Long-Term Care

When it comes to aging in place, seniors in the U.S. have a hodgepodge of programs and services available to them, and health plans can be a connector to and integrator of those services in their respective markets. Speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore, agreed that health plans can also play a valuable role in driving innovations across the Medicare and Medicaid programs, such as providing emergency and acute care in the home, supporting family caregivers, and advocating for policy solutions.

Before CMS in 2020 introduced the Hospital Without Walls program enabling health systems to provide acute hospital care in the home, integrated insurer-provider Kaiser Permanente (KP) launched the Advanced Care at Home (ACAH) model. One of several KP initiatives that support aging in place, ACAH leverages expert care teams and technology to provide 24/7 physician-led acute care and coordinate patients’ recovery in the familiar setting of the home. Eligible patients are identified in urgent care, emergency and/or inpatient settings but must also meet certain social and clinical criteria, explained Rachna Pandya, regional strategic implementation leader of Medicare operations and strategy, during the session, “Best Practices to Support Aging in Place.”

As the CMS Center for Medicare and Medicaid Innovation works toward its goal of having all fee-for-service (FFS) Medicare beneficiaries and most Medicaid beneficiaries in accountable care relationships by 2030, CMMI this year has unveiled three models aimed at advancing value-based care. One of them is the Guiding an Improved Dementia Experience (GUIDE) Model, which combines care coordination, caregiver support and respite services to improve the quality of life for people with dementia and their caregivers while delaying avoidable long-term nursing facility placement. Although the model does not serve Medicare Advantage beneficiaries, its mission appears to parallel specialized MA plans that offer supplemental benefits aimed at helping people age in place, deploy interdisciplinary care teams and empower caregivers to play an active role in their loved ones’ care.

An estimated 6.7 million people in the U.S. are currently living with Alzheimer’s or another form of dementia, and that number is expected to grow to nearly 14 million by 2060. Medicare will cover most of those Americans at some point, but the program as it exists today does not have a standardized care delivery approach for dementia, observed Tonya Saffer, director of the division for health care payment models at CMMI, during a Sept. 13 webinar on the model hosted by Manatt, Phelps & Phillips, LLP.

After issuing a request for information (RFI) and reviewing feedback from stakeholders, Sen. Bill Cassidy, M.D. (R-La.), is circulating discussion draft legislation to improve coverage for Medicare-Medicaid dual eligibles. While several industry experts agree that the legislation is moving integration in the right direction, they also say certain elements of it may be overly ambitious and raise many questions, such as whether states that have limited the number of Medicaid managed care organizations will inhibit the ability of Medicare Advantage plans to participate in the new model.

Cassidy, who frequently tackles health care issues as a member of several Senate committees, led a bipartisan group of senators in drafting the proposal, which was informed by more than 125 responses to the November RFI. According to a Cassidy aide, the senators will collect feedback through July 1 and hope to formally introduce legislation after Labor Day.

As Programs of All-Inclusive Care for the Elderly (PACE) grow across the U.S., sponsoring entities can expect CMS to put additional scrutiny on their operations. New PACE organizations are subject to audits in their first three years of operation, and updated audit protocols for 2023 include expanded collection of data around both the clinical services provided to participants as well as the non-clinical program features such as transportation, according to BluePeak Advisors, a division of Gallagher Benefit Services, Inc. This will require significantly more man hours and readiness on the part of the sponsoring PACE organization, adds BluePeak, which helps PACE organizations and Medicare Advantage organizations prepare for audits.

As Medicare Advantage organizations market a host of new products and benefits for the 2023 plan year, large and regional insurers alike are boosting their Dual Eligible Special Needs Plan (D-SNP) presence. And while those plans continue be the most popular type of SNP — especially as CMS phases out so-called D-SNP look-alikes and pushes states to further integrate Medicare and Medicaid programs — a smaller but growing group remains interested in pursuing the more specialized Chronic Condition SNP (C-SNP) and Institutional SNP (I-SNP) markets.

According to an analysis of CMS’s Landscape Files from Clear View Solutions, LLC, there will be 1,320 SNPs on the market in 2023, compared with 1,192 in 2022 and 1,019 in 2021. Drilling down further, Clear View observes that there will be 1,068 SNPs available next year that were offered in 2022, compared with 926 plans that carried over from 2021 to 2022. The total number of D-SNPs, which serve members who are dually eligible for Medicare and Medicaid, will rise from 723 plans in 2022 to 809 plans available in 2023.

