March 13, 2019

HEALTHCARE POLICY AND PRACTICE 

OPPORTUNITIES FOR SENIOR NUTRITION 

PROGRAMS

PART 1: THE EVOLVING HEALTHCARE LEGISLATION LANDSCAPE
TODAY’S PRESENTERS

• James Michel

• Director of Policy & Research, Better Medicare 

Alliance

• Jennifer Raymond

• Chief Strategy Officer and Director of the Healthy 

Living Center of Excellence, Elder Services of the 

Merrimack Valley, Inc.
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THE EVOLVING HEALTH CARE POLICY 

LANDSCAPE: MEDICARE ADVANTAGE

James Mitchel

Director of Policy and Research
AGENDA

• Brief Overview of Medicare Advantage Structure,

Trends and Payment

• Review of Recent Policy Changes in Medicare

Advantage

• Discussion of Current and Future Efforts in

Medicare Advantage to Address Social

Determinants of Health

• Broader Implications for the Future of Medicare

and Medicare Advantage
LEARNING OBJECTIVES

• Learn the basic structure and financial model of 

the Medicare Advantage program

• Understand what recent changes have been made 

to the Medicare Advantage policy landscape

• Understand how these recent policy changes will 

impact the ability of Medicare Advantage plans to 

integrate more nutrition benefits into care models
• Leading coalition advocating for a 

strong Medicare Advantage

• Alliance of ~130 organizations

• 400,000 Medicare Advantage seniors 

across the country

• Key Activities:

• Policy engagement and 

development

• Thought leadership

• Communication & outreach

• Research
BMA NATIONAL ALLIES

ADVOCACY ORGANIZATIONS

Alliance for Aging Research 

American Benefits Council

American Speech-Language-Hearing Association

American Telemedicine Association Asian 

& Pacific Islander Health Forum

Association for Behavioral Health and Wellness 

Coalition of Texans with Disabilities

Healthcare Leadership Council International 

Council on Active Aging

National Association of Nutrition and Aging 

Services Programs

National Black Nurses Association

National Caucus and Center on Black Aging 

National Hispanic Council on Aging National 

Minority Quality Forum

Population Health Alliance

Society for Women’s Health Research The 

Gerontological Society of America The 

Latino Coalition

WomenHeart

NATIONAL COMMUNITY 

BASED ORGANIZATIONS

Meals on Wheels America 

YMCA

AGING SERVICE ORGANIZATIONS

Consortium for Older Adult Wellness Elder 

Services of the Merrimack Valley Florida 

Health Networks

LeadingAge

Palm Beach Area Agency on Aging

Philadelphia Corporation for Aging Senior

Resource Alliance

BENEFITS PLANS

Delta Dental of CA, PA, NY, & Affiliates 

LIBERTY Dental Plan Foundation National 

Association of Dental Plans VSP Vision Care

STATE RETIREMENT SYSTEMS

Kentucky Teachers’ Retirement System

PROVIDER ASSOCIATIONS

American Association of Nurse Anesthetists 

American Association of Nurse Practitioners 

American Medical Group Association American 

Nurses Association

American Osteopathic Association

National Association of Hispanic Nurses 

Garden State Chapter

National Hispanic Medical Association 

National Medical Association

New Jersey State Nurses Association

Nurse Practitioner Association of New York State 

Academy of Nutrition and Dietetics

HEALTH SYSTEMS/PHYSICIAN

GROUPS

Atrius Health 

Banner Health

Health Quality Partners

Indiana University Health 

Iora Health

Lehigh Valley Health Network 

Mercy Health

Northwell Health 

Summa Health 

Virtua

Temple Health 

ChenMed

NATIONAL BUSINESS

ORGANIZATIONS

National Association of Health 

Underwriters 

National Association of Manufacturers 

National Retail Federation

U.S. Chamber of Commerce
OVERVIEW OF MEDICARE ADVANTAGE

Medicare 

Beneficiary

Government Contracts 

with Private Insurer

Government Pays 

Private Insurer

Medicare Advantage Plan

• Provides access to Parts A and B covered services, may

include additional supplemental benefits

• Plans may not provide identical access to providers in FFS

Medicare

• Cost sharing may be above or below FFS Medicare, but

must be actuarily equivalent

• Annual out-of-pocket limit

Traditional FFS Medicare

• Provides access to Parts A and B covered services

• May see any provider who accepts Medicare, no network

restrictions

• Beneficiary pays 20% coinsurance for covered services

• Medigap policies are available to reduce beneficiary outof-pocket costs

• No out-of-pocket limit

Private Insurer 

Administers 

Benefit

Government 

Administers 

Benefit

Medicare Advantage is the managed care alternative to fee-for-service (FFS) Medicare.
COVERAGE REQUIREMENTS

