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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Affairs This Week. I'm your host, Jeff Beyers. We're recording on 06/12/2025. As a quick note, I know I've talked about the Insider Program a lot. We have a couple of exclusive events coming up.
Jeff Byers:Next week on June 17, we have a risk adjustment event, where J. Michael McWilliams will discuss trends in risk adjustment and potential reforms. And on July 9, Sarah Rosenbaum will be moderating a panel wrapping up the supreme court session and, what cases were looked at with their relation to health care. And later, have our trend report on the health care workforce coming up. You can still check out our trend report on artificial intelligence in health care as well.
Jeff Byers:Sign up, and, I'm sure I'll talk about that more detail when it actually gets released, the workforce one. Today on the program to talk about Medicare Advantage and its supplemental benefits, we have Kathleen Haddad back on the program. Kathleen, welcome. Hey, Jeff. So Kathleen, Health Affairs Forefront is wrapping up a year long project.
Jeff Byers:It was funded by the SCAN Foundation. It examines the role of supplemental benefits and Medicare Advantage. You know, that's things like in home care, transportation to and from visits. There's probably a food element in there that I'm not gonna get right. Maybe you can let us know what some of those other benefits are.
Jeff Byers:We did a podcast in September on these benefits. Now that the project is wrapping up, what have we learned?
Kathleen Haddad:So, Jeff, we covered so many important topics in this series, and listeners can go to our forefront page to find them. So just to remind people what these benefits are, they are the extra benefits not available in traditional Medicare. Most people are familiar with vision, dental, and hearing supplemental benefits. Let's call them the big three. But over the past five years, CMS has broadened the scope to include, like you said, food, produce, over the counter items, and others.
Kathleen Haddad:And for special populations, there are benefits such as in home help with cooking and cleaning, respite care, home modifications, or help with rent and utilities. We call these nonmedical benefits.
Jeff Byers:Yeah. Okay. Thanks for thanks for backing me up on that food area. Good to know. I I was in the right ballpark.
Jeff Byers:What makes Medicare Advantage supplemental benefits an important policy issue?
Kathleen Haddad:So, Jeff, there are two things mainly. These are benefits that, many beneficiaries really like, and they're important to staying healthy and functional, yet not all these benefits are available to all MA enrollees, and TM enrollees don't have any of them. And then there's the cost, about 70,000,000,000 annually that CMS pays to MA plans to provide these benefits.
Jeff Byers:Yeah. It's interesting. Being comfortable in the home is something that people tend to like. I know my other middle aged people out there feel me. Right?
Kathleen Haddad:Well, many of the people who qualify for these benefits are older, and many of them do have some conditions and and how they how they are able to stay in their homes or being able to stay in their homes is really, really important and it's cost effective.
Jeff Byers:Yeah. I was trying to keep it a little light, but fair fair. Thanks for keeping the program honest. One of the forefront articles in the series talks about how beneficiaries use the benefits and what they like about them. So what can you tell us about that?
Kathleen Haddad:So there's an organization out there called the Public Policy Lab, Jeff, and they, interviewed older adults who rely on these benefits, and they catalogued all their responses into hundreds of data bytes that public policy analysts and advocates can use to understand and communicate how these benefits impact people's daily lives, what they like and don't like, and what's helpful and not. The database is called The People Say, and anyone can use it by going to the web page and creating an account, and it's very searchable. So, hopefully, we can put that in our show notes.
Jeff Byers:And what do beneficiaries like about these supplemental benefits?
Kathleen Haddad:They really like their benefit debit cards. An article we had by Joe June and Claire Cruz, talked about how beneficiaries use their flex cards, and they cover some of their grocery bills or over the counter items like you and I would use FSA cards for. And the beneficiaries really rely on them and they even to afford their monthly grocery bill, and the cards feel lifesaving to some of them. But, the cards also can be very hard to use because not all stores or vendors know what they are or accept them, And there are administrative snafus that, some of the beneficiaries described on, the PeopleSay. And many plans don't make clear how and where the cards can be used.
