Social Determinants of Health

Nearly 4.6 million have enrolled in Affordable Care Act exchange plans for 2024 since open enrollment began on Nov. 1, including 919,900 people who did not have exchange plans this year. The data captures sign-ups through Nov. 18 for people in the 32 states that use HealthCare.gov for enrollment and through Nov. 11 for people in the 17 states and Washington, D.C., that have state-based marketplaces. CMS Administrator Chiquita Brooks-LaSure said in a press release that “we have seen an increase in plan selections and a significant increase in the number of new enrollees year over year.” The open enrollment period runs through Jan. 15, 2024, for states using the HealthCare.gov website, while deadlines for state-based marketplaces vary.

The Biden administration on Nov. 16 released reports outlining steps it is taking to address social determinants of health and emphasizing the need to improve individuals’ social circumstances. The documents include the U.S. Playbook to Address Social Determinants of Health, the Call to Action to Address Health-Related Social Needs and a Medicaid and CHIP Health-Related Social Needs Framework. HHS Secretary Xavier Becerra said in a press release that “it is clear that the health of our people does not exist in a vacuum, but it is affected by our access to stable housing, healthy food and clean air to breathe.”

With more than 78% of Medicaid beneficiaries enrolled in managed care plans as of the latest update to AIS’s Directory of Health Plans (DHP), winning and maintaining state contracts is crucial to MCOs that serve the Medicaid population. Six states have pending requests for proposals (RFPs) that serve about 11 million lives combined, while four states recently awarded new contracts. 

In recent years, new Medicaid RFPs have emphasized population health, asking payers to focus on health equity and social determinants of health while integrating services such as behavioral health, managed long-term services and supports (MLTSS), and pharmacy services into acute care. For example, Georgia will shift its aged, blind and disabled Medicaid population from fee-for-service care delivery to managed care when its new contracts begin, and Virginia plans to combine its MLTSS and managed Medicaid plans into one program. States also want improved analytics capabilities to track member outcomes and simplify claims and appeals processes.  

Fewer Medicare Advantage plans are using Special Supplemental Benefits for the Chronically Ill (SSBCI) to offer non-primarily health-related benefits (NPHRB) in 2024, according to an Oct. 30 report on 2024 non-medical supplemental benefits from ATI Advisory, funded by the SCAN Foundation. The health care research and advisory services firm observed some significant changes across supplemental benefit categories, and one social determinants of health (SDOH) expert expressed disappointment in MA organizations’ uptake of these benefits.

About 30% of MA plans are offering any NPHRB for 2024, just a 2.4% increase from the current plan year. And while fewer plans are using SSBCI to offer these benefits, the Center for Medicare and Medicaid Innovation’s Value-Based Insurance Design (VBID) model got a boost, with 10.4% of MA plans offering NPHRBs through the VBID model in 2024 vs. 5.5% of plans in 2023. (Plans participating in the newly extended VBID model are required to start offering supplemental benefits that address key SDOH in 2025, and ATI suggested some payers may be getting a jump on this.)

“Barbara is a Medicare Advantage member without a car and limited access to other transportation options. She has a health benefit card, issued on Optum’s payments platform, which she can use to pay for eligible over-the-counter items, groceries, and rides,” explains a recent blog post from Uber Health. Announced earlier this month, the new pact with UnitedHealth Group’s Optum health services division is just one example of creative partnerships emerging in Medicare Advantage to attract new members and address health-related social needs. Meanwhile, MA organizations for 2024 continue to strike new alliances with providers, retailers and other insurers to leverage their brands in select markets.

Centene Corp.’s Wellcare, for one, formed a new strategic alliance with Mutual of Omaha. For the 2024 plan year, the insurers will offer two cobranded PPOs — WellCare Mutual of Omaha No Premium and Wellcare Mutual of Omaha Low Premium — in five states: Georgia, Missouri, South Carolina, Washington and select areas of Texas. (Wellcare is also expanding its geographic footprint by 21 counties and adding a new state with entry into Delaware, according to an Oct. 11 press release unveiling its 2024 offerings.)

A significant number of seniors face financial burdens that impact their health, regardless of what type of Medicare coverage they have, according to the Commonwealth Fund’s 2022 Biennial Health Insurance Survey, published Sept. 19. Survey results from about 1,600 Medicare beneficiaries ages 65 and older showed that more than one-third lived at below 200% of the federal poverty level (FPL), an income threshold of $27,180 for 2022. And nearly 1 in 5 seniors reported being underinsured (defined as having high out-of-pocket costs or deductibles relative to one’s income), with low-income seniors reporting the highest underinsured rates.