Benefits

• Provide and pay for Parts A

and B covered items and

services

• Include additional coverage

in the form of reduced cost

sharing or non-Medicare

benefits (mandatory

benefits)

• Plans also have flexibility to

offer other non-Medicare

supplemental benefits for

an additional premium

(optional benefits)

Access

• Provide access to Parts A

and B covered services

• Must meet network

adequacy standards

• Not required to provide

identical access to providers

as FFS Medicare

• Beneficiaries can access

out-of-network services at

higher costs

Cost Sharing

• Can be above or below FFS

Medicare, but overall cost

must be actuarially

equivalent to FFS

• Cannot discriminate against

sicker beneficiaries

• Subject to restrictions and

annual guidance issued by

CMS

• Cost sharing for specific

services (e.g., Part B drugs)

is limited

Medicare Advantage plans must meet general requirements on benefit coverage, 

access, and cost-sharing
MEDICARE ADVANTAGE ENROLLMENT TRENDS

CBO1 PROJECTIONS OF MEDICARE ADVANTAGE ENROLLMENT

MA Enrollment MA as % Total Medicare Enrollment

More than 2 in 5 Medicare-covered seniors will be in a Medicare Advantage plan within 

the next 5 years.

1. Congressional Budget Office
HOW MEDICARE ADVANTAGE IS PAID

Plan Bids above Benchmark Plan Bids below Benchmark

Benchmark = $1,000

Beneficiary premium for 

Part A/B services= $100 CMS savings = $50

Plan bid = $1,100

Plan payment from CMS = $1,000

Plan bid = $900

Plan payment from CMS = $950

Rebate amount = $50

Plans that receive 4 or 5 stars 

are eligible to receive a higher 

rebate percentage

● MA payment structure encourages plans to bid below the benchmark

o Plans bidding below the benchmark receive a percentage of the difference between their bid and

the benchmark as a rebate to offer additional benefits; this percentage rebate varies depending

on the star rating of the plan

o Plans bidding above the benchmark must charge a premium for Parts A and B services equal to the

difference between their bid and the benchmark

Medicare Advantage plans have incentives to “bid” low and maximize the availability of 

rebate dollars.
REBATES AND PLAN STRATEGIES TO KEEP BIDS LOW

• Provide

supplemental

benefits

• Reduce costsharing

Plan Strategies to Keep Bids Low

• Care coordination and care

management to reduce unnecessary

utilization

• Focus on keeping patients at home

and in lower-cost settings

• Provide benefits that are known to

improve overall health

Rebates must be used to benefit the patient directly, either by offering additional, 

supplemental benefits or by reducing cost-sharing, such as plan premiums, which 

creates strong incentives to keep bids as low as possible.

Rebates must 

Benchmark be used to:

Bid
SUPPLEMENTAL BENEFITS DEFINITION

• Supplemental benefits are defined in statute as:

• Common supplemental benefits include:

• Dental coverage

• Hearing coverage

• Vision services

• Social work lines

• Wellness programs

• Fitness benefits

There are stringent rules around supplemental benefit offerings, both in terms of what 

they are and in terms of how they are funded.
NUTRITION & MEAL COVERAGE TODAY

Medicare Advantage

• May cover meal delivery depending on

plan and depending on specific

qualifications

• May be provided in limited

circumstances, such as several weeks

post-hospitalization

• May be provided for certain chronic

conditions

Traditional FFS Medicare

• Traditional FFS Medicare does not

cover meals unless part of a stay in an

inpatient setting

• May still access community-based

services

Medicare coverage of meal and nutrition services today is limited in scope.
MEDICARE ADVANTAGE POLICY CHANGES FOR 2019

• Uniformity rule says that if a

plan offers a benefit, it must

be uniformly available to all

enrollees in a plan

• CMS reinterpreted this rule

• Now, plans may offer benefits

to specific groups of enrollees

who are “clinically similar”

• Allows plans to offer tailored

benefits based on clinical

condition

• CMS reinterpreted the

“primarily health-related”

standard

• CMS’ reinterpretation

effectively expanded what

may be an allowable

supplemental benefit offered

by a Medicare Advantage plan

Uniformity Rule Supplemental Benefits

CMS reinterpreted two fundamental rules governing how Medicare Advantage plans 

operate, which represents one of the most significant policy advancements in MA to-date.
EXPANSION OF SUPPLEMENTAL BENEFITS FOR 2019

Now, a supplemental benefit will be considered 

“primarily health-related” if it is used to:

• Diagnose an illness

• Compensate for physical impairments

• Acts to ameliorate functional/psychological impact

of injuries or health conditions

• Reduces avoidable emergency and health care

utilization

However...