Kathleen Haddad:So some of the funds go unused, and plans retain the unused amount.
Jeff Byers:Yeah. So it sounds like these are pretty popular benefits, but it also sounds like there might be some issues in accessing these benefits. So can you outline more of what some of these issues might be?
Kathleen Haddad:So, yeah, good question, Jeff. In our forefront article in the series, Eric Roberts of Penn wrote about the question of value. So MA benefits, these benefits, supplemental benefits are paid from rebates that MA plans realized by bidding for CMS payment levels that are less than what CMS would pay for similarly sick traditional Medicare enrollees. So the plans are then required to use the rebates, these extra payments, to either lower premiums or offer extra benefits. So many plans use these benefits to use the the rebate to offer supplemental benefits and some as, you know, as marketing enticements to attract enrollees.
Kathleen Haddad:And so at the same time, CMS has increasingly relied on MA plans to provide and coordinate services for under resourced beneficiaries and sicker beneficiaries, including those who are eligible for both Medicare and Medicaid, what we nerds call duals. I'll confess to being a nerd. Another thing is that that Eric Roberts talked about is research that shows the, amount actually passed through to beneficiaries is relatively low, and it turns out that it costs the federal government an additional $2 for every $1 that MA plans allocate to reducing costs or expanding benefits. And this relates to how something complex about how the benchmark for the bid is set set. So I would refer readers to the Eric Roberts article and the link in there for more on that.
Kathleen Haddad:But he also wrote about limited data on the benefits how the benefits are used and the outcomes the health outcomes. So MA plans are required to report encounter records for all supplemental services, but a federal audit concluded, that that Eric cites that MA plans have failed to consistently report supplemental benefit use.
Jeff Byers:We ran an article in the series last month by Amber Christ and Allison Barkoff about problems coordinating benefits between Medicare and Medicaid. What can you tell us about this article?
Kathleen Haddad:So, Jeff, that article was about problems experienced by duals, many who can enroll in D SNPs, special needs plans called D SNPs. So many of these duals qualify under Medicaid for long term services and supports, and some of these services overlap with the supplemental benefits, services like in home care, so people can live in their homes and not in nursing homes. So less than 10% of plans offer LTSS benefits. This was reported by Joe June and Claire Cruz of ATI, a research firm in this space, in their article. But Barkhoff and Christ start off by making clear that neither MA plans nor the Medicare or Medicaid covers the full scope of LTSS needed by aging Americans.
Kathleen Haddad:There can be chaos when these enrollees try to access the services because the plans don't always coordinate the benefits very well. So take, as an example, say someone gets five hours a week of in home support by Medicare Advantage plan and then ten hours by paid by Medicaid, but by different providers who don't talk to each other. Or Medicare, Medicaid can disagree over who pays for the coverage, which can delay the needed care. So a bene or a beneficiary may have signed up for an MA plan just to get a specific supplemental benefit that Medicaid already covers generously, so that's not they're not getting the best value they can in their plan choice. And another article in the series by Rachel Gershon and Julie Carter of Justice in Aging and the Medicare Rights Center, they talk about receiving these kinds of complaints very frequently.
Jeff Byers:So that article is published today, hot off the presses. You can check out Forefront for that article once you stop listening to this podcast while also sharing it with a friend. What other problems with accessing benefits do Gershon and Carter report? Not to not to give too much away so they click. But
Kathleen Haddad:Yeah. Yeah. Oh oh, there's much more in the article, but I can go on here for a while. So, yeah, I'll start. Anyway, enrollees, report misunderstanding the scope of their benefits or being misled by brokers about the benefits that are available.
Kathleen Haddad:You know, just maybe the brokers or representatives from the plans, you know, they're not experts, they may not understand or communicate the complexities involved. Gershun and many of the other authors in this series called on CMS to do a better job requiring plans to provide accurate and complete information for beneficiaries when they're choosing a plan. And the, you know, the issue here is that Medicare plans, advantage plans have wide latitude in determining who among their enrollees is eligible for a benefit. The Medicare Rights Center reports hearing from Benny's who sign up for a plan because of a specific benefit and later learn they're not eligible for it because their condition doesn't fall on the plan's list of eligible conditions. So excuse me.
