Homefront Insights

In November 2019, the Centers for Medicaid and Medicare Services (CMS) withdrew guidelines directing states regarding how to implement Medicaid block grants and per capita cap programs. The political wrangling over the plan has obscured the details of the current administration’s Medicaid block grant proposal in general, and Tennessee’s plans in particular. To understand block grants, one needs to understand Medicaid’s current funding structure.

As a result of managed care, patients missed the close relationships they previously had with their doctors. Many felt that office visits were too short and that their doctors were too busy with documentation. From this dissatisfaction grew two new models of care: concierge care and direct care. There are similarities between the two, but important differences as well.

Described as the biggest Medicare reimbursement overhaul in 20 years, the recent changes to the Centers for Medicare and Medicaid’s (CMS) payment models have caused a lot of buzz. The reason for all the hype is the transition towards a more value-based system and away from the fee-for-service status quo. The intent behind these administrative changes, commonly known as the Patient-Driven Payments Model (PDPM) for skilled nursing facilities (SNFs) and the Patient-Driven Groupings Model (PDGM) for home health care, is to improve the quality of patient care, promote the overall health and wellbeing of the Medicare Advantage population, and lower healthcare costs.

Expanded MA supplemental benefits are largely tied to CMS’s updated guidance allowing plans to cover anything that has “a reasonable expectation” of improving or maintaining the well-being of beneficiaries with chronic conditions.

MA plans are an alternative to traditional Medicare, encompassing inpatient, outpatient, and prescription drug benefits. In 2018, CMS announced that MA plans would expand to cover home-based services as well. The new plans include several new services that are available to millions of MA plan members. Since their introduction in 2010, MA plans have become increasingly popular among Medicare recipients, and the additions planned for 2020 will likely add to this enthusiasm.

When case managers partner with a structured community-based palliative care (CBPC) solution, they gain a set of “eyes and ears” into the homes of members struggling with a serious illness, resulting in better care coordination and better outcomes for members and their families.

As the healthcare climate pivots from fee-for-service to value-based payment models, Medicare Advantage benefits are expanding to include a broader scope of offerings. Insurers are slowly realizing that the value of offering these benefits is far greater than paying for treatment costs, including time spent in high-cost, acute care facilities, once a patient’s illness becomes more severe.