- Guidance Memo: Reinterpretation of “Primarily Health-Related for Supplemental Benefits, CMS, April 27, 2018

• Adult day care services (must be statelicensed)

• Home-based palliative care (and not

hospice-eligible)

• In-home support services (must be

provided by individuals licensed by the

state to provide personal care services or

in a manner that is otherwise consistent

with state requirements)

• Support for caregivers of enrollees

(respite care should be for short periods)

• Medically-approved non-opioid pain

management

• Stand-alone memory fitness benefit

• Home & bathroom safety devices and

modifications (must be temporary)

• Transportation

• Over-the-counter benefits
MEDICARE ADVANTAGE ADDRESSES SDOH IN 2019

• Announced new benefits

aimed at addressing social

determinants of health

(SDOH) for 2019 plan

offerings

• Branding them as “Essential

Extras,” which include food

delivery, transportation,

assistive devices, alternative

medicine, adult day care

and in-home personal aids

• Humana teamed up with

Meals to provide in-person

meal delivery, social visits and

safety checks

• Offered to seniors enrolled in

plans in Richmond, VA;

Louisville, KY; and Tampa, FL

starting January 1, 2019

• UPMC Health Plan

partnered with Pittsburghbased Community Human

Services to secure

permanent, supportive

housing and care

coordination for homeless

individuals

• Those who gained housing

saw an average savings in

annual health care

expenditures of nearly

$6,400.

Medicare Advantage plans utilize new flexibilities in 2019 to test benefits that address 

social determinants of health.
FURTHER EXPANSION OF SUPPLEMENTAL BENEFITS

• BBA specifies that MA plans may offer supplemental

benefits that are not primarily-health related

• Benefit must have a “reasonable expectation of

improving or maintaining health or overall function”

• Plans can target enrollees based on chronic condition

and other factors, such as social determinants of

health

Special Supplemental Benefits for 

the Chronically Ill (SSBCI)

The Bipartisan Budget Act of 2018 eliminated the “primarily health-related” standard for 

supplemental benefits for individuals with chronic conditions, effectively establishing a new 

category of benefits, beginning in 2020.
BROADER IMPLICATIONS

• Arguably the most impactful policy change to

Medicare Advantage since its inception

• First real effort to blend social and medical services

in the Medicare program

• Further differentiates Medicare Advantage from

Traditional FFS Medicare during a period of

significant growth in MA

• Medicare Advantage will inform changes and

reforms in Traditional FFS Medicare
OTHER FACTORS CAUSE UNCERTAINTY FOR 2020

• Provide

supplemental

benefits

• Reduce costsharing

Rebates must 

Benchmark be used to:

Bid

• Proposed rule on

policy and technical

changes to MA and

Part D has not yet

been finalized

• Proposed rule on

prescription drug

rebates in Part D still in

proposed stage

• Both of these will have

an effect on MA plans’

2020 bids

Though the definition of supplemental benefits has been expanded and flexibilities have 

been provided, no additional funding has been provided.
KEY CONSIDERATIONS

• Medicare Advantage plans are developing bids now for

2020 plan offerings, which are due in June 2019

• Other policy proposals will impact what the 2020 plan

market looks like depending on how they are finalized

• Plans will make careful decisions about how to use

limited rebate dollars

• Plans are likely to take a cautious approach to new nonmedical benefits until they have identified which new

benefits provide value and for whom

• New cottage industry of organizations seeking to

support Medicare Advantage plans who want to

develop new benefits is already beginning to develop
KEY TAKEAWAYS

• 2019 and 2020 represent a sea change in Medicare

toward addressing social needs that impact health

• Medicare Advantage will continue to lead in

innovating in new care models and benefit designs

• Social Determinants of Health will be the key

buzzwords in health care for the foreseeable future

• Medicare Advantage plan options in 2020 will be

diverse and will move to a more person-focused

plan model rather than a one-size-fits-all

• Senior nutrition professionals will see significant

new opportunities in Medicare Advantage in the

short-term
THE EVOLVING LEGISLATION LANDSCAPE

A Community Organization Perspective
AGENDA

• Brief Overview of Elder Services of the Merrimack

Valley, Inc.

