policy

Social determinants of health (SDOH) are the conditions in the environments where people live that affect a wide range of health outcomes. Low-income individuals who are eligible for both Medicare and Medicaid (dually eligible beneficiaries) are more likely than other Medicare beneficiaries to have their health outcomes impacted by SDOH needs. Services that improve Medicare beneficiaries’ SDOH needs, such as nutrition benefits, housing supports, and non-medical transportation, target health equity for low-income Medicare beneficiaries by improving these beneficiaries’ health status, access to care, and quality of life.

Dual-Eligible Special Needs Plans (D-SNPs) that are integrated with Medicaid, such as Fully Integrated D-SNPs (FIDE-SNPs) and Highly Integrated D-SNPs (HIDE-SNPs), are a type of Medicare Advantage plan that only enroll dually eligible beneficiaries and coordinate and integrate these individuals’ Medicare and Medicaid benefits. Integrated D-SNPs can also offer dually eligible beneficiaries’ services to address their SDOH needs through supplemental benefits. Both Congress and CMS have recently made important changes to the MA program, giving D-SNPs and other MA plans more flexibility to offer supplemental benefits that address SDOH needs.

Proposal

Building upon Congress and CMS’ foundational work, an SDOH adjustment factor for integrated DSNPs would provide additional funds to be used to offer more SDOH services as supplemental benefits – non-medical food and nutrition benefits, housing supports, and programs to combat social isolation. Providing a Medicare SDOH adjustment for integrated D-SNPs that serve our most vulnerable dually eligible Medicare-Medicaid beneficiaries would provide direct support to these beneficiaries to improve their social determinant of health needs, improve their health security, and promote equitable, effective care.

ACAP estimates that a 1- to 5-percentage point adjustment to the rebate would give integrated D-SNPs an additional $2 to $10 per member per month to use to fund SDOH-related supplemental benefits.

Background

More than 12 million people are dually eligible for Medicare and Medicaid coverage. Of these individuals, more than half have three or more chronic conditions, such as diabetes, heart disease, and depression; require assistance with activities of daily living such as eating, bathing, or dressing; or have a cognitive impairment or serious mental illness, such as dementia, schizophrenia, or a developmental disability.^[1] Dually eligible individuals have needs beyond the medical benefits offered in traditional Medicare and Medicaid coverage. They frequently face challenges in obtaining and seeking care, including housing, transportation, lack of food security, and lack of support from family.^[2]  Additional services such as nutritious food delivery, non-medical transportation, and stable housing can lead to improved health outcomes and cost reductions that are valuable to beneficiaries, to the Medicare and Medicaid programs, and to taxpayers.

Policies that expand access beyond primarily health-related benefits and other health-related supplemental benefits as part of integrated Medicare-Medicaid programs can improve health outcomes and wellness for dually eligible beneficiaries. This type of policy aligns with the 2018 Assistant Secretary for Planning and Evaluation (ASPE) report that recommends that plans have greater flexibility to offer supplemental benefits to address health-related social needs of dually enrolled beneficiaries.^[3]

An Adjustment Factor For Integrated D-SNPs to Address Social Determinants of Health

ACAP-member Safety Net Health Plans recognize that the health of their Medicare members requires meeting needs beyond just the medical benefits offered in traditional Medicare coverage.  Additional services such as nutrition, transportation, and stable housing can lead to improved health outcomes and cost reductions that are valuable to beneficiaries. To this end, ACAP has developed a policy to provide integrated D-SNPs (HIDE-SNPs and FIDE-SNPs) with additional resources to use to fund SDOH services under supplemental benefits.

Under this SDOH Adjustment Factor, integrated D-SNPs (i.e. HIDE-SNPs and FIDE-SNPs) would receive a small, approximately 1-5 percentage point adjustment to their rebate percentage. These additional dollars would then be exclusively used to provide additional supplemental benefits targeted at social determinants of health. The integrated D-SNPs could choose to offer the SDOH benefits either as non-primarily health related supplemental benefits or as a Special Supplemental Benefit for the Chronically Ill (SSBCI). We believe this policy would help address health equity in the dually eligible population by providing these individuals with extra services to address their SDOH needs.

ACAP estimates that a 1-5 percentage point adjustment to the rebate percentage would translate to approximately an extra $2-$10 per-member-per-month (PMPM) rebate dollars to integrated D-SNPs (see Table 1).^[4] In general, for every percentage point increase in the Medicare Advantage rebate, an additional $2 PMPM in rebate dollars would be available to integrated D-SNPs to provide extra SDOH benefits. ACAP’s D-SNP members are currently directly addressing some SDOH needs through supplemental benefits. The SDOH adjustment would enable FIDE-SNPs and HIDE-SNPs to offer even more robust SDOH programs (see text box).  ACAP interviewed five of our integrated D-SNP members to assess how plans would use the additional rebate dollars provided through this policy.

Under this SDOH Adjustment Factor, integrated D-SNPs would receive a small, 1 to 5 percentage point adjustment to their rebate percentage. These additional dollars would then be exclusively used to provide additional supplemental benefits targeted at social determinants of health.

ACAP-member Safety Net Health Plans anticipate using these additional rebate dollars to offer extra SDOH services such as additional non-medical food and nutrition benefits, social isolation programs, social worker support for housing assistance, indoor air quality services, and pest control services. The plans estimate that with an additional $2 PMPM in rebate dollars, they could offer an additional SDOH benefit that was more targeted; with $5 PMPM, a more meaningful program with broader access to more meaningful benefits could be created, and at $10 PMPM a fairly substantial approach to addressing SDOH gaps could be possible. Plans also noted that they may need to devote resources to building out the infrastructure needed to support these services in some geographic areas.  Dedicated funding will allow plans to make these investments with more certainty.

Because of the benefits to dually eligible individuals from this policy, ACAP urges Congress to implement the SDOH Adjustment Factor for FIDE-SNPs and HIDE-SNPs to enable the plans to better address the social determinant of health needs of their dually eligible enrollees by targeting additional rebate dollars for SDOH services. 

Table 1. Rebate Percentage to HIDE-SNPs and FIDE-SNPs Translated to SDOH Funding to Beneficiaries for 2021

Figure 1. Additional Rebate Dollars under the SDOH Adjustment for Integrated D-SNPs Flow Directly to Services for Dually Eligible Beneficiaries’ SDOH Needs

About the Association for Community Affiliated Plans

ACAP represents 78 Safety Net Health Plans, which collectively provide health coverage to more than 20 million people. Safety Net Health Plans serve their members through Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), the Marketplace and other publicly-sponsored health programs. For more information, visit www.communityplans.net.