Kathleen Haddad:I use the term Benny's. I used to analyze Medicare data, and that's the nerd term, so no disrespect meant. But, anyway, the Gershon article also points out that Medicare plan finder doesn't provide detailed information on many of the benefits, like the number of transportation trips offered or in home the number of in home visits allowed. And there are other problems. Some plans require Bene's to opt in or register for specific benefit.
Kathleen Haddad:And if they don't know they have to do this, then they don't get the benefit. And then some plans have prior authorization requirements on the benefits or restricted networks, and enrollees often don't know about this, then that can prevent them from using their benefits.
Jeff Byers:So didn't CMS have solutions teed up for some of these problems in the proposed rule governing these benefits?
Kathleen Haddad:Yeah. Jeff, the rule proposed last fall did. However, many of them were not adopted in the final rule published this spring. So for example, CMS did not finalize its proposal to impose requirements on how plans use debit cards to administer benefits, including guardrails that would ensure beneficiaries are fully aware of covered benefits and how to access them. And, CMS did not finalize a proposal to expand requirements to define in the provider directory what community based services and in home service contractors are, and this would have codified a definition and required them to be included in the provider directory so beneficiaries would know where to go to get the services that they think that, they signed up for.
Kathleen Haddad:And then CMS didn't finalize a proposal to better regulate brokers who sell MA plans.
Jeff Byers:So, Kathleen, as we wrap up, what are some of the academic scholars and and thought leaders thinking about this program moving forward?
Kathleen Haddad:They have a number of recommendations. They propose to that benefits should be standardized to make it easier for beneficiaries, to make cross comparisons across plans, to choose a plan that provides the best value for them. They recommend requiring more detailed information, on the benefits in the provider networks for beneficiaries during open enrollment, one of the items that was not finalized in the proposed rule. They recommend requiring plans to report the data more accurately. Researchers can study if the benefits actually improve health, and there are some issues with this.
Kathleen Haddad:It's hard also for plans to do it for IT reasons, but, you know, it can be done. We sent the the man to the moon. So there's work going on on that. A few authors call for CMS and congress to reevaluate whether MA actually detracts from value, whether traditional Medicare should take over covering some of these benefits such as in home care, especially given overpayment to MA that makes it possible to market and provide these benefits. Eric Roberts and Nina Seshamani, a former CMS director, discussed these issues in their articles.
Kathleen Haddad:But, you know, this is not the direction congress has taken on Medicare. So, still whether or not the benefits are administered in a way that adds value is an important issue that needs to be addressed, Jeff.
Jeff Byers:Yeah. So a lot of information on Health Affairs Forefront. We'll provide a link in the show notes to the series itself. And this project will conclude with a virtual webinar on July 8. Kathleen, what can you tell us about that?
Kathleen Haddad:So the webinar will feature two authors from the series, Eric Roberts and Claire Cruz, who I mentioned, and we'll have the medical director of a community affiliated MA health plan, the health plan of San Mateo, and he'll talk about how they choose supplemental benefits to meet their population's health needs and, the CEO of a vendor of nonmedical benefits called Helper Bees who will give us some insights involved in the issues connecting beneficiaries to the services they signed up for. But I wanna mention a special part of the event will be a short video that features older adults who actually tell us about their lived experience using the benefits, and that was produced by, the People Say in that project.
Jeff Byers:Fantastic. And, that event will be free to all. We will have, availability to sign up for that event, sometime next week. So check our upcoming events schedule on health affairs website. We'll also put a link to the schedule in the show notes, so that will be easy to find the meeting registration page when it goes live.
Jeff Byers:But we hope to see you all there on July 8. And with that, Kathleen, thanks for joining us today on Health Affairs This Week.
Kathleen Haddad:Thank you, Jeff. It was fun.
Jeff Byers:And to you, the listener, if you enjoyed this, it just send it to a friend. Have a great day. Bye.