When Is Assisted Living “In-Home Health Care?”

Last year the Centers for Medicare & Medicaid Services (CMS) expanded how it defines many of the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage (MA) policies. Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals are among the new benefits now being considered for coverage by insurers. More importantly, insurers are now allowed to cover non-skilled in-home care starting this year.

Assisted living providers often provide this type of care, such as helping residents with bathing and dressing. Thus, the CMS change opened up the possibility that insurance dollars could start flowing to senior housing and care companies. Analysts already envision major MA insurers buying into senior housing companies to maximize profits.

Technically, the Assisted Living facility is your home,
so “home health care” benefits should apply.

Only a handful of insurance companies are offering any new benefits in 2019. Among them, Long Beach, California-based SCAN, announced its “Returning to Home” and “Home Advantage” offerings in mid-November. SCAN was able to quickly add new supplemental home care benefits because it has covered similar services in the past

To provide these benefits, SCAN already has contracts in place with home care agencies. According to SCAN executives, it’s possible SCAN would contract directly with an independent living or assisted living company if it has caregivers on staff, and residents signed up for these new plan offerings.

It’s possible a retiree will have health care
provided by a medical organization
owned by the insurer. Would that be
considered a conflict of interest?

Both SCAN and Anthem, another major player in the MA arena, have indicated they are open to contracting with senior living providers or otherwise forging partnerships with them. We can expect a variety of differing relationships between insurers and providers as best practices are devised.

As insurance companies create their benefits packages and consider potential senior living moves, some senior living providers are looking at ways to add MA policies to the 55+ living packages they offer.

Sunrise Senior Living has a newly established plan called Sunrise Advantage which is currently offered in four states (California is not included). The Sunrise plan replaces the insurance company that normally comes in between the health provider and Medicare. Physician referrals to Sunrise are up 300% since Sunrise Advantage launched, per Sunrise executives.

Should we allow the health industry,
providers or insurers, to engage in monopoly?

Senior living providers like Sunrise, who create their own plans can tap into the new supplemental benefits as well as more well-established options. The changes promise to add bottom-line value for the senior living business, while enhancing residents’ outcomes and reducing some of their expenses.

Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. The new rules, developed with industry input, expands that significantly to items and services not directly considered medical treatment.

CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care.

The changes were adopted late in 2018, so many insurers are still designing their modifications, and many changes will come in 2020. Some health insurance experts said additional benefits could include modifications in beneficiaries’ homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating and other personal care needs.

Even though a physician’s order or prescription is not necessary, the new benefits must be “medically appropriate” and recommended by a licensed health care provider, according to the new rules.

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