• Discuss the value of community-based nutrition

services to the client, organizations and health care

systems and payors

• Introduce Medicare Advantage opportunities
WHO WE ARE

• Largest AAA in Massachusetts

• Serve over 25,000 older adults annually

• 250+ employees and 375+ volunteers

• 40+ programs

• Home of Statewide contracting network for

evidence-based programs (Healthy Living Center of

Excellence)

• Consultant and partner in n4a Aging and Disability

Business Institute

• Evidence-Based Leadership Council Member
WHO WE ARE

Mission:

Maximize the independence, well-being, and 

health of older adults, people with 

disabilities, and their families and caregivers

Vision:

All people, regardless of age and disability, 

live with dignity, make their own choices, 

and participate fully in society
POLL

What current relationships do 

you have with Health Care 

systems?

• None

• We informally partner for nutrition 

or other services

• We receive referrals for nutrition 

or other services

• We have a contract with one or 

more health systems 
INTEGRATION WITH HEALTH CARE SYSTEMS

• Contracting with dual eligible plans for care 

transitions, case management, evidence based 

programs, etc

• Among the first care transitions programs funded by 

CMS

• Diversification of funding

• Certified community partner for mass health 

(Medicaid) ACO

• NCQA accreditation
VALUE OF COMMUNITY / HEALTH CARE INTEGRATION: 

INDIVIDUAL PERSPECTIVE
VALUE OF COMMUNITY / HEALTH CARE INTEGRATION: 

COMMUNITY ORGANIZATION PERSPECTIVE

Consumers and 

their families

ESMV staff

ESMV Board

Community 

partners

EoEA and DPH

Health Care 

Partners

Other 

funders/payors
VALUE OF COMMUNITY / HEALTH CARE INTEGRATION: 

COMMUNITY ORGANIZATION PERSPECTIVE

Inputs

Activities

Outputs

Outcomes

Impact
VALUE OF COMMUNITY / HEALTH CARE INTEGRATION: 

HEALTH CARE PARTNER

Integrated 

Provider 

Network

Community 

Value 

Proposition

Defined 

Service 

Delivery 

Package
VALUE OF COMMUNITY / HEALTH CARE INTEGRATION: 

HEALTH CARE PARTNER

Problem Solving vs. 

Service Providing:

“What keeps you up 

at night?”
SOLVING A PROBLEM, NOT PROVIDING A SERVICE

•Existing Community Relationships

•Connection to resources

•Single Contract for all regions/programs

• Marketing and Outreach

• Feedback loops

•Training & Technical Assistance 

• Quality & Efficiency through Centralized Infrastructure

• Continuous Quality Improvement (PDSA)
MEDICARE ADVANTAGE OPPORTUNITIES

• Nutrition

• Housing

• Transportation

• Others
NUTRITION SERVICES

• Assessment: (including Medical Nutrition 

Therapy)

• Education: Healthy Eating for Successful Living, 

MNT, Evidence-based Programs

• Resources: Home Delivered Meals, Congregate 

Meals, Brown Bag, Famers Market, Farm-to-table
POLL

Do you provide Medical 

Nutrition Therapy?

• No

• Yes, in clinical settings

• Yes, in community based 

settings

• Yes, in the home
PART II: MEDICAL NUTRITION THERAPY IN THE HOME
CONTACT INFORMATION

Jennifer Raymond

Chief Strategy Officer, ESMV

jraymond@esmv.org

www.esmv.org

www.healthyliving4me.org

James Michel

Director of Policy & Research, Better Medicare Alliance

JMichel@bettermedicarealliance.org

https://www.bettermedicarealliance.org/

Uche Akobundu, PhD, RD

Director, NRCNA

uche@mealsonwheelsamerica.org

https://nutritionandaging.org/
QUESTIONS AND DISCUSSION
UPCOMING WEBINAR
HEALTHCARE POLICY AND PRACTICE OPPORTUNITIES FOR 

SENIOR NUTRITION PROGRAMS

• THURSDAY, MARCH 19, 2019 

• Part 2: Launching An In-home Medical Nutrition 

Therapy Program

• To learn more and to register, please visit: 

https://nutritionandaging.org/training/
• 2018-2019 plan THANK YOU!