In the last couple of years, CMS and congress have granted Medicare Advantage (MA) plans additional flexibility to address enrollees’ unmet needs. Plans can now target specific medical and non-medical benefits to beneficiaries with chronic conditions and unmet needs. These ‘supplemental benefits’ include services like enhanced dental and vision services, hearing, OTC medications and supplies, transportation services, chiropractic, acupuncture, gym memberships, meal delivery, and many more. Members have broader access to many of these services that do not need to be provided by Medicare providers or certified facilities. With flexibility in uniformity requirements, instead of a one-size-fits-all approach, MA plans can tailor these supplemental benefits to specific population segments.
The main idea behind supplemental benefits is that by addressing the social determinants of health (SDoH) and other unmet medical needs, the overall health outcomes can be improved for high-need, high-cost members. While a lot of MA plans have expanded their supplemental benefit offerings, the utilization of these benefits remains very low (< 25% for most plans). There are many reasons for that including but not limited to confusing benefit designs, lack of awareness, challenges working with community-based organizations (CBOs), and technical and infrastructure bottlenecks.
That said, supplemental benefits offer a great promise. If implemented well, Medicare Advantage (MA) plans can use these benefits for competitive differentiation, improve star ratings and reduce the cost of care. Given the limited funding for these benefits, health plans should evolve from the current state (patchwork, ad hoc, disconnected approach) to a more thoughtful approach to implement these benefits. Technology can play a critical role in operationalizing and scaling these benefits. Sprite health provides the complete technology infrastructure to health plans for maximizing the value of supplemental benefits. With our dynamic benefits platform, plans can streamline how members are matched with supplemental benefits, and deliver a simplified, frictionless member experience to make it easy for them to get the most out of their benefits in one central location. With one connected system, the health plans get the flexibility to create tailored benefits, optimize their delivery networks, and connect the members to the right provider/program at the right time.
Tailored benefits designs
The first step is to identify the right benefits that should be offered to what subpopulations. Healthcare is local. Understanding the specific needs at the community level is key to creating benefits that members will appreciate. To get a clear picture, plans can leverage our member data platform. The platform integrates data from multiple EHRs, Claims, SDoH surveys, and other community SDoH resources to create a complete 360-degree view of each member. The inbuilt analytics provide insights into the specific issues, conditions, and needs at each member and community level, that can be used to identify the good benefits that your members need. Tailored benefits can include services that can have a direct impact on outcomes for members with specific conditions or equity gaps. For example, offering medically tailored meals for members with diabetes, blood pressure monitors and cuffs for members with hypertension, acupuncture, and massage therapy for members with ME/CFS or Fibromyalgia. Plans can create targeted benefit designs with specific eligibility criteria (based on chronic conditions, socioeconomic factors, or others), and budget to have a measurable ROI. The flexible and completely customizable plan structure removes barriers to care and enables you to design a competitive solution.
Single point of access for health and coverage
There are a lot of supplemental benefits (and growing) offered by MA plans with little cohesion between each provided benefit. The generosity of the benefit varies as well, with some plans offering allowance and others limiting the use to specific partners with predefined limits. For a member who qualifies for multiple supplemental benefits, it can be overwhelming to understand which ones will work for them at the moment, how these benefits work and how to make the best use of them for their needs.
To make it easier for your members to engage and achieve improved outcomes, MA plans must ensure that their members can find everything they need to manage their health in a single experience. Any tools you provide them should be simple and easy to navigate. And, the experience has to be personalized. No two members are alike, and each has different motivations when using the tools.
Plans can benefit from a care navigation solution that provides members easy, convenient access to personalized benefits, throughout their entire health journey, encouraging engagement and addressing their most acute needs. Members are able to find exactly what they need with minimal clicks and searching. The experience is personalized. The solution takes an omnichannel approach to guide members to the right benefits from the start. And while you can offer this access through digital tools, the same tools can be provided to your member advocacy teams for offline support. Members’ needs are likely to evolve during the year, that’s why the platform provides AI-powered recommendations to the advocacy team to adequately support these needs at any time.
Seamless coordination of medical and non-medical care
For supplemental benefits to work, it is essential to identify the barriers to care (such as transportation issues or access to housing) and then connect members with the resources and community services they need to address social determinants of health. A number of health plans are contracting with multiple community-based organizations (CBOs) in order to cover their geographical service area. However, most CBOs have limited experience in health plan contracting and lack resources for HIPAA compliance and coordination. This lack of coordination can lead to poor member engagement. Given that sustained engagement is critical to identifying and eliminating health inequities, health plans need a better approach to collaborating with solution providers.
Plans can use the integrated care management solution to guide members to the most appropriate community-based organizations through a configurable matching algorithm that considers factors like member needs, specialty, insurance coverage, proximity to the member, and network affiliation. The analytics and closed-loop referral coordination capabilities make it easy for members to access the services they need and provide you insights into partner performance across your referral network.
Elevated member experience
Member satisfaction is the most significant contributor to Star Ratings for Medicare Advantage (MA), and Medicare drug plans (Part D). This means that engaging with members in a way that is highly individualized is fundamental to enabling growth and retention. We provide a range of solutions that can help you deliver a personalized, intuitive, proactive, and connected member experience across all channels. Members can access all benefits from a central location, with recommendations that are specific to their needs. They can see available dollars to spend on plan-approved services and products. Members get a convenient way to pay for eligible items and approved services with a personalized debit card that can be loaded on a monthly, quarterly, or annual basis.
Simplified administration and reimbursement
Most health plans are providing supplemental benefits using a combination of mail order, online or in-store fulfillment approaches. The providers of these benefits can range from one to thousands, each with its own method of invoicing for the consumed goods and services. Traditional claim systems are not designed to support these use cases. Health plans can leverage our technology infrastructure to cost-effectively administer and reimburse benefits by connecting these disparate pieces. Our integrated analytics, predictive intelligence, and live performance dashboards make sure you see how each provider/program in your supplemental benefits ecosystem impacts your members every day.
If you’re a Medicare Advantage member and believe you qualify for supplemental benefits, you can use the plan finder to search for a health insurance plan that offers the benefits that are right for you. If you are a payer, connect with us to learn how we can help you streamline your supplemental benefits offerings.