case management
encounters more successful?
Forexample…
InamembersatisfactionsurveybyaMom’sMeals
partner,95%ofrespondentssaidMom’sMeals
helpedthemmanagetheirchroniccondition,and
98%wouldrecommendtheplanbecauseitoffered
ahome-deliveredmealsprogram.
Did you realize a lower rate of hospital
admissions/readmissions among enrollees?
Forexample…
Astudyreporteda38%reductionin30-day
readmissionsforpatientsreceivingpost-discharge
meals.
2 ADMISSIONS/READMISSIONS
Has the length of inpatient stays decreased
among enrollees?
Forexample…
AstudypublishedinJournalofPrimaryCareand
CommunityHealth6foundthatmemberswho
receivemealshavefewerhospitalreadmissions
(50%),shorterlengthsofinpatientstay(37%)and
lowertotalcostofcare(31%).
3 LENGTH OF INPATIENT STAY
Has the number of trips to the ER decreased
among enrollees? Have enrollees used
emergency transportation less frequently?
Forexample…
AstudypublishedinHealthAffairs7 reported a
70%reductioninemergencyroomvisitsbydually
eligibleMedicareandMedicaidbeneficiarieswithin
asix-monthtimeperiod.
4 ER & EMERGENCY TRANSPORTATION USE
Whileinthedevelopmentphase,thinkaboutthecriteriayou’llusetomeasuretheresultsofyourbenefit.
Thissteppresentsaprimeopportunitytobringcross-functionalareasoftheplantogetherforalignment
aroundthenewbenefit.
Theresultsyoumeasurecanhelpyouto:
• Improveclinicaloutcomesformembers
• Stengthenandincreaseyourplanperformanceinfuturebenefityears
• ContributetohigherHEDISandStarratings
• Differentiateyourplantoenrolleesandnetworkproviders
• Assist CMS in addressing the cost of chronic conditions
• Addressfoodinsecurityformemberswithunmetsocialneeds
Basedonourexperience,Mom’sMealshaspinpointedeightmainmeasurementcriteria:
STEP 3: DETERMINE MEASUREMENT CRITERIA
Has there been a decrease in total cost of care
among enrollees?
Forexample…
AstudypublishedbyHealthAffairs8 reported
thatmealdeliveryprogramsreducetheoverall
healthcarespendinduallyeligibleMedicareand
Medicaidbeneficiariesby40%.
5 TOTAL COST OF CARE
What type of clinical improvements have
enrollees experienced?
Forexample…
Astudyamongpeoplewithdiabetesbya
Mom’sMealspartnershowedatherapeutic
reductioninbodymassindex(5.8%).
6 CLINICAL IMPROVEMENTS
Has your home-delivered meals benefit helped your
plan achieve higher HEDIS and/or Star measures?
Forexample…
AstudyamongpeoplewithdiabetesbyaMom’s
Mealspartnershowedtherapeuticimprovements
inbloodsugarcontrol(5.9%),whichhelped
toaddresstheStarmeasureforDiabetesCare
(ControlledBloodSugar).
7 HEDIS & STAR MEASURES
Are enrollees talking about how home-delivered
meals have impacted their lives? What are
they saying?
QuotesfromafewrecipientsofMom’sMeals:
“Iorderedthediabeticfood.Thishashelpedmeto
managemydiabeticnumbers.”
“Mom’sMealspreventmefromeatingjunkfoodand
havehelpedmelose35poundsoverthelastyear.”
8 INDIVIDUAL OUTCOMES/SUCCESS STORIES
7
8
Home-deliveredmealsincludedas
SSBCI are considered a non-primarily
health-related benefit.
Home-deliveredmealsmaybeprovided
beyond a limited basis asanon-primarily
health-relatedbenefittochronicallyill
enrollees,undertheSSBCIprovisions.
SSBCI are not time limited, whichallows
MAplanstheflexibilitytodesignthebenefit
forhome-deliveredmealsforthelengthof
timetheybelievewillcreatethemostvalue.
Mealsofferedasanon-primarilyhealth-
relatedbenefittochronicallyillenrollees
undertheSSBCIprovisionsarenot required
to meet the uniformity requirements.
ClarifiedbyCMSinitsHPMSMemoradum(ImplementingSupplementalBenefitsfor ChronicallyIllEnrollees5(April24,2019))
NON-PRIMARILY HEALTH-RELATED SUPPLEMENTAL BENEFIT FOR CHRONICALLY ILL ENROLLEES
CONSISTENT WITH THE SSBCI PROVISIONS (filed in PBP Category B9b/13i)
1
Manyplanshavealreadyincludedhome-deliveredmealsas
a primarily health-related benefit.Someplansfiledifferent
benefittypesfordifferentplans,suchasHMO,PPO,D-SNP
andC-SNP.
Home-deliveredmealsmaybeprovidedona limited
basis consistentwithexistingguidancesetforthinthe
MedicareManagedCareManual(MMCM).
Forexample...
• Immediatelyfollowingsurgeryoraninpatienthospital
stay,foratemporaryduration,(typicallyafour-week
period),providedtheyareorderedbyaphysicianor
non-physicianpractitioner
• Forachroniccondition,includingbutnotlimited
tocardiovasculardisorders,COPDordiabetesfora
temporaryperiod,typicallytwoweeks.Mealsmustbe
orderedbyaphysicianornon-physicianpractitioner
andbepartofasupervisedprogramdesignedto
transitiontheenrolleetolifestylemodifications.
