Social Determinants of Health

Millions of seniors report needing long-term services and supports that can assist with daily activities and disease management, but many don’t qualify for Medicaid, the primary source of LTSS coverage. Medicare Advantage plans have stepped up to fill in the gap with “LTSS-like” supplemental benefits, which range from select Special Supplemental Benefits for the Chronically Ill such as home modifications and service dog support, to Expanded Primarily Health-Related Benefits, including adult day services, in-home support services and caregiver support.

New research from ATI Advisory explores who has access to and ultimately enrolls in MA plans that offer LTSS-like supplemental benefits. The analysis of CMS data found that 82% of Medicare-only beneficiaries (i.e. those who are not dually eligible for Medicaid) have access to at least one plan that offers at least one LTSS-like benefit. Despite the wide availability of LTSS-like plans — particularly in high-population urban areas — just 9% of beneficiaries are enrolled in them, representing about 2 million people.

As artificial intelligence software proliferates in the health care sector, a good deal of attention has focused on the ways that AI could make existing health disparities worse. Experts say that AI also has the potential to mitigate or reverse health disparities — so long as health care organizations, and insurers in particular, proactively and continuously counter biases in their current and future software platforms.

“We’re at this inflection point where we have new tools. We have new technology that actually may have that opportunity to address health inequality in a way we haven’t been able to before. But we’re at this inflection point where that same tool can actually amplify that bias, amplify the inequality that already exists,” said Maia Hightower, M.D., during a March 26 panel organized by the National Institute for Health Care Management (NIHCM) Foundation.

Data sharing and staff contacts are the keys to improving collaboration between Medicaid managed care organizations and public health departments, according to California officials and plan staffers. Leaders from managed care plans say that close collaboration improves outcomes for high-needs populations who struggle with one or more social barriers to health.

“When you're looking at claims data, we're obviously not going to see a claim for homelessness. We’re not going to be able to capture that. But when we take our data and bump it against data that's available to some of the public health jurisdictions, and we find out that some of our members are facing housing instability, then that also gives us the ability to understand that maybe their health outcomes are directly being affected by these social determinants of health,” said Nishtha Patel, manager of care transformation at Inland Empire Health Plan (IEHP), during a March 21 Manatt LLP webinar. “No matter what we do intervention-wise, if we're not addressing those, their health outcomes are not ever going to improve.”

During a keynote session at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, health plan leaders offered sobering assessments about the state of health equity in the U.S. Still, they offered concrete steps their organizations have taken with community partners to address systemic inequalities.

“I would give us a grade of ‘C’ [on health equity]. Probably, before the murder of George Floyd, I would have given us a ‘D,’” said Karen Dale, market president and chief diversity, equity and inclusion officer at AmeriHealth Caritas. Floyd was killed by a white police officer during an arrest made outside a Minneapolis convenience store in May 2020, sparking nationwide protests over police brutality and racial inequality.

Starting with the 2027 Star Ratings, CMS will begin rewarding Medicare Advantage plans for their efforts to assess social risk factors and address disparities in certain quality measures with the new Health Equity Index (HEI). Not all plans will qualify and only a third of top-performing plans will be rewarded, but the time is now for plans to look at how they are doing on the claims-based measures that will be impacted and how they are performing for members with one of the qualifying factors (i.e., eligible for Medicare and Medicaid, disability and/or the Part D low-income subsidy).

During a recent panel moderated by AIS Health, a division of MMIT, speakers at the 7th Annual Medicare Advantage Leadership Innovations forum discussed best practices for assessing members’ social needs and how plans can use data to address them and move the needle forward on health equity.

More than half — 52% — of adults covered by commercial insurance deal with social risk factors that can raise health care costs, according to a Feb. 20 white paper from UnitedHealth Group and the Health Action Council (HAC). UnitedHealth and HAC executives say that the report’s findings can help health plans and plan sponsors be more proactive in addressing social determinants of health (SDOH)-related needs in commercial populations.

Some SDOH challenges faced by the commercially insured population include social isolation and problems with finances, food, and housing, per the report. Twenty-six percent of the studied group faced one SDOH risk, 16% faced two SDOH risks and 10% faced three or more.

In a post published on the insurer trade group’s website, AHIP CEO and President Mike Tuffin advocated for a better-funded Medicare Advantage program. The post occurred about two weeks after CMS released the 2025 Notice of Medicare Advantage and Part D payment changes, which the agency estimated would result in a -0.16% revenue change without an increase in risk scores. Tuffin wrote that “it is essential that funding keep pace to ensure stability and prevent erosion in the benefits and affordability seniors count on in Medicare Advantage.” He cited an ATI Advisory report from March 2023 that found MA enrollees save an average of $2,400 annually compared with fee-for-service Medicare members, as well as a January AHIP report that found the MA population “is both more diverse and lower income than enrollees in fee-for-service Medicare.”

A recent report from Morgan Health, JP Morgan Chase & Co.’s health care venture fund and consultancy, documents troubling disparities for health care access and outcomes among Black, Asian American and Hispanic employer-sponsored insurance plan members; lesbian, gay and bisexual (LGB) plan members; and ESI members with low incomes. Experts tell AIS Health, a division of MMIT, that plan sponsors and insurers must consider plan design and provider incentives, among other strategies, to close health disparity gaps.

Plan sponsors and insurers can take proactive steps to reduce health disparities among their plan members, experts say — and they add that there are clear business incentives for doing so.

More than a year after unveiling their intent to form HealthRight Group, SCAN Group and CareOregon have abandoned their plans to combine. According to news reports, the parties called off their proposed combination on Feb. 13 after the Oregon Health Authority twice delayed offering a recommendation on whether to approve the deal, which would have created a $6.8 billion Medicaid and Medicare Advantage insurer. “SCAN and CareOregon share a commitment to preserving and protecting nonprofit, locally based healthcare and that has always been our goal in combining under the HealthRight Group,” said SCAN, the parent company of not-for-profit Medicare Advantage insurer SCAN Health Plan. “Our intent in coming together was to support Oregon’s healthcare system and the people that CareOregon serves. However, despite our efforts, there are still questions about our combination. As a result, SCAN Group and CareOregon have mutually agreed to withdraw our applications with the Oregon regulatory agencies and to terminate our affiliation agreement.” SCAN and CareOregon, which serves Medicare and Medicaid enrollees in Oregon, in December 2022 told AIS Health, a division of MMIT, that the partners aimed to be a “formidable not-for-profit partner” in the government program space.

Seniors who experienced fluctuations in eligibility for Medicare Part D’s low-income subsidy (LIS) spent more money on prescription drugs and filled fewer prescriptions overall, according to new research published in JAMA Health Forum. While researchers said questions remain about whether these temporary losses can impact medication adherence and health outcomes — particularly among non-white seniors — policymakers should consider streamlining LIS eligibility systems to reduce administrative barriers.

In 2023, 13.4 million Part D beneficiaries received full or partial LIS benefits. The program provides assistance with paying premiums and deductibles, and it reduces any post-deductible cost sharing for beneficiaries. The majority of LIS beneficiaries are “deemed,” meaning they are automatically enrolled in the program based on dual eligibility with Medicaid and/or enrollment in a Medicare Savings Program (MSP). (This also includes non-duals who receive Supplemental Security Income.) But 17% of LIS beneficiaries are “nondeemed,” meaning they are not enrolled in Medicaid or an MSP and must apply for LIS themselves. All LIS beneficiaries undergo annual redeterminations, but the process for deemed beneficiaries is automatic, leaving the nondeemed population to face potential administrative challenges and unnecessary coverage loss.