By coverage type, the most likely group to be underinsured were traditional Medicare (TM) beneficiaries without any supplemental coverage. TM beneficiaries with supplemental coverage (such as a Medigap plan, union-based coverage or dual eligibility with Medicaid) were the least likely to be underinsured, with Medicare Advantage members falling in between. In their analysis of the survey results, the report’s authors pointed out that seniors may not want to pay premiums for Medigap plans, can be denied from purchasing supplemental coverage, or be “subject to underwriting…because in most states, there is only a limited period during which plans are required to issue policies.”

Beneficiary switching from fee-for-service (FFS) Medicare to Medicare Advantage more than tripled between 2006 and 2022, contributing to the MA enrollment boom that’s taken shape over the past two decades, according to a study published this month in Health Affairs. MA enrollment has been “accelerating” since 2019, researchers said, and switchers from FFS to MA were the biggest driving force behind this trend.

The study authors broke down beneficiaries from CMS’s enrollment database into five categories: stayers, switchers to MA, switchers to FFS, beneficiaries who newly gained eligibility, and beneficiaries who lost eligibility (largely those who died during the year). While new enrollments among those who had recently turned 65 also contributed to MA enrollment growth, it was at a smaller scale than growth caused by switching activity among existing beneficiaries, researchers observed.

Economic instability, food insecurity, limited access to transportation and overall lack of support are seniors’ top barriers to staying healthy, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the second-annual Social Threats to Aging Well in America survey polled 2,601 seniors across Alignment’s six-state service area, asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses illuminate the types of supplemental benefits that could prove most valuable to seniors weighing their coverage options as the 2024 Annual Election Period approaches.

Not having enough money for medical expenses was the most common overall obstacle to health, reported by 41% of survey respondents who anticipate any upcoming challenges. And about 20% of respondents cited financial instability as their top obstacle to health and wellness. One in 5 seniors said they’ve skipped out on needed medical care, and lack of funds was the No. 1 reason for doing so. In addition, 14% of seniors said they have outstanding medical debt, and 11% do not think they will be able to pay all of their medical bills in the coming year. When asked about supplemental benefits, nearly half (46%) of respondents said they would take advantage of assistance with rent, mortgage payments, and/or utility bills. Seniors also responded positively to fuel and grocery allowances.

More than a quarter of HIV-positive Medicaid enrollees did not receive at least one of three necessary services for viral suppression in 2021, according to a new report from the HHS Office of Inspector General (OIG). According to one expert, that missed care is certain to rebound to Medicaid managed care organizations (MCOs) in the form of a heavy cost burden: If HIV isn’t continually treated with antiretroviral therapy (ART) drugs and patients are not monitored by practitioners, the virus will cause a patient to develop AIDS — and patients are more likely to transmit the virus to others.

Medicaid covers a notable portion — 40% — of people in the U.S. who contracted HIV in 2018, per OIG. In the report, OIG reviewed 2021 claims data for 265,493 enrollees with HIV across the country. The main findings of the report were:

The Section 1115 waiver that allows states to provide limited Medicaid coverage to incarcerated people has drawn applications from 18 states, according to KFF data from Aug. 11. Most of those states have chosen to limit the coverage to specific populations, such as incarcerated people with positive HIV/AIDS diagnoses, substance use disorder (SUD) or serious mental illness (SMI) — and experts say that the varied scope of state uptake could, over time, show which interventions are most effective in helping the vulnerable populations that the waiver is meant to serve.

Per KFF, of the 18 states that have submitted waivers, four — California, South Carolina, Utah and Washington — have had their waivers approved. Fifteen have pending waivers. (Utah and Oregon have both submitted multiple waivers; both of Oregon’s are pending approval from CMS, while Utah has had one approved and one is still under consideration.)

Supplemental benefits are popular among Medicare Advantage members, but they’re particularly valuable for Medicare-Medicaid dual eligibles, suggests a new report from Elevance Health, Inc.’s Public Policy Institute. Following legislation and regulatory changes in 2018 and 2019 that established new types of supplemental benefits and expanded the definition of what CMS considers “primarily health-related,” payers began to offer supplemental benefits that target members’ health-related social needs (HRSNs), such as food insecurity and lack of access to transportation. Elevance is one of the first payers to release any data on the uptake and utilization of these benefits, while research on duals’ unique social needs and supplemental benefit use continues to emerge. A July 2023 study from Humana Inc., for example, found that 80% of duals in a sample population of its MA enrollees reported experiencing at least one HRSN, vs. 48% of non-duals. Deft Research in its 2023 Dual Eligible Retention Study, meanwhile, found that duals “absolutely depend” on their supplemental benefits and are likely to switch plans if not satisfied with their supplemental benefits.