Primarilyhealth-relatedbenefits fall under uniformity
requirements andmustbeavailabletoallplanmembers.
PRIMARILY HEALTH-RELATED SUPPLEMENTAL BENEFIT (filed in PBP Category B13c)
2
What About Nutrition Education?Healtheducationandmedicalnutritiontherapy(MNT)offeredassupplementalbenefitsareconsidered primarily
health-related, andshouldbefiledinPBPCategoryB14c.Theservicesmustbeprovidedbypractitionerswho
arepracticinginthestateinwhichs/heislicensedorcertified,andarefurnishingserviceswithinthescopeof
practicedefinedbytheirlicensingorcertifyingstate.(i.e.,physician,nurse,registereddietitiannutritionist).
STEP 4: INCLUDE A MEALS BENEFIT IN YOUR BID
Whenpreparingyourbid,youhaveseveraloptionsforincludingahome-deliveredmealsbenefit.Mealsare
coveredasasupplementalbenefitthatmaybeincludedinanMAplanundertwoprimarycategories.
STEP 5: COMMUNICATE YOUR BENEFIT
OnceyourbenefitspackageisapprovedbyCMS,youwillneedtomovepurposefullyandswiftlytoleteligibleand
prospectivemembers,casemanagers,yourprovidernetwork,andagentsorbrokersknowthathome-delivered
mealbenefitsarenowavailableunderyourplan.
Outreach to Eligible Members
Inallcases,home-deliveredmealsbenefitsmustbeexplainedwithinplanmaterials,
suchastheEvidenceofCoverage,memberhandbookorotherofficialplandocuments.
TomakeiteasyforourMAplanpartners,Mom’sMealshascreatedalibraryofattractive,
easy-to-usematerialstocommunicatewitheligiblemembersabouttheplan’sspecific
home-deliveredmealsbenefit.Thesehavebeenusefulnotonlyinhelpingeligible
memberstomakeinformeddecisionsaboutparticipating,butalsoforestablishinga
pointofdifferentiationfortheplan.
Outreach to Case Managers & Care Coordinators
Casemanagersandcarecoordinatorswillhavedirectcontact
withenrolleeswhoareeligibleforyourhome-deliveredmeals
benefit.Introducecasemanagerstoyourbenefit,andhelp
themtounderstandhowitworksandwhat’sincluded.
ForourMAplanpartners,Mom’sMealshasconductedon-
siteandvirtualtrainingsessionswithcasemanagerstoteach
themaboutthebenefit,howtoaccessthebenefit,andhow
toidentifyandrefereligiblemembers.
Outreach to Your Provider Network
Mealscanbeahelpfultooltoproviders
whoarecaringformemberswith
chronicconditions.
Mom’sMealsisabletodelivertoanyU.S.
address,whichmeansthatyoucansupport
memberslivinginhard-to-reachareaswho
maybenefitfromhome-deliveredmeals.
9
Talkwithourteamaboutdevelopingahome-delivered
mealsbenefitspecificallyforyourchronicallyill
membersunderSSBCIforthe2021benefityear.
Catherine Macpherson, MS, RDN,
VP Product Strategy and Development,
Chief Nutrition Officer
Direct:1.844.280.2134
John Phillips
Vice President, National Program Development
Direct:1.888.343.8020
Sources1,5AnnouncementofCalendarYear(CY)2020MedicareAdvantageCapitationRatesandMedicareAdvantageandPartDPayment
PoliciesandFinalCallLetter.U.S.DepartmentofHealth&HumanServices,CentersforMedicareandMedicaidServices.April1,2019.
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf2KathrynColeman.ImplementingSupplementalBenefitsforChronicallyIllEnrollees,U.S.DepartmentofHealth&HumanServices,
CentersforMedicareandMedicaidServices,Washington,DC,memorandumissuedApril24,2019.https://www.cms.gov/Medicare/
Health-Plans/HealthPlansGenInfo/Downloads/Supplemental_Benefits_Chronically_Ill_HPMS_042419.pdf3LTQAQualityAlliance.MedicareAdvantage’sNewSupplementalBenefitfor2019:PlanViewsandResponses.November14,
2018.http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images/LTQA-Report-on-MA-Flexible-Supplemental-Benefits-
FINAL-11-9-18.pdf4MedicareManagedCareManual–Chapter16-B,Section20.1.2.https://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Downloads/mc86c16b.pdf6AudreyJ.Weiss,Ph.D.andAnneElixhauser,Ph.D.OverviewofHospitalStaysintheUnitedStates,2012.AgencyforHealthcare
ResearchandQuality,HealthcareCostandUtilizationProject,StatisticalBrief#180,October2014.https://www.hcup-us.ahrq.gov/
reports/statbriefs/sb180-Hospitalizations-United-States-2012.pdf7SethA.Berkowitz,MD,MPH;JeanTerranova,JD;LiisaRandall,PhD6;KevinCranston,MDiv;DavidB.Waters,MA;JohnHsu,MD,
MBA,MSCE.AssociationBetweenReceiptofaMedicallyTailoredMealProgramandHealthCareUse.JAMAApril22,2019JAMA
InternMed.2019;179(6):786-793.doi:10.1001/jamainternmed.2019.0198.8SethA.Berkowitz,JeanTerranova,CaterinaHill,ToyinAjay,ToddLinsky;MealDeliveryProgramsReducetheUseofCostlyHealth
CareinDuallyEligibleMedicareandMedicaidBeneficiaries,HealthAffairs,Vol.37,No.4,April2018