As the U.S. population ages and as payers and providers increasingly embrace home-based care — especially in light of the COVID-19 pandemic — a program that one expert calls the “best-kept secret in health care” seems poised to finally have its moment in the sun. However, there are a variety of barriers that need to be tackled in order for Programs of All-Inclusive Care for the Elderly to significantly grow, and recent compliance issues at the largest PACE participant raise questions about the involvement of private equity-owned, for-profit companies.

The PACE model employs comprehensive medical care and social supports to help frail, elderly Americans remain at home when they otherwise would require a nursing home level of care. Eligible enrollees — who never have to pay cost sharing — receive health care services at an adult day center, which is staffed with interdisciplinary care teams and also offers classes, games and other wraparound services.

Medicare Advantage plan operator MCS Advantage, Inc. agreed to pay $4.2 million to resolve False Claims Act allegations that it violated the federal Anti-Kickback Statute (AKS) by offering kickbacks to health care professionals in the form of gift cards. According to the July 1 press release from the U.S. Dept. of Justice, MCS allegedly implemented a gift card incentive program between November 2019 and December 2020, when it distributed 1,703 gift cards to administrative assistants of providers in the aggregate amount of $42,575 to induce them to refer, recommend or arrange for enrollment of 1,646 new Medicare beneficiaries into an MCS plan. The Puerto Rico insurer did not admit liability as part of the settlement agreement. The company voluntarily closed the gift card program in December 2020, which the DOJ and HHS Office of Inspector General took into consideration, according to the press release. “The Settlement highlights the breadth of the AKS, as well as the flexibility that enforcement authorities have in utilizing the AKS as a vehicle to deter behavior deemed to be problematic” and suggest that remuneration to induce referrals of beneficiaries to specific federal health care program plans, along with to specific item or service, may be within the confines of the AKS, the law firm Holland & Knight suggested in a July 11 blog post.

As the pandemic underscores the importance of enhanced support for community-dwelling seniors with complex care needs, two not-for-profit Medicare Advantage organizations have teamed up to sponsor an “integrated care delivery organization” designed to serve enrollees who qualify for Programs of All-Inclusive Care for the Elderly (PACE). Long Beach, Calif.-based SCAN Health Plan and Boston-based Commonwealth Care Alliance (CCA) last month unveiled the launch of myPlace Health as part of their shared mission of keeping seniors healthy and independent.

Robbie Pottharst, CEO of the newly launched company, confirms that myPlace is seeking to become a PACE organization and align with local health plans that may already serve dual eligibles who qualify for PACE and that, in his words, “can lend capability, expertise and a lot of accelerators to build this business.” Pottharst previously held leadership roles with Cityblock Health, Kaiser Permanente and CareMore Health, where Sachin Jain, M.D., served as president and CEO before taking over the reins at SCAN.

Despite better-than-expected financial results posted for its fiscal-year 2022 second quarter, shares of InnovAge — the largest provider of Programs of All-Inclusive Care for the Elderly (PACE) — tumbled last week amid concerns about its ability to grow in the face of intensifying regulatory scrutiny. Between federal audits and issues with its state partners, InnovAge’s many struggles relate to program compliance and may demonstrate the difficulties of scaling up a specialized care model in a highly regulated industry.

Providing services primarily through a dedicated center, PACE organizations support frail, elderly Americans who require a nursing-home level of care by offering comprehensive medical care and social supports to help them remain at home. The PACE market serves about 51,000 participants, most of whom are dually eligible for Medicare and Medicaid, and it is largely composed of regional organizations. As the dominant PACE organization, InnovAge serves 12% of that market.

In its new rule proposing an array of policy and technical changes for the 2023 Medicare Advantage and Part D contract year, CMS devoted a large section to advancing integration of Medicare and Medicaid benefits for dually eligible individuals. Though the rule is largely in line with the goals of the SNP Alliance, whose member plans serve approximately 2.5 million Special Needs Plan (SNP) enrollees, the organization says many of the proposals will require greater collaboration between states and plans, as well as more specificity and standardization around the proposed collection of social determinants of health (SDOH) data.

The proposed rule, Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (87 Fed. Reg. 1842, Jan. 12, 2022), included the following provisions: