Medicare Advantage (MA) is the program by which private plans can offer Medicare coverage. Medicare beneficiaries can choose either traditional fee-for-service (FFS) or enroll in a private MA plan. Over one-third of beneficiaries choose private plans, but that proportion varies greatly by the region of the country.
Traditionally, services related to social determinants of health (SDOH) have been delivered outside of health care coverage; however, recently enacted flexibilities in the Medicare Advantage program allow private health plans to more easily use funding to coordinate, purchase and contract for SDOH services for their members. These have included areas such as food, transportation, home improvement, pest control, and housing.
Nonetheless, for many organizations looking to engage with Medicare Advantage plans in their community, there is not easily accessible information on whom to engage and what the potential of the engagement may be. Key questions include:
- Who is offering MA plans in my community?
- Are they offering plans that target members who may need SDOH services?
- Are there enough MA members needing SDOH services to have a viable program/business?
- Do the MA plans in the community have sufficient resources to pay for SDOH benefits?
- What types of SDOH interventions may be most needed and attractive to the MA beneficiaries in a community?
Answering these basic questions is the first step in understanding whether an MA engagement approach is right for your organization. At a high level, a large number of MA beneficiaries is a better opportunity than only a few hundred members. Additionally, having more competition in a market may translate into a greater need to differentiate products than in a consolidated market.
It is also important to know what percent of Medicare beneficiaries are in MA plans and whether they are in traditional coverage, employer coverage or specialty plan coverage—each of these product types will require different engagement approaches. Not knowing this context could make your engagement approach fall flat!
In MA, plans provide a “bid” of how much they believe it will cost them to deliver traditional Medicare benefits to their covered members. If that amount is below the benchmark rate in a county, then the plans get a rebate. They can use this rebate to provide for reduced cost sharing or additional benefits. This is the pot of funds from which most SDOH benefits arise. Thus, counties with higher average rebate amounts may be better opportunities than those where plans have more limited rebate dollars with which to work.
Additionally, knowing the organizations that may be offering products to low-income beneficiaries that may be more in need of SDOH services will help target and prioritize your outreach efforts. This can be looked at through examining Low-Income Subsidy (LIS) enrollment in a county.
Your organization should also be aware of specialty plans: those MA plans that target a specific population that may have greater needs for an SDOH intervention. Since an MA organization offers a benefit package by plan, an SDOH-associated benefit may be a more attractive benefit to one of these specialty plans because a larger percentage of the plan’s enrollees could be users of the SDOH benefit.
Finally, as a rule-of-thumb, MA beneficiaries that are paying a monthly premium for their plan are going to be reluctant to pay significantly more for SDOH benefits. Thus, for counties with lower percentages of zero-premium plans and higher average premiums, SDOH products that are cost-saving, or budget neutral will be more attractive versus those that may take several years to demonstrate an ROI.
If you are interested in affordably obtaining this information for your organization please visit ZAHealth’s product shop. We also have the data resources and expertise to aid your organization in its MA partnership endeavor:
- Interpretational guidance – Want an expert set of eyes to evaluate your market opportunity, we are glad to provide our take-aways of your market and where we see opportunities based on the data.
- Custom reports – We are glad to develop custom reports that incorporate new data or new views of our existing data to meet the unique needs of your business.
- Business consulting – We have decades of experience working with health plans, leading care delivery organizations and SDOH innovators; let us help you turn your concept into a successful business.